The CommonHealth

Krishna Udayakumar explains how he systematically assembled data to make sense of the fast-moving global marketplace in vaccines, amid the pandemic, building on prior trust with private and public entities, and positioning the Duke Global Health Innovation Center as the go-to source. Starting in late 2020, that meant painting the picture of worsening inequities that reflected the overwhelming power advantages of wealthy states and powerhouse vaccine developers, rhetorical commitments to solidarity notwithstanding. We are now rapidly approaching a pivot point, as supply escalates later this year: estimated western production of 7 billion doses in 2021, 14 billion in 2022. The big worry looking ahead? Lack of delivery capacity and financing in low and lower-middle-income countries, which may, as a result, become “mired” in 20-40% coverage. The G7 summit was a “mixed bag, ” leaving us “nowhere near the end of the story.” The big question 12-18 months out: will it be a western consortium that vaccinates most of the low and lower-middle-income countries? Or will it be the world’s vaccine “workhorse,” China? Or some combination?

Philip Zelikow, former executive director of the 9/11 Commission, has launched an ambitious fast-moving planning effort to scope what a commission on the pandemic in America would examine, how it would be organized, what value it would deliver, how it would navigate our treacherous political terrain, why it needs to move fast to nail down what happened. Listen in to learn more.  Philip Zelikow is an American attorney, diplomat, academic, and author. He is a professor of history at the University of Virginia.

This week the CSIS Schieffer Series hosted a high-energy exchange on “The Next Phase Of Covid-19.” Steve and Andrew were joined by Jeremy Konyndyk, executive director of USAID’s Covid-19 Task Force, who delivered a stirring keynote address outlining USAID’s vision for addressing the burgeoning pandemic crisis while simultaneously investing in long-term health security preparedness in acutely vulnerable low-income countries. A roundtable followed on the historic legacy of US presidential leadership amid global health crises -- and the lessons for the escalating urgent demands unfolding in South Asia, Latin America, and elsewhere. Steve, Andrew, and Jeremy were joined by Julie Gerberding, co-chair of the CSIS Commission on Strengthening America’s Health Security and executive vice president and chief patient officer of Merck; and Gary Edson, president of the COVID Collaborative and former White House official under President George W. Bush who played a pivotal role in launching PEPFAR and the Millennium Challenge Corporation (MCC). 

Dan Diamond has covered health, politics, and the White House for the Washington Post since January 19. What is going on in the international side of the US response to the pandemic? It is “piecemeal,” unclear who is making decisions, lacks a strategy, the approach is “much vaguer” than the domestic response. The US has announced a number of important steps which are “staccato moments.” President Biden came into office with the country “on fire.” His team is still settling, and there is no single person in charge of the international response. The issues are a complex “thicket” full of geopolitical risks. Nonetheless, it feels as if a moment is arriving where the administration is going to pivot to the international arena. Internally, senior officials are “raring to go.” Domestically, Dan has observed closely the four focus groups of vaccine-hesitant people launched by Republican pollster Frank Luntz, one session was a “transformative experience,” another a “total dud.” Perhaps the Community Corps will be able to bring to scale hyperlocal engagement with those who remain hesitant. Perhaps they simply need more information and more time. It’s “heady times,” practicing this form of journalism in Washington. Hypercompetitive, everybody wants a piece of the story. Dan Diamond is the National Health Reporter at the Washington Post 

Dr. Monica Gandhi has thought deeply about the complex transition we have entered, with many vaccinated, and many not. We need to behave differently in private versus public settings. Being polite and compassionate remain essential. Resistance to vaccines comes from different populations, each requiring a different approach: racial and ethnic minorities; youth; those who ask what will be the rewards for getting vaccinated; and the recalcitrant. There has to be far more “positive motivation,” a form of “proactive, vaccine optimism” based on a concrete blueprint for how our lives will improve through vaccines. CDC guidance during this transition, on travel and outdoor masks, has been confusing but will improve as more people are vaccinated. School closures in the United States have been excessive. “It is political.” We are “not looking at data cleanly.” Global vaccine inequity is the world’s biggest moral challenge: we need to do “whatever it takes” to expand manufacturing and access. The population living with HIV whom she serves in San Francisco suffers from extreme loneliness, “untold mental health effects.” Her advice: “Please go see a friend.”Dr. Monica Gandhi is Professor of Medicine at the University of California San Francisco, Director of UCSF AIDS Research, and Medical Director of the HIV Clinic at San Francisco General Hospital (“Ward 86.”)

Dr. Castrucci joined us to discuss his evolving collaborations with noted Republican pollster Frank Luntz, an expert who is a “master class in communications.” Through a series of surveys and focus groups, they have teamed up to understand how best to engage conservative Republican voters who refuse or are otherwise deeply resistant to getting vaccinated against Sars-CoV-2. “Covid has been politicized since day one” and the question now is how to “change the conversation.” “If this is a political debate, we all lose.” What is the solution? Every health provider has to make engagement with patients on the vaccine a routine part of every patient’s visit. “Good stories and good facts” is “our formula, ” which can educate versus indoctrinate. Give people the facts, and they will “change hearts and minds.” Dr. Brian Castrucci is the President and CEO of the de Beaumont Foundation, based in Bethesda, Maryland.

We sat down this week with the acclaimed survey expert, Mollyann Brodie who been exceptionally busy in recent months, engaging over 11,000 American adults. She finds it remarkable “how fast and dynamic vaccine confidence has moved” across all population groups, reaching acceptance among two-thirds of Americans. The “moveable middle,” of persons waiting to decide, has been cut by half to 17%. Black and Hispanic populations have moved towards higher acceptance but still account for a large share of those postponing a decision. As for “persistently reluctant” individuals, the 3 in 10 evangelicals and Republicans, particularly younger, male and rural citizens? “Nothing we have thrown at them… has caused them to tell us they are willing to move.” What to do? “At the margins, carrots seem to work for a sliver” of this population: i.e. if vaccines improve the ability to visit family, travel overseas, receive a bonus from an employer. “They have their own set of concerns” over personal liberty, disruption of economic life, distrust of government. Politics needs to be removed from discussions. The focus needs to shift to meeting these individuals where they are. “Hyperlocal efforts,” conversations among themselves, with their own physicians, with their own family members, hold promise.  What gives her hope? “ I have never seen a movement of this kind in my lifetime.. of so many individuals and organizations on the ground trying to help us get to herd immunity.”  Mollyann Brodie is Executive Vice President and Chief Operating Officer at the Kaiser Family Foundation, as well as Executive Director of the Public Opinion and Survey Research Program.

Dr. Deborah Birx, former Trump White House Coronavirus Response Coordinator and renowned global HIV/AIDS leader, spoke to us about a rich assortment of issues: the recent drama surrounding her statements about the Trump administration; her almost 7 months on the road across America, far from Washington, visiting with 44 governors; the corrosive divisions in our society; what might cure vaccine hesitancy; President Biden’s early achievements; DOD’s profound contributions; the secret power of millennials and retailers; the potential value of a 9/11 Commission, and more. “This virus does not recognize party. .. The more we make this pandemic partisan, the more it divides us.”  “I have worked in pandemics that were highly politicized… that creates vulnerabilities, we could not see it here.” In March, 2020, people were listening, responding to science and data, how to stop the spread, what it might do to our health system. Then the focus swiftly morphed to the economy. “For those of us who stayed.. we believed we could recapture how severe this pandemic is.” By the fall, “we were never able to move people to testing as a public health measure in itself.”    On vaccine hesitancy, her message to all mothers: “No matter what age your son, tell him for your peace of mind to get vaccinated.” “To daughters and sons, call your dads.” “Do it for your family.”  Dr. Deborah Birx is Senior Fellow at the George W. Bush Institute. 

Journalist, writer, editor Frances Stead Sellers returned to share new insights. Leaders like Henrietta Fore, UNICEF, struggle with “incredible added burdens” dealing with crises in childhood education and disrupted immunizations while “vaccinating the world” against Covid-19 with Gavi. “Imagine being Henrietta Fore. .. The strains on the organization are enormous.” Francis Collins, head of NIH, faces similar expansive responsibilities, and uses his own voice “as a person of faith” to address vaccine hesitancy. The Washington Post Live series, one-on-one conversations, creates a new “intimacy” where guests are more reflective. Over and over during the pandemic, journalists face the “We don’t know” quandary of scientific uncertainty. “We keep getting ahead of ourselves.” That requires laying out what different experts believe, a form of “service journalism”. Vaccine hesitancy among Republican men is a “new phenomenon,” very “distressing,” that reflects our immense national divisions. People want to hear from their friends, from trusted individuals. It is important for people’s “barber to be seen getting vaccinated.” Her personal hope for the future? “I desperately want to return to real-life meetings… Nothing beats face-to-face meetings.”Frances Stead Sellers is a Senior Writer and Reporter on the National Desk at the Washington Post.

Dr. Jennifer Kates and Josh Michaud, Kaiser Family Foundation, take us on a tour d’horizon. Rapidly accelerating vaccine coverage has resulted in “a huge, huge change.” By the end of June, we will have twice the volume of vaccines needed to inoculate America’s 260 million adults. Improvements in testing and surveillance lag – “We can’t just focus on one intervention.” At the same time, state leaders relax controls, and variants increase transmissibility, concentrated among youth. “We are definitely at risk.” The equity agenda? “It’s not going well yet…. Most states are not doing a good job on equity…. It is the key aspect of this rollout over the next few months.” Many southern states are weak performers on vaccines (AL, TN, TX, GA, AR, SC, MS) while many smaller states are strong performers (AK, ME, SD, ND, RI, WV, CT). 55% of Americans now “want to be vaccinated,” while those who prefer to wait-and-see has dropped from 30% to 22%. But 15% are refusing, and another 7% will take the vaccine only if required. The chief challenge: how to reach Republican voters – especially male, rural, younger – with what message and what messenger? Digital certification of vaccination is “going to happen” but “can be quite fraught” over privacy, discrimination, and civil liberty concerns. Dr. Jennifer Kates is Senior Vice President for Global Health and HIV Policy; Josh Michaud is Associate Director for Global Health Policy, at the Kaiser Family Foundation in Washington, D.C.