Book Event: Lawrence O. Gostin’s “Global Health Security: A Blueprint for the Future”

J. Stephen Morrison: Welcome to the Center for Strategic and International Studies, CSIS, in Washington, D.C. I’m J. Stephen Morrison, senior vice president here where I direct the Global Health Policy Center. We’re thrilled and honored today to host Lawrence O. Gostin – Larry Gostin, as we all know him – a close friend and colleague, to discuss his newly published and exciting book, “Global Health Security: A Blueprint For the Future,” published just this week, I believe, by Harvard University Press.

Congratulations, Larry.

Larry Gostin: Thank you, Steve.

Dr. Morrison: The book arrives amidst the launch of several other very promising and important books on the pandemic, what happened, and what the future may look like. Something simply as big, complex, and profound as a pandemic spurs big minds to turn to books, to put light, to cast light on what’s happened, what we continue to experience, and what the future holds. So today’s part of a series, really. July 7th we hosted Yasmeen Abutaleb and Damian Paletta from The Washington Post to talk about their book, “Nightmare Scenario: Inside the Trump Administration’s Response to the Pandemic That Changed the World.” And our session today falls just one week before we host, Andrew and I host Leana Wen on our podcast series, “Coronavirus Crisis Update,” to discuss her personal memoir, “Lifelines: A Doctor’s Journey in the Fight for Public Health.” There are other books, important books we’ve heard about – Andy Slavitt’s “Preventable,” Scott Gottlieb’s “Uncontrolled Spread,” and several others.

I want to offer a special thanks to the staff at CSIS who’ve made this program possible at the Global Health Policy Center. Special thanks to Mackenzie Burke, along with Humzah Khan, Michaela Simoneau, and from our production team, Dhanesh Mahtani, Mary Wright, and Margaret Rogers.

This afternoon we’ll be having a conversation. I’ll say a bit more about that. The conversation’s going to be among Larry Gostin and my close colleague and friend Andrew Schwartz, chief communications officer here at CSIS.

Let me turn now to Andrew to introduce Larry.

H. Andrew Schwartz: Thanks, Steve.

And as you all know, Steve and I have had a lot of practice co-hosting because we host the “Coronavirus Crisis Update” podcast together, which Larry has graciously been on recently. Our podcast, we’ve done well over a hundred episodes since we started. I don’t think we thought, or we hoped that we wouldn’t be in a “crisis update” for so long but events have found us where we are where we are.

I’m thrilled today to have Larry Gostin with us. I first learned about Larry Gostin because he was a really good friend of my parents, and my mom, Dr. Shirley Schwartz, and my father, Dr. Joseph Schwartz, socialized with Larry. And my mom had this way of talking about people that she really liked and she would always recommend them to me, and she would say, you know, Andrew, Larry’s a really neat guy; you need to meet Larry because he’s a neat guy. And my mom reserved that for the people she thought were the smartest people in the world that she had ever met.

And Larry, you certainly fall into that category.

Mr. Gostin: Well, you know, you might not know, Andrew, but Shirley used to say that you were very special and I had to meet you.

Mr. Schwartz: Well, she – I’ve always been a mama’s boy, that’s for sure. And, you know, I’m sitting here – my mom passed away but I’m sitting here remembering her and this is really special for me to have Larry with us.

Larry Gostin, of course, is university professor and director of the O’Neill Institute for National and Global Health Law at Georgetown University, at Georgetown Law. He is the university professor, Georgetown University’s highest academic rank, and he’s the founding O’Neill chair in global health law. Larry directs the World Health Organization Center on National and Global Health Law, and he’s a professor of medicine at Georgetown and professor of public health at Johns Hopkins University. I could go on, but I think all of you who are tuning in today and all of you who are here with us in the room know the many things that Larry’s done, including this latest book which is really fantastic.

Steve, did you want to start with a question? Because I know we have a lot to get through with Larry today.

Dr. Morrison: Yes. Thank you. Thank you, Andrew.

Welcome, Larry.

We’re going to have this conversation for the next 30 minutes or so and then we’re going to open things up. We have several terrific experts and friends with us today in our audience and I’m hoping that we will hear from you in terms of your comments and remarks. The microphone right there; please step there when we get to that part of the program. We’re going to cover a lot of ground in sort of rapid fire. It’s meant to be a conversation.

So, Larry, first conversation: I mentioned in my opening remarks there’s been a steady proliferation of books on the COVID-19 pandemic. How do we make sense of what happened and continue to see – and how do we think strategically about the future?

So, your book: What sets it apart? Tell us what sets it apart –

Mr. Gostin: OK. I’ll be happy to.

Dr. Morrison: How do you want it to be remembered, and who do you want to read it?

Mr. Gostin: Yeah. Well, first of all, Steve, I want to thank you and Andrew and CSIS. You know, you and I go back many epidemics – (laughs) – too many to even mention right now. And, you know, I’ve just been such an admirer of yours for a long, long time.

You know, my book actually is very different from all the others. The main thing is that I actually started the book six years ago, way before COVID-19, and the idea that I presented in the book and the thesis is that, you know, there will be a pandemic and this is how we can prevent it; I’m giving you a blueprint. Of course – (laughs) – the pandemic happened; it was worse than any of our nightmares, and of course, it’s ongoing, particularly in low- and middle-income countries. And so, you know, my book is about COVID because it talks about the failed response to COVID, but it really looks at the vulnerability of global – national and global health security writ large. And it does provide a blueprint of – if you really want to secure ourselves, our nation, our world from, you know, horrible infectious diseases, this is how you do it. And it includes things that have really gotten off the radar but we need to return to, like antimicrobial resistance, mosquito-borne illness. We just saw the WHO approval of the malaria vaccine yesterday, and it’s just so many other areas that we’ve forgotten. And so it talks about how to prevent zoonotic spillovers, talks about biosecurity and lab leaks and bioterrorism, the intentional release of dangerous pathogens. And I hope the book gets attention now more than ever because, you know, truly we underappreciated Mother Nature. She threw at us a virus that was so wily that nothing could stop it. We tried to mask, we tried to distance, and it kept roaring back. We even locked down whole cities and it roared back. But one nice – more than nice – just miraculous thing is that science became a formidable opponent to SARS-CoV-2 in terms of the vaccine. And now we’re in a race to vaccinate the world, but we’re going awfully, awfully slow.

Dr. Morrison: So there’s a number of issues embedded in that which we can pick out. I want to just race ahead on the blueprint. What are the three or four top-line points in the blueprint on what you want to say to a policymaker in the executive or Congress or somewhere else who’s thinking about, OK, this needs to be – I’m going to pick up this book; it says it’s a blueprint. What are the top-line items?

Mr. Gostin: Yeah. So, you know, let me start by telling you the book’s thesis, which is is that we lurch from complacency to panic and back to complacency. And we just reflected deeply as a nation on 9/11, but from a public health point of view, this week is an anniversary that’s even more important, which was the anthrax attacks. I’ve got a journal article coming out on this which basically shows how the United States really beefed up its preparedness after 9/11 and the anthrax attacks, and it worked well during influenza H1N1 and then came Ebola, Zika, and COVID. And we basically hollowed out our public health system. We hollowed it out by reducing considerably emergency funding for planning for health emergencies. We hollowed out the public health workforce in the United States. We devalued and weakened global institutions like the World Health Organization. And we ended up ill-prepared.

So, you know, what do we need to do? Some of it, as Andrew and I were talking about earlier, before the cameras went on, are really quite simple but they take some political commitment. One is to transform our health systems, build up our core capacities for surveillance, laboratories –

Dr. Morrison: So face up to the reality of a hollowed-out public health system.

Mr. Gostin: Yeah. Face up to that reality. Invest in research and development to get even better quicker than we did now with platforms. You know, the mRNA platform is a really good example of that. And you know, we were on Ebola commissions that talked in very precise terms about how you would need to do that. And then deal with things like preventing zoonotic spillovers, which are really about 70 percent of novel diseases. This is going to take kind of a one-health approach. I mean, we have to focus on wet markets, on intense animal-human interchange. We have to think about land deforestation. And then we also have to secure our high-security laboratories. We need to have in place better global protection against gain-of-function research. And I could go on and on. Antimicrobial resistance would be one of my top – because before COVID, this was widely thought in our community to be the greatest existential threat, so if you can imagine that if we have really novel infections or even standard infections like AIDS, tuberculosis, malaria, and they become resistant to our treatments in what bad shape we’d be, or if we go into a hospital and we get a strep infection and we can’t cure it.

Mr. Schwartz: Larry, you just said something that really stands out to me, and especially where we are now with the COVID disease. You mentioned Americans going in and out of complacency, and people in other countries as well, but certainly here. We now seem like the Delta variant is receding; there’s some evidence of that. And people are really quick to want to get back to normal. People have had it with wearing masks. They don’t like distancing. We’re, you know, we’re very social people in this country; we like to be together; we like to go to ball games together; we like to go to concerts together. We see signs of this receding now, but of course, if we go back to our behavior, where we’re acting like we’re done with this, we run the risk of it roaring back. Where do you think we are?

Mr. Gostin: You know, we’re in certainly a lot better shape than most of the rest of the world now because we’re gaining in our vaccination rates.

Mr. Schwartz: We still have 67 (million), 70 million people in America unvaccinated.

Mr. Gostin: They are. And, you know, and I’ve been talking to policymakers in the White House and others about, you know, where we’re headed and I think President Biden’s vaccination mandates are going to start to grip. They’ll grip once OSHA comes out with this emergency temporary standard for mandatory vaccinations and large businesses. But we’re already seeing cities, states, large and small businesses starting to do vaccine mandates along with places like universities. California’s announced a mandate for schools, and FDA is suing to have a 5-to-12 authorization. And so I think we’re headed in the right direction, but we know, without any doubt, that – two things, that, one, is that once we let our guard down it surges and that we need layered protection until we’re really safe.

And the other that we know is that so long as SARS-CoV-2 is widely circulating, almost unchecked in other parts of the world, that even more dangerous variants could travel to the United States. And so I think our, you know, our job really is to focus on vaccinations here in the United States, to get extraordinarily high levels of vaccine coverage, doing whatever it takes to get there, but also globally. I’ve been – I organized an open letter to President Biden and the White House and senior congressional leaders just this week really talking about transferring technology and other mechanisms for boosting global vaccination coverage. And The Washington Post today reported and commented on it, was Moderna agreeing to set up a factory in Africa. The problem is that it won’t be up and running for two years. It won’t do as much good. But the bigger problem is that we just rely too much on charitable donations.

You know, basically – and you’ll remember this, Steve, with influenza H1N1 and even President Obama – you know, basically we keep the medical resources for ourselves; once we feel comfortable we start to donate them. Donations always come too little and in insufficient supply. And we don’t want beneficence; we want countries to be able to produce their own medical resources, diagnostics, treatments, and vaccines. And that’s got to be one of the key linchpins to preventing this scenario and also preventing the huge inequalities that we’ve seen, which I think is really the prevailing narrative of COVID-19, are these massive inequalities.

Mr. Schwartz: Now, that ties in really well with my next question because there is an awful lot of confusion in this country about boosters, and just about everybody I know, whether it’s my parents, my parents’ friends, young people at CSIS, on college campuses, my students at Tulane University, they’re confused about the efficacy of boosters and whether they should get a booster now, whether they should wait. For some of them it’s a decision that they’re making based on actual global health; they’re even thinking, well, I don’t want to get a booster because it would take away from somebody in a poorer country. There’s so much disinformation – and misinformation about this, also – that is swirling around it. So what do you think about the communication efforts on boosters as we see them now? And how can we do better?

Mr. Gostin: You know, I’ve always thought that CDC was the shining star of the federal agencies and it’s the envy of the world. But our health communication has been, frankly, pitiful in so many different areas. We’ve seen different views from U.S. federal agencies, you know, from FDA, from CDC, and the White House. We’ve seen a divergence between WHO and CDC. That’s generally, but with boosters, it’s been worse. You know, basically the White House got it out in front of career scientists at the CDC and the FDA. They announced it, even though they had a “P.S.” to say of course it requires CDC, FDA approval. Then, you know, and the head of CDC, the head of FDA joined with Joe Biden in this, even though they didn’t have – (laughs) – a career scientist on board then. We knew it was going to get a rocky ride. Then FDA advisers made one recommendation, CDC advisers made another recommendation, and then Rochelle Walensky, the director of CDC, overrode her. That’s not a way for clarity.

Mr. Schwartz: I mean, think of it this way: If we were fighting a war and we had different messages coming from one agency or another, think about how confused that would be, and we really are at war with this disease.

Mr. Gostin: The public is utterly confused. And it goes back, you know, with differing views about masks, about aerosolized spread, and so much more, and sometimes, you know, agency heads or agencies themselves say things that you just – you want to shake your head and say, did you, you know, say that, particularly, you know, about what vaccinated people could and couldn't do.

Mr. Schwartz: Sure.

Mr. Gostin: And there were three CDC guidelines on that within a couple of months, just kind of bouncing back and forth, and that’s – you know, we need to get better at our health communication and we absolutely – it’s vital to just gain the public’s trust. One of things we’re finding out is that even with all the science, with all the public health and the public health measures, you know, unless you can get the community to adopt their behavior and trust public health, we’re doomed to failure until you get, you know, a vaccine on a white horse. But we can’t always rely on that.

Dr. Morrison: Larry, this conversation leads also to sort of the recognition that a year into this administration and, you know, the move towards the six-point plan and a focus on mandates, patience has run out; there’s a – leaning towards a more coercive approach. We’re forced to recognize that as a country the effort to bring the temperature down and to take some of the politics out of the response has not been very successful. We remain – if you look at the confrontations of the governors from Florida, Texas, Arizona, Idaho, places that are really lit up right now, the partisanship and the politicization around vaccines, vaccine mandates, masks, social distancing, restricting large gatherings, it’s hardened up. I mean, it’s hardened up and we haven’t been able to transcend partisanship. We haven’t been able to transcend the drive towards politicization. We remain a very divided country in a sort of dangerous way, despite the best efforts to figure out a way forward on this. How did we wind up in this place, do you think?

Mr. Gostin: Well, I think it’s no secret that, you know, America’s in a mess; it’s not just in public health. I mean, we are such a divided and, in some ways, you know, dysfunctional – you could see that with the debt ceiling and a whole range of things that are going on right now. But it really does dismay me and it does you and our other colleagues to see that kind of basic science and public health has a political lens. And you see it with, you know, masks, lockdowns, business closures, and of course now with vaccines. Now, I think part of the problem is, you know, the idea that we’ve tried to blame and shame people who are unvaccinated. I don’t believe in that, and I don’t believe in taking away their health care insurance or anything like that, because, you know, many of them are sincere, decent human beings that are trying to make the best judgment within incomplete information. But the truth is that I do support mandates and I think that if we see mandates as just utilizing a neutral scientific tool, vaccines, we want to save you no matter where you – who you are or what your beliefs are. And if we see it as a kind of return to a tradition in America of, you know, looking after your neighbor, your family, your community, your nation, your world – in other words, the common good – we have to somehow get back to that. We’ve got to this stage where, you know, it’s all about, what are my rights? What do I – why is my voice not prominent and definitive, when we have to start thinking more like a community. How we get there is really hard.

I have to say, I think mandates do work and over time they will make vaccines become the norm and the default, easier options, and once that happens a lot of the opposition is going to melt away over time, at least – and that’s been demonstrated. Even in France with Emmanuel Macron’s “pass sanitaire,” remember, there were protests in the streets, but within days of him making the announcement, 3 (million) or 4 million additional people got vaccinated. And we’re seeing the same thing happen in the United States. Our vaccine rates are actually starting to rebound.

Dr. Morrison: OK. Let’s shift to some of the international issues. There’s a lot of talk today and your book addresses these issues around global governance, around global architecture. To many people who are not experts in this field, this strikes them as somewhat confusing rhetoric, because for many of us, I think, it’s pretty obvious how ill-prepared we were and how chaotic the response has been. And when you look at the world and you look at the response, the U.S.-China confrontation has dominated and become a major barrier in getting an international response. Alliances have frayed. Multilateralism has frayed. Nationalism has dominated. We’ve had the recent U.S.-led summit, which was an effort at reigniting high-level diplomacy and summitry. But it’s really come up against all of these realities and it’s raised the question of, how do you get – how do you reignite U.S. leadership and engagement in this world? You’ve been a great advocate of WHO, WHO reform, of not losing sight of its central importance, but also acknowledging its weaknesses and the like. So part of this question of global governance is how to bring about a renewal of summitry and U.S. leadership in this current world. How do you bring the Chinese in? How do you restore the WHO to be viable in this period? We now have a sexual abuse scandal that’s upon us that’s going to further complicate the question of WHO’s role. These are all big questions. What are your thoughts on what we should be most focused on when we’re talking about global governance and institutions?

Mr. Gostin: Wow, you’ve asked so many important questions there, Steve. I mean, let’s start with U.S. leadership. Well, perhaps we should start with China and the U.S.; really, that has to be sorted out. We are the two greatest superpowers. And it was sad beyond belief to see WHO caught in the middle of a superpower struggle with the United States announcing its withdrawal from WHO and China coming before the World Health Assembly in a pandemic, you know, praising WHO. That was completely – (laughs) – backward. And so that dynamic has to change. In terms of U.S. leadership, we absolutely require U.S. leadership now more than we ever have before. We need something big and bold. If you think about the most beautiful days of the United States in relation to global health, immediately George Bush’s PEPFAR comes to mind, our support of the Global Fund comes to mind, and, frankly, our Ebola response in West Africa. Even though we were late, the United States finally, after the CDC predicted, if unchecked, over a million infections in West Africa, President Obama got an emergency authorization; he sent in the military to Liberia. Our partners in France and the U.K. sent the military into their closest allies in the West African region. And we turned it around. We absolutely were able to turn it around.

Right now, I think the U.S. needs a new paradigm. As I’ve indicated before, I think the days of us being the charitable benefactor have to be gone. We have to lead so that low- and middle-income countries have the resilience to be able to meet pandemics or novel outbreaks on their own terms and not wait for the cavalry to come in, led by the United States. So I think that’s an old model. And I think even Moderna has been very, very resistant to White House pressure. They’ve announced today that they’re going to open up something in Africa, but it’s still under this kind of beneficence model, so I’d like to see Biden lead on technology transfer and to invest there in Africa, India, and other areas.

Dr. Morrison: That implies the U.S. using its muscle –

Mr. Gostin: It has to.

Dr. Morrison: – against the corporate players in a much more systematic and serious way. Right?

Mr. Gostin: It does. Yeah. And I had an op-ed in The Washington Post recently saying exactly how President Biden could do that with the Defense Production Act, where he’s got ample authority under that act to require companies to sign technology-transfer agreements with reasonable compensation, which the United States could provide. I think he could do that.

But ethically, I think he’s on strong ethical and political grounds to do it because Pfizer and Moderna didn’t just wake up one morning and have a miraculous vaccine. First of all, there’s been a decade of NIH basic funding for mRNA technology platforms. Secondly, Moderna got a whole lot of money from Operation Warp Speed. Thirdly, both Pfizer and Moderna got premium prices with pre-purchase agreements from the United States and NIH owns some of the patents. And so we do have a lot of leverage. We should use it.

Dr. Morrison: We haven’t – we’ve been pretty reluctant to use it on the international side, right. I mean, when you look at the widening vaccine gap even as production has ramped up – we’re now producing a billion and a half quality Western vaccines per month but the gap has actually worsened in the last –

Mr. Gostin: Yeah.

Dr. Morrison: – in recent months.

Mr. Gostin: It is, and that’s why I think that, you know, going forward, we have to enable kind of huge vaccine producers like the Serum Institute of India, which are highly capable, and we have this view that, well, how could somebody in India or Africa produce a messenger RNA vaccine? They just don’t have the technology.

But they can. They have a really good scientific track record. They want to do it, and even our partners like Japan is wanting to get that technology and produce it for the Asian region.

So there are ways that we can actually ramp up vaccinations globally now but also to kind of harden our defenses in the future when the next outbreak comes. We don’t want to just repeat what’s happened here. So it is within President Biden’s tools.

I just want to say one thing about the World Health Organization. You know, if there wasn’t one, we would create it. And I know all of the flaws and the errors that WHO has made. But, nonetheless, they are really vital.

I think Tedros has been a moral voice of conscience in terms of vaccine equity, and we’ve seen – you know, WHO has faltered in relation to a big pandemic as countries have really asserted their own sovereignty and just refused to kind of play in the global space and with mutual solidarity.

But if you look at how WHO operates, you know, when outbreaks occur like with Ebola or Zika or other outbreaks, that they’re actually right there on the ground and we need them. And so I would absolutely strengthen WHO’s powers. I support the pandemic treaty that our European partners are pushing for.

I have, really, ideas. The O’Neill Institute at Georgetown is actually hosting a Foundation for National Institutes of Health-funded project to support WHO and partners in terms of a pandemic treaty. And there are a lot of powers we can give WHO and also would give them the kind of funding so they’re really not operating along the budget of the size of, say, one large U.S. teaching hospital.

Dr. Morrison: Andrew?

Mr. Schwartz: Larry, you and Steve have both talked about the U.S. needing a new paradigm for dealing with this. President Biden pretty famously said at the U.N. General Assembly several weeks ago that he does not want to get into and we will not get into a cold war with China.

Mr. Gostin: Yeah.

Mr. Schwartz: But it seems like we’re drifting towards that in any case. So what does a cold war with China – between the United States and China – do to the future of cooperation in this space?

Mr. Gostin: Well, of course, the problem there is as long as there’s distrust between the two governments, and the sad thing for me, because I have such close ties to China and I’ve been there so many times – very close colleagues and dear friends, actually – you know, there’s also a toxicity among people to people because governments are fueling that kind of rhetoric.

So, of course, it impedes our idea of globalization, of free trade. But beyond that, the really hard questions we need China for – for WHO reform, for a pandemic treaty – we need China to help us with antimicrobial resistance because they are one of the, you know, major global players in the global pharmaceutical supply chain.

We need them for climate change, for regulation of wet markets and live animal trade. Nothing can happen unless the United States and China start to cooperate, you know. And, of course, you know, we have genuine disagreements, you know, with the Uighurs and others. It’s just, in my mind, from a human rights point of view, intolerable.

But we absolutely have to cooperate on the existential issues that are facing the world where there are several, they’re pressing, and there’s no time to lose. And, of course, what we need to see is Xi Jinping and President Biden get in a room and hammer it out and we need a blueprint, a strategy, for how we’re going to tackle all of the areas we agree on and we disagree on.

Mr. Schwartz: Well, I mean, one of the few things that’s agreed upon in Washington is that both Democrats and Republicans both have a disdain for China.

Mr. Gostin: They do.

Mr. Schwartz: And, you know, it’s become a bipartisan value even though it’s also a political piece of polarization and we, certainly, know that in the next presidential campaign there’ll be – you know, both candidates on both sides will be trying to show how tough they are on China. We, clearly, just got into a nuclear sub deal with Australia and the U.K. to try to curb China’s behavior – not contain China, but to curb China’s behavior.

How do we put all that aside and work within the medical community to prepare for the next pandemic?

Mr. Gostin: Yeah. Well, interestingly, and I mentioned the – our hosting the regional consultations in support of WHO for the pandemic treaty – the Foundation for the National Institutes of Health wanted front and center to have international open scientific exchange as part of that.

And, in fact, in JAMA recently we have companion articles. Secretary Becerra and Secretary Blinken wrote an article where they also highlighted the importance of this kind of open scientific cooperation as well as getting genomic sequencing data to be shared, virion pathogen samples, which China has, frankly, not been good on, not just for this but for SARS and for novel influenzas.

So we need to – there’s so much that we can do cooperatively to try to, you know, make us more resilient in this world. It just seems so obvious to any thoughtful person what we need to do whether it’s climate change or wet market regulation or AMR, whatever the issue might be. Why don’t we do it?

Dr. Morrison: Larry, first of all, I want to invite our friends in the audience to come forward and offer remarks and comments. We want to bring you into this conversation. We’ve reached a good point in our program here. So please come forward. There’s a microphone there. Queue up and we’ll come to you.

On this last discussion point around China, I just want to add, you know, we are in a stalemate right now around the COVID origin controversy.

Mr. Gostin: We are.

Dr. Morrison: And no clear path out of that, and that’s become an enormous barrier politically, psychologically, institutionally, freezing the ability to move forward on all these other areas. And so at some point, I do want you to offer us some clues. Maybe it comes down to appealing to Xi Jinping and President Biden to walk back somehow.

Mr. Gostin: I absolutely have ideas on the origins.

Dr. Morrison: OK. So we’ll get back to that. But I want to hear from our audience members.

Mr. Gostin: OK.

Dr. Morrison: Please introduce yourself. Thank you for joining us, and we’ll move through a few in a bunch. Thank you.

Q: Hi, Dr. Gostin. Good to see you. I’m Chris Collins. I’m with Friends of the Global Fight Against AIDS, TB, and Malaria, and I just finished your book last night.

Mr. Gostin: Thank you.

Q: So I really, really enjoyed it a lot.

Mr. Gostin: Thanks.

Q: And I was really pleased that you called out a couple things that you don’t always hear when people talk about health security, which is universal health coverage – UHC – and the foundational importance of health systems themselves, and I thought that was great and one of the contributions of the book.

But let’s be honest that our policy and politics, we have trouble talking about those things in terms of the way we do international – the way we fund global health. You know, talking about funding health systems hasn’t been something that lawmakers have wanted to do a lot. UHC hasn’t been on the table, really, in terms of the U.S. conversation, in terms of where we’re trying to go globally.

So what are your thoughts about these two things that you’ve raised as really essential in health security? How do we inject that more into the political conversation? What is the policy action step on that? Obviously, I think, you know, the Global Fund is the biggest funder of health systems in the world and it really stepped up to the plate for COVID-19. I think it has a big role.

But what’s the policy action to take on pursuing the health systems and UHC side of global health security? And the one last thing I would say is, I encourage you to write about it because you’ve written this book. We all know you. You know, you’re a trusted expert. Would love to see you – something in the Washington Post on that issue.

Mr. Gostin: Great. Steve, did you want me to answer after each person?

Dr. Morrison: Yeah. Why don’t we go ahead?

Mr. Gostin: Just, you know, quickly. Of course, you’ve really – you’ve really nailed it. If there were one thing we would need to do would be to develop, you know, core health system capacities. The International Health Regulations actually requires it now but there’s huge noncompliance. We never did talk about the IHR. We probably should have but there’s no time.

And so there are things we can do. One of the ideas, of course, is that there’s noncompliance with the IHR core capacities but there is an article in the International Health Regulations that calls on countries – rich countries – to help fund robust health systems and core health system capacities. But it’s not been complied with. And I’m part of a global health law consortium. We’ve recommended ways to get around that.

I recently talked to a very senior USG official and I think their view is that they’re open to the idea of renegotiating the International Health Regulations. That would actually be front and center for me.

But, politically, you know, we have been, as a global community but particularly the United States, very focused on siloed international assistance, you know, whether it’s for AIDS, TB, malaria, or child-maternal health, or women’s health. These are all extraordinarily important points. But you help all of those issues, but much more if you have horizontal strengthening of health systems, and I absolutely agree with you.

Dr. Morrison: Marian?

Q: Thank you so much, Dr. Gostin. You’re just incredible to listen to and I’m tempted to take a page from Stephen and ask you about 14 different questions. I’ll try and stick to two.

My name is Marian Wentworth. I’m the chief executive officer of Management Sciences for Health, which you probably know does health system strengthening in, what, 40 countries right at the moment, and about 30 of them we’re actively working on COVID-19 programs.

And a lot of the comments that you make around domestic debates spill over or, perhaps, also bubble up for the same reasons in a lot of the countries in which we work. One of the debates that’s happened in this country early on, which is still lingering, is this notion that public health runs in opposition to economics.

You know, the idea that do we do masking, do we close restaurants, or do we fuel the economy, as opposed to – I ran businesses for many years before Management Scientists for Health – as opposed to outbreaks disrupt supply chain, they upset workforces, they have all kinds of devastating economic effects.

And so I’d love to hear you expound on that because you’re going to think of more nuances than I could possibly think of. And the lightning round question I would ask if I were in Stephen’s shoes is every pandemic seems to have created some kind of really important innovation in public health. What do you think this one is?

Mr. Gostin: Yeah. Boy, both really great questions. I actually think you stated the argument about the conformity between public health and economic development beautifully, as well as it could be stated. You know, the truth is, is one of the things we did learn from this pandemic is that the best way, really, the only way to get an economic rebound is by keeping the virus in good containment.

That leads to your second question, you know, what is the singular, you know, public health achievement? It’s sad to say that in terms of nonpharmaceutical interventions, just, you know, our basic way that we deal with public health and have for so many years – and all of us have written and thought about it, you know, surveillance and genomic surveillance, you know, laboratories, diagnostic testing, contact tracing and case investigations, isolation and quarantine, all of those kinds of interventions – we just haven’t done them very well.

Some countries did and, you know, one could point to, you know, countries in East Asia. China has done it, you know, fairly well, speaking of China. But for the most part, we’ve done a bad job and we’ve done a bad job in the United States.

And so if you want to look at, you know, the two most important lessons that we would learn, for me, is, you know, political trust in science, public trust in public health agencies, and behavior change as one part, and the other is the value of science.

Because in the end, as I say, no matter what we’ve done, this virus keeps roaring back. It is in China. It is in Vietnam. It is even in New Zealand and Australia, which are island nations. It’s a really wily virus, the kind we almost – it’s almost the perfect virus, actually. That’s the beginning of the book where I talk about why this is the perfect virus.

And so we do need to quickly get vaccinations and that’s really our hope for the future to really get back to normal and to contain this.

Mr. Mossison: John Lang?

Q: Thank you, Steve. And congratulations, Larry, on your book. I’m John Lang from the United Nations Foundation.

You talked about the leaders of China and the United States getting together, about the need for political commitment to transform health systems, and others have talked about the need for greater leadership.

But I have to say, in my Foreign Service career I spent a lot of time working in or on sub-Saharan Africa, and I know leaders in that part of the world who have been great on public health issues such as HIV/AIDS or Ebola or polio or COVID, and others who have been very weak. And sometimes the great people are replaced by the weak people and the weak people are replaced by the strong health leaders.

So we all know we need the leadership but that doesn’t mean we can get it and there will never be a perfect world out there where every leader is strong on a health issue. Do you have ideas in your blueprint for how to institutionalize certain health measures so that you can overcome weak leadership?

Mr. Gostin: You know, I’m a member of the advisory board for the Global Health Security Index, and before the COVID-19 pandemic, as you know, Steve, we ranked the United States top in preparedness. Europe, the U.K., and others were close behind. And boy, were we wrong, and the reason we were wrong was because of, you know, the failure of political leaders.

And, of course, we tend to focus on, you know, Mexico, Brazil, and the United States that really had, you know, nationalist inward-looking leaders that were anti-science. But it’s true in other countries as well. And sub-Saharan Africa does have some great leaders but it has some really miserable ones, and how you institutionalize that is hard.

I think the only way you can do it is through strong civil society empowerment, by making national institutions robust and strong, and we’ve seen that, you know, say, with FDA and even CDC trying to fight back here but not nearly to the extent that they should have. But we just need to actually focus on strong health systems, strong civil society, and to make sure that we have robust institutions that can resist political interference.

Dr. Morrison: Charles Holmes?

Q: Yeah. Thanks so much, Steven, Larry, Andrew. This has been terrific. Something that you talked about earlier – Charles Holmes from Center for Innovation in Global Health at Georgetown and the O’Neill Institute.

Something you spoke about earlier, Larry, was the sort of failure of communication. We talked about it a little bit in macro level. But it also, I think, ties into something else you said, which is that we’ve gutted our sort of public health capacity at the local level. We’ve heard numbers, around tens of thousands of losses over the last two decades in our state and local health departments, for instance.

As we think about, in particular, from our global work what really works to connect with communities, it made me think about how important that frontline local public health establishment is in our own countries. If we think about the lack of efficient communication from the federal level around vaccine efficacy and safety down to the local level, that gap could be narrowed, obviously, with a full cadre of public health leaders at that local level.

And the community health workforce that we’ve seen work so effectively in the global arena is also, largely, lacking here. Interested, number one, of any thoughts you have about how we can very quickly and swiftly build that, not only for our health security but many other reasons.

And number two, what other elements of local communication do we need to be thinking about? Maybe that workforce at the local level needs to pull in more private sector expertise, more ability to use mass media or mid-market media to get its messages across. Interested in any thoughts you may have there. Thanks.

Mr. Gostin: Yeah. Thank you very much, Charles. That’s a really good point, because we’ve been talking a lot about top-down national approaches, national governmental approaches and how that’s important.

And, of course, in a pandemic, it’s, you know, particularly important because, you know, in a federalist society like we are or so many other countries are, you know, pandemics don’t respect state borders or local jurisdictions and so you do need national and global coordination, which is really, sadly, lacking.

But the truth is, as you said, you know, whether it’s in sub-Saharan Africa or Latin America or in the United States, you know, having leadership from the bottom up, I think, civil – strong civil society. We saw that with civil society engagement, religious institutions and others in West Africa in Ebola being extraordinarily important. But most important are community health workers, local public health officials, who know the community and where the community can have that trust.

And the only way we can do that is to focus on it, to actually invest in it, to value it. I mean, you remember early on in the pandemic when every time, you know, a health worker would pass, you know, people would cheer or ring their bells. We’re not seeing that anymore, and we probably never saw it for the public health officials.

There’s some horrible things in some states with local public health officials having to retire or being threatened, you know, with their life, having to put security in, and imagine that. You know, you’re there, a local public health official trying to do your best and you’re undermined.

Steve mentioned these states that have – there are 11 states that have passed laws that actually block public health measures like masking in schools or vaccination. There are probably up to 20 states that have limited the emergency powers of public health officials and governors. And when the next pandemic strikes, you don’t want your public health agency and your governor not to be able to move nimbly, flexibly, to the new danger that’s arising.

So you’re absolutely right, Charles. We need to – we need to value local public health and we need to invest in it.

Dr. Morrison: Larry, we’re getting close to the end of our hour. I want to offer one remark and with a question attached to it and I want to ask you to respond to that, and then ask Andrew to close with some final remarks.

This week, we had – this last two weeks, we had the amazing exhibition or installation down on the Mall, Suzanne Firstenberg’s “Remember: In America.” It occurred, these white flags beneath the Washington Monument accumulating to the 700,000 mark, last Friday.

It was a – really, a remarkable reminder of the gravity of what has happened to our society, and it begs this question of how are we going to remember and act upon this. We’re so – we’ve talked about how divided we are and how polarized and how this polarization is now embedded in actions in legislatures and law and the like.

Some people, like Phil Zelikow, who is the director of the 9/11 commission – Philip and others, you’ve been involved, I’ve been involved – over the last year thinking about a national commission.

Mr. Gostin: Right. Mmm hmm.

Dr. Morrison: Should we have one that would reach beyond the books that are coming out, draw upon those, not be stuck by the fact that Congress is not going to authorize a national commission as it did for 9/11, and aware that the Biden administration is going to have to be careful in its actions in this period?

But, nonetheless, there’s a call for an independent commission with great gravitas, unassailable credentials, good judgment, good scientific public health capacity, drawing from different parts of our society.

What’s your thoughts about the merit and value of this, and what should we be doing to make it possible?

Mr. Gostin: Yeah. There’s just this medical journal article that I’ve got coming out actually ends with asking for that.

First of all, on the white flags, doesn’t it remind you a little bit of the AIDS quilt –

Dr. Morrison: Yes.

Mr. Gostin: – back in the day? And I think having these powerful visible symbols of the hurt and the pain is really important to remind us that, you know, we are all Americans, we all are in this together and that, you know, everybody’s dying and it doesn’t matter your political stripes.

We do need a reckoning in the United States after this pandemic. How could the world’s richest, most powerful country where our spending per capita on health is twice that of any other country in the world, how could we have been one of the world’s worst performers and how can we become more resilient in the future?

That does need a 9/11 type of commission. And, of course, what we’ve gone through with COVID is infinitely more impactful than even 9/11. Just think about the suffering throughout the United States and globally economically, educationally, health wise. In every possible way it’s changed our very lives.

So yes, we absolutely need that. Congress really should authorize it but in a bipartisan way. No, we did not do that with the elections, you know, and the storming of the Capitol. We should have. But there is no reason why we should not want good solid people who are either nonpartisan or bipartisan to actually help us with a blueprint, and we have to reflect back and go forward with a greater resilience.

So I absolutely support a 9/11 type commission, Steve.

Dr. Morrison: Thank you, Larry.

Andrew?

Mr. Schwartz: Larry, I just want to close by thanking you for your generous time today, for these insightful comments and answers to our questions. I want to remind everybody who’s watching that Larry’s new book, “Global Health Security: A Blueprint for the Future,” is a really important document for all of our futures. It’s available now, just out this week by Harvard Press.

Larry, thank you so much for your time today. This was a fascinating discussion, and I know that we’ll be having many more to come in the future.

Mr. Gostin: Really grateful to you, Andrew, and to you, Steve, and to CSIS. You’ve long been dear friends and colleagues in this struggle, and it’s really been an honor to be with you.

Dr. Morrison: Thank you.