2

The COVID-19 Pandemic

Understanding the challenges facing the nation’s—and the world’s—airline industry begins with understanding the COVID-19 pandemic itself. The workshop led off with three keynote presentations that offered a general overview of the pandemic and provided context for the following discussions. Ashish Jha, the dean of the School of Public Health at Brown University, discussed the pandemic from a public health perspective and offered a stick take on what to expect relative to the pandemic in the future. William Haseltine, the chair and president of ACCESS Health International, spoke about the pandemic from a virologist’s perspective and offered a significantly different look at the likely future of the pandemic. Victor Dzau, the president of the National Academy of Medicine, focused more on societal and political issues related to the pandemic.

There were common themes highlighted by the keynote speakers. For example, the pandemic was not a surprise for many, there have been warnings and calls for preparedness before, but despite these warnings, many countries in the world, including the United States, were not prepared. The response to the pandemic was not effective in many countries, including the United States, in part due to lack of coordination. Similarly, there were many issues with the global response as well. The impact of the pandemic was beyond health, impacting societies and economies. The pandemic exacerbated inequities and disproportionately affected vulnerable populations. These themes would extend into the other sessions as well.

COVID-19 FROM A PUBLIC HEALTH AND MEDICINE PERSPECTIVE

Jha began by saying that the goal of his presentation was to provide “an overview of where we are with the pandemic, a little bit of how we got here, where we are exactly at this moment, and where we should expect to go.” His presentation only touched, briefly, on the topics of aviation and safety.

Explaining why he thinks this analogy is fitting, he said that he thinks of the acute phase of the COVID-19 pandemic is likely to last about 18 months, at least in the United States and Western Europe. Citing January 2020 as the beginning of the pandemic, he expects the pandemic to shift from its acute phase to more of a chronic phase by July 2021 or so.

Jha said that he chose January 1, 2020, as the start date of the pandemic because even though the virus had been circulating in China, and likely other countries before then, December 31, 2019, is when China officially notified the World Health Organization (WHO), bringing COVID-19 to the attention of the global community. Speculating about an end date for the chronic phase of the pandemic, he said that vaccines will be widely available

in the United States and many other high-income countries by July 2021. Although life will not be completely back to normal by then, he commented, “I think you can imagine that things feel qualitatively better by the time we get into the summer months.” It is possible that the acute phase could stretch into 2022, he said, “but I don’t think this is going to be something that we’re going to be dealing with in an acute phase for years and years.” The acute phase is likely to be followed by a chronic phase that will require a different approach.

The second major point that Jha made was that a pandemic was widely predicted. He noted that “lots of people saw a global pandemic as only a matter of time.” Various commissions were formed after the 2014–2016 West Africa Ebola outbreak, and these commissions talked about how to prevent the next pandemic. “None of us knew that the next pandemic was going to come in 2020,” he said, “but no one was surprised.” It is important to talk about how to prevent the next pandemic, because all of the conditions that contributed to the current pandemic are still in existence, and will be for a long, long time, so it is likely the world is “entering an age of pandemics.”

There are several drivers for the growth in pandemics, Jha said. First, the number of novel agents infecting humans has gone up in the last 30 years. This is because most new infections in humans come from animals, and the number of interactions between humans and animals has increased significantly because of economic growth, environmental changes, and the fact that people are consuming more meat. Growing deforestation and environmental changes also mean that humans are interacting with animal habitats much more often.

A second driver is climate change, which is affecting the movement of disease vectors in various ways.

Finally, globalization is making the world more interconnected, and growing numbers of people travel from place to place around the world. Globalization is largely a good thing, Jha said, as it has had huge economic benefits for many poor and middle-income countries. On the other hand, globalization has made it much easier for diseases to spread around the world. A major difference between the 2003 outbreak of the original SARS virus and of the outbreak of the related COVID virus is the dramatic increase in global travel between 2003 and 2020. Global travel from the United States increased by 50 percent from 2003 and 2020, he said, and travel by Chinese citizens, both domestically and internationally, grew by a factor of eight during that same time span. Other countries, such as India, are seeing similar dramatic growth in travel, and global travel from the African continent is expected to grow sharply in coming years.

The increase in global travel turns local disease outbreaks into global disease outbreaks, Jha said. Combining air travel, economic development, climate change, and broader environmental changes is a recipe for global pandemics.” Thus it is important to talk not only about the best way to deal with the COVID-19 pandemic but how to prepare for others in the future.

Jha’s third major point addressed preparedness. If one looked at preparedness metrics before the pandemic, some of the best-performing countries were the United States and the United Kingdom. “I certainly thought of preparedness as a set of structural and clinical and human resources assets,” he said. “I thought about laboratory capacity and public health capacity, clinical facilities and capacity, hospitals, doctors, nurses, labs—all of the things that the United States excels in and Western Europe excels in.”

The lesson from the pandemic, however, was that while those factors are important, they are not sufficient by themselves. Factors involving governance, leadership, social cohesion, and misinformation have proven to be more impactful on pandemic response and have contributed to the United States and the United Kingdom to be among the worst performers in the world as measured by the numbers of COVID-related infections and hospitalizations. The lesson, Jha said, is that there are clearly elements of preparedness that were not given enough consideration and for which metrics remain undefined. Future pandemic responses will require a rethinking of how national and sub-national preparedness for pandemics are assessed.

Next, Jha discussed the two broad categories of societal response—the public health response and the biomedical response. The distinction is somewhat arbitrary, he said, but it is still useful in discussing different approaches.

Social distancing is one example of a public health intervention, of which the most extreme version is a lockdown. But for any level of public health intervention, the goal is to keep people from gathering too closely. A second public health intervention is mask wearing, which is known to be very effective, Jha said. A third is testing for virus prevalence in the community and tracing known cases. The combination of testing and contact tracing is a very powerful tool, and some countries, such as South Korea, have used it to effectively avoid outbreaks.

The classic biomedical interventions are therapeutics, and have been somewhat effective against COVID, Jha said. There are not many drugs that can be used in an ambulatory setting, and even for inpatient treatment modalities the only major success has been with steroids, such as dexamethasone, with limited data indicating that remdesivir given early may also be potentially helpful. Finally, effective outpatient treatments rely on monoclonal antibodies, but their use has not been widespread, and much is yet to be learned how best to employ them.

One really important innovation on the therapeutic side, Jha said, is the improvements in how doctors and nurses take care of patients. A COVID patient admitted to a hospital now, 14 months into the pandemic, is, on average, 50 to 60 percent less likely to die from the disease than a patient admitted in March 2020. “That’s a phenomenal improvement over 11 months,” he said. The improvement in outcomes is partially due to the use of dexamethasone, partially due to remdesivir, but mostly due to vast improvements in clinical practice—knowing who needs to be intubated, knowing when to turn a patient from lying face up to lying face down, and knowing who needs to be taken care of in the intensive care unit.

A great deal of progress has been made in developing diagnostic tests, Jha said, and they have been used effectively as medical tools but not so effectively as public health tools, where they are widely employed for community testing and contact tracing.

Additionally, he said, “vaccines are a very, very powerful set of tools, and they are our way out of this pandemic.” It was almost miraculous how quickly effective vaccines were developed for COVID-19, he said, although he added that the claimed efficiency of the current vaccines—whether it is 66 percent, 85 percent, or 95 percent—should be “taken with a grain of salt.” The important aspect of all of the vaccines approved to date is that they appear to be extremely effective at preventing severe illness and death; the most important attribute of a vaccine. The available data so far do suggest that they also probably reduce transmission by a meaningful amount, he said.

One last tool that Jha mentioned was the imposition of travel restrictions as a way to slow down or stop the spread of a pandemic. He stated that in his review the literature indicates that really aggressive restrictions clearly have some effects. However, while travel restrictions do not have very large effects what they do is delay the spread of a pandemic generally by week although not by months, and certainly not by years. The restrictions provide a window of opportunity for a country to prepare for dealing with the pandemic. Thus travel restrictions are sensible under certain circumstances, he said, “but my plea to policy makers has been for them to understand exactly how big an effect to expect from the travel restrictions—not very large—and use the time they are buying to do something useful.”

The United States finds itself in a precarious moment, Jha said. There is good news—infections are down about 45 percent over the previous 3 weeks, with the number of new infections in the United States having peaked around January 11. Furthermore, hospitalizations are down, and although the death rate has not yet dropped, it should shortly come down substantially because of the sharp drop in new cases. Vaccinations are also getting under way. So, thanks to the combination of decreasing cases and increasing vaccinations, Jha said he is very optimistic about the future.

The threat on the horizon, however, Jha said, is the appearance of a number of new variants of the COVID virus. Although viruses mutate all the time, he said, most mutations make little difference to how the virus behaves. A mutated virus is referred to as a variant, or a new strain, when it has significant functional differences from the original strain—which may make it more lethal, more contagious, or more likely to escape the body’s immune response—all characteristics of the new variants of COVID-19.

Finding these variants requires more than the current testing methodologies, which identify the presence of the virus but not the fact that it is a variant. Identifying different variants requires genomic sequencing. The United Kingdom has been doing genomic sequencing aggressively—which is why they have identified variants so quickly. The United States has, however, not been conducting much genomic sequencing testing, although there are plans to ramp up efforts in order to better identify new variants and track where they are spreading.

Variants are most likely to arise in places where there are a large number of infections, environments that provide the virus more chances to mutate. Jha noted that a major flaw in the Barrington Declaration, which calls for herd immunity by letting people get infected. By allowing large outbreaks, such a strategy also gives viruses more chances to mutate. Viruses are also more likely to mutate in people with chronic immunodeficiencies or other illnesses, because their bodies are not able to clear the viruses as quickly, allowing the virus more time to reproduce—and occasionally to mutate.

Among the different variants that have been identified, Jha said, currently the most worrisome is the UK variant. It is much more contagious than the original COVID-19 virus, which could be a challenge over the next 6 to 8 weeks. Fortunately, the new variant is no more deadly than the original strain, and is equally susceptible to the existing vaccines. There are still many unknowns about other variants, such as the South Africa and Brazil variants, but Jha said he believes the current vaccines will also provide protection from them. So the future of the pandemic still seems dependent mainly on the success of the vaccine rollout, and Jha said he expected that soon 2 million people a day would be getting vaccines. “By the end of March, early April, if things go well,” he said, “we’re going to have a large, large, large chunk of older people in America, high-risk people in America, vaccinated.”

Internationally, Israel’s vaccination program has been a standout, and the UK is also doing well. Vaccination programs are proceeding much more slowly in Canada and much of Europe; a situation that Jha described as “puzzling.” But still, he said, he expected those countries to pick up momentum in the coming weeks.

Much of the rest of the world remains way behind, and a large percentage of countries have not even started vaccinating. And so, as the pandemic shifts to a chronic phase in the United States, sometime in the summer, the fact that much of the world will remain unvaccinated is a huge problem, Jha said, for two reasons. The first reason concerns equity. Some countries have cornered the market on vaccines and have gotten past the virus, while in most countries, large numbers of people are still getting infected, getting sick, and even dying. This inequity could lead to a great deal of social and political instability and prove challenging in terms of global travel.

Countries where the virus is still rampant could serve as breeding grounds for new variants, and some of these variants might not be so vulnerable to the existing vaccines. Jha said, “and then we could find ourselves at some point again having a population that’s largely vulnerable to these new variants and having to update our vaccines, vaccinate everybody again, and be in this vicious cycle that could last a very, very long time.” The only way to avoid this situation is to have a very aggressive global vaccination strategy. “I am deeply worried that without [a global vaccination strategy], we will continue to see a world where some places are vaccinated, other places are not, and outbreaks will continue to happen,” which would make it difficult to restart the global economy, which will ultimately affect everyone.

In closing, Jha said that the COVID-19 pandemic will eventually come to an end. All pandemics come to an end. But that does not mean that the virus will have completely gone away.” We will be dealing with this virus for many, many years in pockets, little places here and there,” he said, so it will be important to develop a strategy for living in a world with a virus that continues to circulate at low levels, occasionally causing outbreaks and sickens, even kills people. That will be the chronic phase of the pandemic, and, if the vaccinations continue to go well in this country, it should not be too far away. Dealing with the chronic phase, Jha said, will require “a lot of time and effort thinking about how to bolster our information systems, our surveillance systems, and also our leadership and governance infrastructure—all the things that I had personally not paid enough attention to over the years—to make sure the world is much, much better prepared for the next time.”

A VIROLOGIST’S VIEW OF COVID-19

Haseltine offered a different take on the pandemic. As a professor at Harvard University and Harvard School of Public Health, he was deeply involved in fundamental research for cancer, HIV/AIDS, and influenza. He created many biotechnology companies and has been a pioneer in the genomics area, and for the past 15 years, he has headed his own foundation, which advises governments on health system strengthening. China, the Philippines, India, and many other countries are among the clients of the foundation.

The past half a century or so has been a golden era for humanity, he said, in terms of the protection that vaccines have provided against disease. One of the effects has been an enormous explosion in the world’s population, Haseltine said, which has grown from under 2 billion to 7.8 billion people during his lifetime. As a result of the effectiveness of vaccines, he said, people have forgotten about the power of infectious disease. “Infectious diseases are devastating,” he said. “They have, at times, killed two-thirds of a population of Europe and other countries—in the 1300s, wiping out basically most of Europe.”

Living under the protection of vaccines has made people sloppy in the way they deal with infectious diseases, he continued. He remembers a time when he was a child when the threat of the polio virus kept children

restricted in much the same way that the COVID-19 virus does today. “We could only go out in groups of three in the summer, we couldn’t go to swimming pools, we couldn’t go to movie theaters.” That all changed with the development of the polio vaccine. Once the high-income countries were free of polio, the decision was made to remove polio from the poorer countries as well as a way of making sure it could never rise again. First, though, a worldwide effort was launched to eradicate smallpox—an effort that was ultimately successful. Smallpox eradication is an object lesson, Haseltine said. “We got together as a world, vaccinated every possible place where there might be smallpox, and eradicated smallpox from the globe. That’s a lesson we should remember. We can do it.”

The fight against HIV/AIDS has not been as successful, because there has not yet been a vaccine that prevents infection from the virus, although the disease has been mostly tamed through the use of public health measures and highly effective drugs that were developed through an expensive, tightly focused effort. Many people are not aware, Haseltine said, that the United States has been a real leader in the global fight against HIV/AIDS. A program established under George W. Bush, the President’s Emergency Plan for AIDS Relief, or PEPFAR, has saved tens of millions of lives in Africa at a cost of nearly $90 billion.

Turning to COVID, Haseltine echoed Jha in saying that the pandemic did not catch people in the infectious disease community by surprise. Indeed, as early as 1985 in testimony to Congress, Haseltine warned that something of the sort would happen. “Whether it was going to be a coronavirus, I didn’t imagine,” he said. “I thought it might be another 1918 flu or another terrible disease, but the idea that it would be a highly transmissible respiratory disease was clearly in the works.” And after the 9/11 terrorist attacks, a number of groups worked together to develop an infrastructure for creating accelerated responses to biothreats, whether man-made or of natural original. Unfortunately, he said, when COVID appeared in early 2020, no one approached these groups for help in defending against it.

Outside the United States, he said, things developed differently. The SARS pandemic in 2003 had enormous economic consequence, and China, South Korea, Singapore, and other East Asian countries caused the collapse of South Korea’s and Singapore’s export business. China was also worried about the same issue. “So it was a serious issue,” he said, “and I believe the SARS pandemic taught the East Asian countries a lesson; an epidemic is not only a human disaster, but also an economic disaster.” Because the East Asian countries took the threat of an economic disaster very seriously, the region began to prepare for the next pandemic. Among other things, they invited specialists from the Harvard School of Public Health and other institutions to offer advice on how to contain and control viral outbreaks. Representatives visited Harvard every summer to learn how to contain and control a pandemic, and experts from Harvard traveled to China to teach at the Central Party School, to educate the top leadership about issues of how to control a pandemic, he explained. “And it turns out, they learned the lesson,” he further stated.

Sadly, he continued, while China learned and would apply these lessons from Harvard and other Western institutions, the United States did not. In China, after some early mistakes in Wuhan, where the COVID-19 virus first appeared, the public health measures were very effective. The country required that anyone who had COVID symptoms or who had had contact with a person with COVID symptoms had to be isolated for at least 14 days. In some cases, an entire city was locked down under very stringent conditions, which proved to be successful. Haseltine said, “They drove infection to zero. They eliminated COVID from their country.”

Today, the only COVID-19 cases in China are those brought from the outside, and so China has very stringent restrictions on who can come into the country. Not only must a traveler to China have a negative PCR (polymerase chain reaction) test, but he or she also needs a negative IgM (immunoglobulin M) test, which detects the small percentage of people who have tested negative on a PCR test but who can still pass along the COVID virus.

“If we want to eradicate COVID from the world,” Haseltine said, “all countries have to do the same. It takes only one person with COVID to start the whole thing all over again.”

However, he said, knowing what needs to be done and actually doing it are two different things, and he listed a number of factors that can keep a country from taking the necessary steps to control a pandemic.

First is leadership, and the response of U.S. leadership to the COVID-19 pandemic was terrible, Haseltine said. “The fact that we have close to half a million people dead today is almost directly related to the very, very poor leadership,” he said. “There is blood on the hands of our leadership.” It was extremely frustrating for people who knew what needed to be done to watch leaders behaving in ways that leadership knew would end up killing many people.

A second issue is governance. In the United States, the federal government left many decisions and much of the responsibility of responding to the pandemic up to the states. Some “fundamental restructuring” is required in the United States and in other countries, too, he said.

Finally, solidarity is a major factor. China was able to act as one country in responding to COVID-19. The United States can learn from this, he said.

The current administration has good people working on the pandemic, he said, and the vaccination efforts are going well, but that will not be enough to eradicate COVID-19. “Without a tremendous effort on public health to do the very basic blocking and tackling, which we taught other countries how to do, we’re not going to control this pandemic, no matter what vaccines, no matter what drugs we have.” Having worked with countries around the world, he said, his experience is that the solution is not as simple as giving people vaccines and medicine. “We’re not going to eliminate [the pandemic] without many changes in fundamental approaches to public health.”

As an example, Haseltine described how Egypt was able to eliminate its significant problem with hepatitis C. Egypt set up testing centers where people were given finger sticks to see if they had antibodies to the virus. The 4 million people who tested positive were each given a PCR test to verify the result. Those who tested positive were given free drug treatment. “Everyone was treated,” he said. “No more hepatitis C.” In addition, the program was inexpensive—Egypt paid 50 cents for each finger-stick test, $5 for each PCR test, and $35 for the hepatitis C treatment. “So countries can do that with the right organization and the right will,” he said. And they treated prisoners, they treated army officers, they treated everybody with that system. This is the sort of public health system that can really make a difference, he said.

Looking to the future, Haseltine said he is much more pessimistic about COVID-19 than many others in the field, and his pessimism stems from the nature of coronaviruses, the category of viruses that includes COVID-19. Experience with other types of coronaviruses shows that these viruses can come back every year to infect the same people. There are people on record, he said, who have been infected every year for 4 or 5 years in row by the same type of virus.

Haseltine made the point that COVID is comparable to the flu. COVID shares two key features with the flu: immunity created from exposure to the virus fades over time, and variants of the virus appear regularly.

Haseltine went on to point out that vaccination has not eliminated the flu. Every year, the flu kills 20,000–30,000 Americans and hundreds of thousands of people all over the world. Reasoning from that situation, he said, once can predict that until the COVID-19 virus is eliminated from the United States, there will be a recurring COVID problem each winter, like the flu, but COVID-19 is 10 times more lethal than the flu. “Instead of 20,000 people dying, it will be 200,000 Americans dying,” he said.

It may not be that bad, he said, if vaccines and drug treatments can lessen COVID-19 spread and its effects, but “it’s still going to be a war.” Given that vaccines haven’t wiped out flu and anti-flu drugs haven’t eliminated its yearly death toll, he said, the best bet for dealing with COVID-19 is to take public health measures seriously.

Switching to variants, Haseltine discussed the challenge they pose. “Viruses are wily,” he said. “I worked years and years on HIV. I know how tricky viruses can be.” They are constantly changing in ways that allow them to avoid vaccines and the natural immunity that people develop from having infections. Offering some practical advice, he said that even people who have been vaccinated or who have been infected with the COVID-19 virus should take the same precautions they would even if they had not been vaccinated or infected. In short, public health measures will remain important, even with vaccinations.

Addressing the aviation industry, Haseltine said he remains concerned about the risks of flying. To anyone who has to fly, he offers this advice, which is what many people in Asia already do: Put on a hazmat outfit, put on an N95 mask, wear a face shield, put on latex gloves, put on booties, and bring your own food. “That is what safe flying looks like,” he said, “and it’s still not entirely safe.”

He is particularly concerned about the emergence of variants that can get around some of these measures. The virus might evolve, for instance, to become more stable in the air so that it can get past face masks and shields. Or it might evolve to more easily get past people’s immune systems. And it is not clear how well vaccines might protect against variants, he said. Vaccine testing is conducted when the immune response of the vaccine is active, but immunity does not remain at its peak. Immunity degrades over time, and at a certain point the vaccine may stop providing significant protection against variants.

“This is not the world we knew a year ago,” Haseltine said. “It’s a more dangerous world for travel, it’s a more dangerous world for association with friends, and it certainly is a much more dangerous world for getting together.” It is particularly worrisome that the country seems likely to go through a period of what he called “vaccine euphoria” in which people who are vaccinated believe they can do whatever they want. But they cannot—not without taking a risk with their own lives or a risk of infecting others. “That is the sad and hard reality,” he said. “But from my many years of fighting hand to hand with these critters, I can tell you, our future is not going to be without a lot of bumps and lumps.”

SOCIETAL AND POLITICAL ASPECTS OF THE COVID-19 PANDEMIC

Dzau begin his presentation by noting, as Jha had, that the COVID-19 pandemic was not a surprise. In particular, he pointed to the report A World at Risk: Annual Report on Global Preparedness for Health Emergencies,¹ which warned of the threat of rapidly spreading pathogens creating a global pandemic. Many people knew this was a possibility, Dzau said, and despite warnings that such a pandemic could kill millions of people and have trillions of dollars of economic impact, very little action was taken across the world.

Summarizing the current (as of February 3, 2021) situation with the pandemic, Dzau said there had been about 100 million cases globally with about 2 million deaths. “The U.S. leads the charge, I’m afraid to say, by having 26 million cases and 460,000 deaths to date,” he said. Several variants have also appeared, including the U.K. variant, the Brazilian variant, and the South African variant. Already, 70 countries around the world—including the United States—have reports of seeing these variants.

The pandemic is not just a health crisis only, Dzau said. It is an economic crisis, it is a societal crisis, and it is a moral crisis. As of early 2021, 90 percent of countries around the world have seen their health care systems disrupted, resulting in people, particularly in low-income countries, not getting their usual care. Globally there are an estimated 1.6 billion children out of school, with an average of 6 months of learning lost. There has been a 30 percent drop in investments that transition to clean energy. Finally, it is estimated that an additional 150 million people will be pushed into poverty worldwide by 2030.

In its 2020 annual report, the Global Preparedness Monitoring Board (GBMP) listed the following lessons learned from the COVID-19 pandemic,² presented by Dzau on a slide:

• COVID-19 has revealed a collective failure of the world to take pandemic prevention, preparedness, and response seriously and prioritize it accordingly.
• We live in a world where a shock anywhere can become a catastrophe everywhere, which means we are interconnected.
• The impact of COVID-19 is well beyond health.
• The human dimension of preparedness has been overlooked. Responsible leadership matters most, and citizens have a critical role to play.
• Current measures of preparedness are not predictive.
• Health emergency preparedness requires effective, agile systems.
• No one is safe until all are safe: Global preparedness is not simply the sum of national preparedness, and the world of pandemic preparedness needs consolidation, not further fragmentation.
• The return on investment for global health security is immense.

Recently Schmidt’s Futures, a philanthropic organization, funded a study comparing how 23 nations responded to the COVID-19 pandemic, looking for the factors that influenced how well they responded. One lesson, Dzau said, was that the politics of implementing measures, not the soundness of the policies, were most responsible for the outcomes. Another lesson was that leaders must weigh the complex political, economic, and public health

___________________

¹ Global Preparedness Monitoring Board (GPMB), 2019, A World at Risk: Annual Report on Global Preparedness for Health Emergencies, Geneva: World Health Organization.

² GPMB, 2020, A World in Disorder: Global Preparedness Monitoring Board Annual Report 2020, Geneva: World Health Organization.

trade-offs as they craft response actions in their local contexts. The GPMB study group defined three broad categories of responses to the pandemic across the 23 countries—control countries (e.g., Taiwan, China, South Korea, and Singapore), consensus countries (Germany, Austria, Japan, and Sweden), and chaos countries (the United States, Brazil, India, and the United Kingdom). One of the most important “pre-existing conditions” shaping the pandemic response, the researchers found, was the country’s level of trust, cohesion, and solidarity. It doesn’t matter whether the solidarity and cohesion come from a more authoritarian, top-down force (as in China) or from trust and idealism in a democratic government (e.g., Germany), the cohesion in a society was vitally important in shaping the country’s response.

Overall, Dzau said, there are three conditions required for success in responding to such a pandemic. One is the presence of social trust, cohesion, and solidarity. A second, previously described in a 2020 paper in The Lancet co-authored by Dzau, is the existence of a coordinated national strategy in which there is trust.³ And third, an effective global collective response is absolutely necessary for stopping the pandemic. Without a coordinated global response, variants can develop in one part of the world that could then affect people in other parts of the world, potentially even those who have been vaccinated.

Judging from those necessary conditions, Dzau said, the United States failed in its response to the pandemic. For example, there was no strong, coordinated federal response; by contrast, the Trump Administration delegated to the states the primary responsibility for dealing with the pandemic. In addition, public health measures were politicized, and a false dichotomy between the economy and public health was promoted. Overall, there was a lack of responsible citizenship, with individualism seen as being in conflict with social and moral responsibility and the public good. Finally, despite the necessity for a coordinated international pandemic response, the United States withdrew from the World Health Organization, and it proceeded to secure vaccines for its own citizens without regard for global equity.

One major issue for the U.S. response was the lack of a national strategy and coordination, Dzau said. Because there was no public health mandate and, even more concerning, inconsistent messaging—for example, there was extreme variation about mask wearing from state to state on public participation in a basic non-pharmaceutical intervention. Furthermore, guidance regularly changed about who should get tested, and there was slow and inconsistent implementation of widespread testing. Initially, there were widespread shortages of personal protective equipment and ventilators because the Trump Administration failed to immediately invoke the Defense Production Act. The lack of guidance resulted in the use of various of new therapeutics without sufficient data (e.g., remdesivir) across the country. The vaccine response had some bright spots—there was a record-setting pace to develop, study, and approve vaccines—but there were challenges with supply, distribution, and administration.

Among the challenges regarding vaccine distribution, Dzau said, was the unequal provision of the vaccine, with communities of color receiving proportionally far fewer COVID-19 vaccinations than white counterparts, despite the fact that members of disadvantaged minorities are at much higher risk than whites of serious complications of the virus.

Another issue related to the U.S. response to the pandemic has been the distribution and use of monoclonal antibodies, an effective treatment for many COVID-19 patients. Initially, Dzau said, there was a shortage in the availability of monoclonal antibody treatments, but more recently the problem has been that not enough patients who could benefit from the treatment are getting it, even though there is currently an oversupply of the drugs. The current problem is the lack of clear guidance as to which patients can benefit from monoclonal antibodies and then dealing with complex logistical challenges to provide the drug, which is given intravenously in an outpatient setting.

The good news, Dzau said, is that the Biden Administration does have a well thought out plan for dealing with the pandemic—including rejoining the World Health Organization, restoring U.S. leadership globally, and building better preparedness for future threats.

Dzua stated that the global response to the pandemic has also been messy without a global strategy and coordination and an international entity to oversee the response. While WHO aided member states with their individual responses, a lack of funding and various political constraints hindered its ability to respond to the pandemic. The

___________________

³ V.J. Dzau and C. Balatbat, 2020, Strategy, coordinated implementation, and sustainable financing needed for COVID-19 innovations, Lancet 396(10261):1469–1471.

global research and development system is fragmented and poorly coordinated, with no single entity that can integrate efforts and results. This is exacerbated by widespread nationalism, driving every nation to turn inward to address the problem. Ultimately, he said, until everyone comes together to address global equity and access, there cannot be an effective global response to a pandemic.

Fortunately, Dzau said, there is an ongoing effort to create such a global response. It began in a meeting in March 2020 called by the GPMB and was attended by representatives from a number of international organizations, including WHO, the Coalition for Epidemic Preparedness Innovations, the vaccine alliance Gavi, the Bill and Melinda Gates Foundation, and others who have interests in public health. The goal of the meeting was to encourage global leaders to unite in order to ensure that everyone, everywhere can access new vaccines, tests, and treatments for COVID-19. The meeting led to the creation of the Access to COVID-19 Tools (ACT) Accelerator, or ACT-A, which is governed by the G-20 countries. ACT-A has a three-pronged approach to address the pandemic globally: a vaccine partnership called COVAX, a therapeutic partnership, and a diagnostics partnership. ACT-A plans to provide 500 million tests and 245 million courses of therapeutics by the middle of 2021 and 2 billion vaccines by the end of 2021.

One problem that COVAX addressed is the tendency of high-income countries to get a huge percentage of available vaccines. COVAX’s approach to mitigate this disparity is to pool financial resources from many countries fund vaccine development, purchase them at scale, and invest up-front in manufacturing so that vaccines are ready to be distributed as soon as they are licensed. This scheme allows all countries to have access to vaccines regardless of their relative financial situation.

ACT-A priorities for 2021 are being driven by three factors, Dzau said. First, vaccine demand is high. The second is the existence of continual viral mutations and subsequent differences in countries’ responses to those variants. Third, there is under-investment in global solutions and an increasing number of bilateral deals.

ACT-A still needs about $27 billion to reach its goals, but that will not come close to providing everything that is needed around the world, Dzau said. It would require an additional $30 billion to provide 20 to 80 percent vaccine coverage in low- and lower-middle-income countries to provide testing in those countries at 90 percent of the testing rate in high-income countries, and to cover treatment in proportion to testing. “So we really need a sustainable financing mechanism in order to have enough for everybody,” he said.

Making the case for investing in such efforts, Dzau said that the G-20 countries have provided about $13 trillion in funding to support their businesses and economies. If the countries of the G-20 were to invest $27 billion to help ACT-A reach its goal, it would result in more than $466 billion in economic benefits over the next 5 years. Ultimately, though, there is a need for long-term, sustainable financing so that countries and international agencies do not have to seek funding in the middle of the next pandemic.

In addition to obtaining sufficient financing, global vaccination efforts face a number of other challenges, Dzau said. A major challenge is ensuring equitable distribution of vaccines worldwide. To date, he said, more than 7 billion vaccine doses have been purchased—more than 4.1 billion by high-income countries, over 1.2 billion by upper-middle-income countries, 500 million by lower-middle-income countries, and over 1 billion by COVAX, most of which are going to lower-middle-income and low-income countries. In short, high-income and upper-middle-income countries are acquiring most of the vaccines. Even among those countries backing COVAX, standard practice is for countries to sign bilateral deals in order to ensure that their own populations have access to the vaccines. Some high-income countries, such as Canada, even ended up with far more vaccines than they needed. This vaccine nationalism—or “vaccine apartheid,” as Dzau said that some have called it—leads to the unequal distribution of COVID-19 and, according to a RAND study,⁴ could cost the global economy as much as $1.2 trillion a year in lower gross domestic products because of delays in eradicating the virus globally.

The global distribution of vaccines has a variety of logistical challenges as well. Distribution systems are not well developed in many low-income and lower-middle-income countries, so it is often difficult to get vaccines from the port of entry to the health care providers. In addition, many countries have a dearth of the sort of storage facilities required for vaccines; the Pfizer vaccine must be stored at −70°C, for example. WHO has estimated that

___________________

⁴ M. Hafner, E. Yerushalmi, C. Fays, E. Dufresne, and C. Van Stolk, 2020, COVID-19 and the Cost of Vaccine Nationalism, Santa Monica, CA: RAND Corporation, https://www.rand.org/pubs/research_reports/RRA769-1.html.

up to half of all vaccines worldwide have the potential to be wasted because of logistics and storage challenges. Even once the vaccines have been distributed, many countries do not have a health care workforce sufficient to apply them.

The GPMB’s 2020 annual report offered recommendations for strengthening the global response to COVID-19 and better preparing the world for future pandemics and other health emergencies. The recommendations fell into the following five areas: responsible leadership, engaged citizenship, strong and agile systems for health security, robust global governance of preparedness, and sustained investment.

The National Academies of Sciences, Engineering, and Medicine are also involved in addressing these issues, Dzau said, and he listed several projects that the National Academies are currently implementing. One focuses on a sustainable global financing system prioritizing the global common good for pandemic prevention, preparedness, and response, for example, and another to establish an early warning surveillance systems for zoonotic viruses of pandemic potential.

In closing, Dzau offered the following lessons learned from the current pandemic: a need for strategy and coordination in public health interventions at national and global levels; a need for a coordinated end-to-end research-and-development system for vaccines, diagnostics, and therapeutics; a need for a multilateral approach with all countries working together; a need to ensure global equity, which is only possible with solidarity; and a need for sustainable financing to ensure pandemic prevention, preparedness, and response at a global level.