Book Launch—Fair Doses: An Insider's Story of the Pandemic and the Global Fight for Vaccine Equity

This transcript is from a CSIS event hosted on October 30,2025. Watch the full video below.

J. Stephen Morrison: Hello and good afternoon. Welcome to the Center for Strategic and International Studies. I’m J. Stephen Morrison, senior vice president here at CSIS in Washington, D.C., where I direct our Global Health Policy Center. I want to welcome our online audience as well as those who’ve gathered here in person.

It’s a real honor to Introduce Dr. Seth Berkely, a longstanding friend and a longstanding much-admired leader in global health. Congratulations on the book, Seth. A big milestone, “Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity.”

During the COVID-19 pandemic, when Seth was leading COVAX – the subject of much of the book, which we’ll hear more about – I saw him several times in Washington, D.C., in Munich, in Geneva. And I have to say, Seth, I was concerned. He looked at times – particularly the longer and the deeper we got into this pandemic, he looked battered, exhausted, beleaguered. This pandemic war had taken a toll. And I remember thinking that very thing, that this really stretched people. It encumbered people. It changed the way they looked, the way they sounded. And it changes people, and changes people we’ll hear some about today. And we just need to remember that this pandemic war was a war, and we need to remember how tough those days were and how much of a price it took on many, many people, including Seth.

So I’m happy to see him here today, a few years later, a memoir completed, looking very refreshed – (laughter) – and healthy.

Seth Berkely: Ready for the next battle. (Laughs.) 

Dr. Morrison: Every good memoir starts with a dramatic bar scene. You all know that. (Laughter.) Seth is no exception. So don’t be surprised this memoir starts with Seth; his wife, Cynthia; and Richard Hatchett sitting down at the Hard Rock Café bar in Davos. That became an iconic story, a symbol of that breakout moment – the epiphany, the moment of crisis, a moment of hope and inspiration – before it became clear, as we hear in the book, just how difficult and complex and painful this ambition, this project, this vision that you laid out on a – on a napkin, I suppose.

And I just – we have folks here. We have Jennifer Nuzzo here today from the Pandemic Center at Brown University. Seth started his medical career and training at the medical school – Alpert Medical School at Brown. He’s now a senior fellow with Jennifer at the Brown Pandemic Center. Every – things have come full circle. Maybe we could ask the Brown Center to do a memorial napkin to that iconic scene – (laughter) – that started all of this.

Seth’s biography is familiar to many of us. CEO of Gavi and head of COVAX during the pandemic in the years 2011 to 2023. Prior to that, president and CEO of IAVI, 1996 to 2011. Time in the mid-’80s at CDC. Time in the later ’80s in Uganda working on the early stages of AIDS surveillance. And a few things jump out about his biography: An exceptional mix of scientific expertise, policy knowledge, political and diplomatic savvy and humanity, and a – and a high level as we’ve seen in this book of self-knowledge and self-criticism, and boundless energy and commitment to the cause.

His career had exceptional longevity and continuity not just in HIV/AIDS – spanning New York City, Uganda, CDC at critical moments as that pandemic unfolded – but it spanned and connected the HIV generation of leadership with those that led during COVID. And the knowledge and wisdom, hard lessons learned in that initial HIV struggle carried forward.

At the Munich Security Conference in February of 2020, Seth joined a town hall that we did together with the deputy foreign minister of China, with the head of emergency operations at WHO, with the head of The Wellcome Trust, and others. This was in mid-February, while there was still considerable uncertainty about what exactly was happening, and it was one of pretty fierce denial. I mean, we had the Chinese government slap down any allegations or assertions that some of the facts emerging were scary at that time. It was then, as in many other instances, where Seth had the courage to speak out.

And I just want to mention that you have been very outspoken and very quick to respond in this latest period, and we’re very grateful for that. It’s very important that we have this rigorous, tough-minded, and consistent voice coming from you and others in this – in this moment.

The memoir appears at this fraught moment, as the administration under RFK Jr. is dismantling the vaccine ecosystem, including support of Gavi, mRNA, guidance on COVID vaccines, and other things. We’re in this fraught moment of extended COVID hangover – the turn away, the taboo, the amnesia. And here we have an effort at telling the story – the inside story from Seth’s perspective.

And that does bring home a kind of uncomfortable reality that we’ve got two universes that we’re living in right now, and how to crack those universes. How do we bring the knowledge and perspective you’re bringing forward across those barriers? And I hope we’ll hear more about that, how to do that, because it’s not easy. We’ve had Tom Frieden here recently. We’ve had Mike Osteholm and Mark Olshaker here recently doing book events. This same discourse has been happening about how do we bring these forceful and powerful books forward in an age that’s less reliant on reading books, right? And you’ve been very astute at translating all of these things into timely op-eds, podcasts, many other media to try and spread the word. These books remain terribly important at this moment. They’re part of the historic record. They’ll shape our discourse in this fraught – in this fraught environment.

So last word, Seth: We’re all in your debt and thank you for all you’ve done, and it’s great to have you here, and I look forward to the conversation.

Katherine, thank you for organizing this and putting this together. Priya Chainani, Caitlin Noe, Michaela Simoneau on our staff have put a lot of time into this. And for the production today, Arturo Munoz and Dwayne Gladden, thank you so much for doing that.

Over to Katherine and over to Seth. (Applause.)

Dr. Berkely Thank you. (Applause.)

Katherine Bliss: So it’s great to see everyone here and online. In the week or so in the runup to this event, I had sent Seth an email just saying, you know: I’m reading the book. I’m going to send you some proposed, you know, questions to structure the conversation. And you know, he wrote back and said: Yeah, that timing is fine. And I hope it doesn’t give you PTSD. And I kind of laughed.

Dr. Berkely: (Laughs.)

Dr. Bliss: I was like, oh, ha, you know, because I had – I’d gotten through the fun part, which was kind of the – (laughs) – the first few chapters and the background. And then as I got further into it I was like, oh yeah, I’d forgotten about that; and, oh – then, oh, that backstabbing, or that, you know, something. And it was – it really – there were moments, definitely. 

Dr. Berkely: (Laughs.)

Dr. Bliss: But despite a very clear-eyed look at challenges and analysis of the obstacles faced during the COVAX period, the book really offers a number of inspiring stories and examples of dedication in the midst of a really dark period. This is day three, I think, since publication, and I know you’ve been in New York and here in Washington and you’re going to Boston and, you know, really kind of on the road to talk about these issues. So congratulations.

Dr. Berkely: Thank you so much. 

Dr. Bliss: So “Fair Doses” is part memoir, part history of vaccines and the pandemic, and really kind of a review of global health financing, politics, and international collaboration. And the foundational pillars of the story really seem to kind of be technology and innovation, politics, and then the financing or market-shaping issues. But there’s kind of a connected sub-scene that runs throughout about tolerance for risk. And I didn’t analyze how many – I did have the PDF, so I could have analyzed how many times the word came up, but you know, risk – you know, risk financing, people’s tolerance for risk, governments, lawyers, all of that comes up quite a bit. And I believe you write that you actually started the book while you were still at Gavi.

So I wanted to start by asking you: What prompted you to write this book? And you know, was it therapeutic? Was it cathartic? (Laughter.) Like, you know, what was this process like? And why did you focus on these particular issues?

Dr. Berkely: So thank you, Katherine, and I’ll answer the question in a second. And thank you for that lovely introduction. Normally when I get an introduction like that I should just shut up and leave because I know I won’t be able to live up to it, but thank you. It’s really great to be here.

I did start the book. The purpose of the book originally was really about the amazing history of vaccine equity. Of course, we’ve never gotten to perfect equity, but you know, if you look back in time there was – less than 5 percent of people in the world received even a single dose of vaccine in the – in the mid-1970s, and now we have this as the most widely distributed health intervention in the world. And how did that happen? What were the – you know, the institutions, the people, the stories behind it?

Obviously, when COVAX happened there was a lot of misinformation about what happened. And I felt it was critical to capture that, and including the stuff we did wrong but the stuff we did right, because at the end those lessons are going to be critical because it’s evolutionarily certain we will have more outbreaks and we will have more pandemics. And if we don’t learn from history, we’re doomed to repeat it. And my real worry was the people who said, oh, it was just a complete failure, it didn’t work, weren’t doing justice.

The facts are that it was the fastest rollout in history. It was the most equitable rollout in history. No, it wasn’t equitable. No, it wasn’t fast enough. And you know – but it was much better than had ever been done before. And the reason we did it and the reason we set up COVAX was because we knew what the headwinds were going to be like. We knew what the problems were going to be like. And sure enough – (laughs) – we hit all of those problems. And so, you know, it’s getting into those nuances.

The other thing I wanted to do was during – which is uncharacteristic for me; I tend to be very direct and tend to be outspoken – (laughs) – as Stephen accused me of. But I was – on some things I was quiet during COVID because my role was to try to do anything we could to get vaccines available. So that meant not calling out leaders who were doing bad things or calling out companies who were doing bad things. It was to continue to try to do diplomacy behind the scenes. But I realized it’s also important to say that. So I tried in the book at least my opinion who were the good leaders, who were the bad leaders. That’s political leaders. That’s pharmaceutical company leaders. It’s civil society. It’s international institutions. And you know, I’m sure it will stir up a lot of controversy, but I think it’s really important to have that accountability out there so that, you know, we can learn from it.

So those were really the purposes. Now, when the book was written in ’23 and ’24, and then when the book, you know, takes forever to get a book published, and as we were moving towards it getting published, well, the world changed, and I literally thought I should just rip up the book and start from scratch. (Laughs.) Now, I kind of came around and said, you know what, the lessons are the same and the issues are maybe more important, so I was able to stick a little preface in the front to say the world has changed, and in the back I wasn’t able to go back in and say in this new world, you know, how might we think about things differently. But I suspect those are some of the conversations we’re going to have to have because I do think we will become sane again as a world. I don’t think vaccines are finished. I don’t think, you know, conspiracy theories are the way we’re going to drive science. And so as we move back to a more reasonable world, it’ll be a different world. Again, how do we – how do we structure? How do we learn? How do we make sure we’re going the right things? At the end, we have to follow science. That’s it.

Dr. Bliss: So it sounds like it was at least in part cathartic, like, just, you know, kind of getting out of – out of the dark period. But as you say, I mean, it’s a history of vaccine equity and the fight for equity. And you know, equity is a theme throughout the book. It kind of comes up twice in the title, and –

Dr. Berkely: Yeah. I was told, by the way, that I shouldn’t put “equity” on the cover because it’s a lightning-rod word and, you know, you’ll be destroyed. And somebody who was actually going to do a blurb for the book said I’m not going to do it because it has “equity” in the title. Just to give –

Dr. Bliss: Wow.

Dr. Berkely: I said, this is not DEI; this is vaccine equity. It’s not –

Dr. Bliss: OK. Well, but they say controversy sells.

Dr. Berkely: Yes.

Dr. Bliss: So, you know, maybe that’s good.

But you know, it seems clear that, you know, you went into the pandemic already very convinced that equitable access to resources is critical for achieving global health goals. You talk about that in several chapters. When you were here in Washington in February of 2020 – I guess right after that Munich Security Conference meeting – you know, you, you know, really emphasized that issue. And when you came back in 2022, we had a long discussion about kind of the tension between equity and sustainability, and you know, how do you – how do you kind of promote both of those at the same time in the midst of a crisis.

So I wanted to ask you to reflect a little bit on the professional experiences you had that shaped your understanding of equity in the health context, and how the pandemic tested and maybe caused you to refine that thinking a little bit.

Dr. Berkely: Yeah. I mean, I don’t want to go too much back into my childhood and experiences I had as a student, et cetera, but –

Dr. Bliss: The chemistry set. (Laughs.)

Dr. Berkely: Yeah. No, no, but I do, by the way, in a short bit in the book, because I spend a lot of my time talking to students, and I always get the question, you know, how did you get where you get? And, you know, how do you get a career in global health? And so I put a little bit of my own, you know, history. And the reason that’s important is, unlike – if you want to be the world’s best cardiologist, you know, you go to these three centers, you know, you train under this person, you do this fellowship, you know, you publish in this journal. You know exactly – there’s a track for that. For global health, it’s not so. And so it’s a lot more about mentors. It’s experiences. And so, you know, trying to explain all of that that went into it.

But from a young age I believed that this was an important factor. And why was it tested so much in the pandemic? I mean, again, we’ve had ups and downs, but we’ve moved towards equity. We’ve moved towards increased coverage. You know, today we went from that 5 percent I mentioned before to, you know, about 90 percent of people in the world get access to a routine vaccine, of families and childhood vaccine. And so that still means 10 percent doesn’t. And that’s a real problem. And that’s an important thing. But there’s nothing else like that. And so, you know, we’re seeing all this progress.

And when you get into pandemics, I talk about a lot of potential solutions but one of the challenges you have is this tension. It is the job of a political leader to provide whatever countermeasures you have for your population. It’s their job. And that is, in a sense, perhaps, in tension with the job of global equity. Because, you know, you should, you know, do your country. And so we weren’t unrealistic. You know, we weren’t singing Kumbaya and we’ll just spread it everywhere. We understood that there was going to be nationalism. But the issue is, do you go, for example, to 100 percent coverage of your country? Do you hold all the vaccines, particularly if you’ve ordered five or six or seven different vaccines because you didn’t know which was going to work? Or do you, as you cover the high-risk population, then say we need to now cover the high-risk population in other places, whether that’s the health care workers, or the elderly, or others.

And obviously, my belief would be that that’s the right way to deal with this. But that is a fundamental tension. You’re never going to stop that, you know, instinct of a leader to provide for their country. And so the question then is, as we build systems, you know, how do we get it so that you can do both of those? And one of that is going to be having enough volume of product and having enough, you know, production facilities distributed in different places around the world, so that you can, you know, do both somewhat at the same time. So, COVAX, 39 days after the first jab in the U.K., we had our first injection in a COVAX country. And then, you know, 43 days later in Africa, because WHO took a long time to prequalify. And then another 42 days later we had – we had sent vaccines out to 100 different countries. So, I mean, this was fast-moving. It should have been faster. It should have gone, you know, better. But a lot of lessons there.

Dr. Bliss: So, speaking of lessons learned, then, I mean, you really point to a number of different lessons over the course of the book. And said just now that, you know, once 2025 came around you sort of wanted to go back and rethink them, but then, like, well, you know, the lessons really do hold. And you point to some of the challenges and missed opportunities – not having the upfront financing, and, you know, really, really needing that.

Dr. Berkely: Right. That’s the single most important thing, in a sense.

Dr. Bliss: So let me – let me ask you to talk about that. I mean, you talked about, you know, maybe not working with Africa CDC early enough, some of the challenges with UNICEF, like, a lot of – a lot of different issues over time. But the issue of the upfront financing, what – say a little bit more about that.

Dr. Berkely: So there really were a few really big ones. And then there were lots of others that were there. You know, when we decided, in that bar scene, that we would do something, we had no money, we had no people, and we had no mandate. And we decided to do it anyway. And Richard Hatchett took some of his money that he had and he gave it to a number of companies to begin to work on COVID vaccines, one of which was Moderna, to actually create the clinical lots for that. A small amount but, you know, important. And, you know, I went back and went to the partners and everybody and said, do this. This gets back to the risk question, which I didn’t quite answer but is very important.

So had we had money at that moment in time, we could have done a number of things. We could have put orders in place. We could have gone ahead and begun to do technology transfers. We could have gotten countries ready. And, you know, those were all things that would have accelerated it. It wouldn’t have completely changed things because of the reason of vaccine nationalism and what I just talked about, but it would have changed the dynamics. And certainly, if we could have done more tech transfers, we might have had more volume quicker, you know, for other things. But the second part of this – and, by the way, there is a system now which we should talk about to try to do that, although I don’t know how long it’ll last given the impatience that exists.

But the surprise to me was this risk question. And just to give you an example of this, so the World Bank, which stepped up when there’s a pandemic – every time there’s a pandemic, they step up. They say, you know, we’re going to take care of it. We’re going to do it. They said they had $12 billion, then they said they had $20 billion. Let me tell you, trying to raise money when somebody says, I got $20 billion here, it increased the degree of difficulty. But at the end what donors heard was that that money wasn’t getting to the places, wasn’t doing what it needed to do. Now, what it turns out, and I didn’t understand this, is the bank can’t take risk. So what we heard is you can’t put $1 of IDA money at risk.

And so the idea is we can buy vaccines once we know they’re certified, once we know that they’re, you know, regulatory approved, once we know – and, of course, by that time, you know, it’s too late because they’ve all been bought. And so this issue of risk. So at the end, we ended up, as little Gavi, David, we ended up backstopping the World Bank, Goliath, you know, because of the fact that we took risk. And that was very hard for the Gavi board. And my hat’s off to them, because, you know, if you think about what was happening, we were spending billions of dollars to buy vaccines that we had no idea whether they were going to work. I mean, no idea – we had some – you know, a lot of research had gone on ahead of time that gave us some suggestion. But we didn’t know. And imagine, you know, my head would have been on a stake if all of that money had– had not succeeded.

But in a pandemic, you have to do that. And if I want to give credit to – you know, to the Trump administration, I mean, Operation Warp Speed was exactly that. We opened the Treasury. We got a lot of money there. You know, we’re going to put, you know, $10, $11, you know, billion dollars on the table to take risks at developing vaccines. And, lo and behold, we, you know, we had vaccines in record time, 327 days. This is what you have to do in a pandemic. And the question is, how do you have that discussion for developing countries, in addition to the conversation that went on for wealthy countries? And this is an important part of going forward. There are many other lessons. And I do go through the experiences and what worked and what didn’t work. But those were two really important ones.

And I’d say one other, which is it was surprising to me how poorly prepared the global community was. We didn’t have indemnification and liability, you know, knowledge to move forward. We didn’t have no-fault compensation. We didn’t have, you know, agreements to do dose donations. We didn’t start wanting to do dose donations. We thought, you know, having developing countries get the – you know, the leftovers that nobody wants is not the way to deal with the pandemic. On the other hand, obviously when it became – we found out that many countries had bought five, six, seven vaccines, so enough to vaccinate their population many times over, and then they desperately wanted to get rid of them because they certainly didn’t want them expiring on their watch, you know, we should take those donations because the world was short.

But then, you know, they had the legal liability. Now we had to take on the legal liability. You know, the companies weren’t going to take it. And so there were all of those types of lessons. There was no – we tried to do humanitarian stuff at the beginning. We set up – we set up a humanitarian buffer. It was the right idea. Five percent of doses for those situations. But, lo and behold, because they’re not working with governments in those circumstances but with NGOs, who takes the liability?

A number of manufacturers said, you know, what? At this point they’ve been in hundreds of millions of people. There aren’t a set of, you know, Wall Street lawyers that are going to be, you know, in these communities. We’ll accept the fact that we won’t, you know, have insurance, because we still had our no-fault compensation. But other companies said, no way. We’re not doing it without this insurance. And then NGOs said, we can’t do this without insurance because we certainly can’t take on the risk. So these are the types of problems that really need to be worked on and driven forward in the future.

Dr. Bliss: So the theme of leadership has come up a number of times. And you’ve offered some – throughout the book and here’s – some examples of not-so positive leadership, you know, especially some of these debates about indemnification and some of the legal issues to be sure, but – and the vaccine nationalism. So we don’t have to get into all the bad examples here, because that might – that might take a while and get us back to the PTSD question. (Laughter.) But I wanted to ask you to reflect on some of the positive examples you saw during the pandemic. And who – you know, whether among heads of state or some of the private sector groups that you worked with, or civil society – who really kind of stood out, or what groups really stood out for their positive leadership in the crisis?

Dr. Berkely: Yeah. I mean, you know, the challenge is, even some of the ones that stood out for positive leaders may have done some things that were negative for political reasons. And I try to be nuanced about that and tell both sides of the story. But, you know, there was a whole set of leaders at the beginning that talked about how important this was. You know, President Macron played a very important role. And at the end there’s a funny story about him delivering doses in his plane to an African country because he was going to visit and wanted it to be there. We saw Boris Johnson host, you know, the vaccine summit and bring people together to try to drive forward. And there we ended up with, you know, 42 heads of state, including 19 of the G-20 heads of state on there, all talking about the importance of equity, not all necessarily following up on that.

We saw up company leaders. You know, AstraZeneca was not a vaccine company. They had a small MedImmune division, but they really weren’t a big company. But they wanted to do the right thing. And when I had a problem, I called up or sent a text to the leader at the company, Pascal Soriot. And, you know, within 24 hours he responded. And sometimes he couldn’t fix it, but where he could – when he couldn’t he explained why, and where he could he leaned in and tried to do that. It wasn’t true with some of the other leaders. And, you know, on civil society, again, we had strong support from some.

We also had a counter movement. Very hard for me to push back on. They had the people’s vaccine. It should be free, no IP, and available to people everywhere. Well, you know, I mean, who could be against that? But, you know, the practical issue was, here’s vaccines that every person in the world, every country wanted. And who’s going to make those vaccines that are free and have no patents and are going to be available everywhere? So, I mean, you end up in these crazy debates. And that distracted because there was then a whole group of NGOs who were pursuing that, and the whole IP question. And we tested that, because at the end the WTO went ahead and said we can have, you know, TRIPS freedom in doing this. And what happened is vaccines didn’t come any faster or any better. And so I think these are, you know, really, really pieces that were important.

The other thing I’d say, though, is that people were disappointed. And, you know, the delays that were there have had dramatic effects afterwards. Certainly, Africa got doses slower than other parts of the world. Now, they had less severe disease and they had less people at risk, but that doesn’t – you know, we’re trying to do the right thing equitably. And, you know, they were rightfully angry about that. And part of that was the way deals were structured, because we ended up contracting with the Serum Institute of India, the largest vaccine manufacturer in the world, as one of the 11 different companies that we were working with to drive vaccines forward. So the largest portfolio. We didn’t put all our eggs in one basket, but they were a big basket. And then when India, you know, had the problems it had, and I talk a lot about that in the book, there was an export ban –

Dr. Bliss: This is during the Delta variant.

Dr. Berkely: Yeah, when the Delta variant appeared and we saw the funeral pyres burning. And the opposition in India said to the, you know, the prime minister, here you were given out vaccines that could have been used for India. And they were, like, no more vaccines. I mean, they didn’t say that publicly, but they just stopped. And the challenge that was interesting, why was that such a big deal for Africa, was the AstraZeneca was also doing doses. But the AstraZeneca doses, they didn’t want to do the poorest countries. They wanted the Serum Institute of India to do the poorest countries. They wanted to do middle income and, you know, and countries that were richer, because that was better in the long term for business. So you ended up with the – when the ban stopped, it stopped for the countries that were the poorest.

So these were some of the kind of crazy things that, you know, you had to work through. And we were constantly blocking and tackling and trying to change the way we worked. And, by the way, I mean, people are saying “me.” We had an unbelievable team of people so dedicated. Initially no staff members, so everybody was working double and triple time, you know, because we had to deliver routine vaccines, but we also had to go ahead and deal with the COVID vaccines and build the infrastructure for that at the same time. And so people were heroic in what they were able to do.

Dr. Bliss: So in the introduction to “Fair Doses,” you say – or, you write, “I wrote this book to help people understand that vaccines are our most important public health tool, and that they must be developed and used as widely as possible by rich and poor alike around the world.” Like, this idea of equity. I think it’s fair to say that it may be a challenging prospect here in the United States right now to move some of these ideas forward. We have increases in nonmedical vaccine exemptions in many states, some states dropping school enrollment mandates altogether, the largest outbreak of measles in several decades. And a secretary of health and human services who has downplayed the role of measles, mumps, rubella vaccines and realigned the Advisory Committee on Immunization Practices, while cutting funds for research and terminating staff at CDC, where you worked.

So I want to ask how you feel about the timing of the book. I know you said you had finished it and then, you know, the publication process takes a while. But given the outbreaks and the turmoil within the vaccine world here, and, of course, internationally, because so many things are connected, are you confident that this message will be able to resonate in this context? And will we see things get back on track?

I should add, sorry, I’m posing this last question before we’re going to open up to some questions here in the audience, so give you one second to think about that. And I’ll give you all some time to think about your questions. And we do have a microphone in the back if you – if you want to pose a question then. So, please.

Dr. Berkely: At the end, rationality will return. I believe that. And I think science will, you know, get attention again. And things will be different, but I think we will get there. One way we can get there is we can wait until we have big epidemics of diseases that were formally controlled and that parents didn’t see for their kids, lots of kids dying, lots of adults dying. That is not what anybody would think is a good idea. But, you know, that’ll happen. And of the hardest parts of this discussion is this artificial separation between international and domestic. You know, measles was eliminated in 2000. So by definition, cases that are in the U.S. are imported cases. And people say, oh, that means, you know, it’s whatever person you don’t like or country you don’t like. But, you know, the big Disney outbreak that occurred, you know, a decade and a half ago? It was a Swiss tourist who was the – was the index case. And the point is that anybody can carry these diseases anywhere.

So I’m optimistic, you know, we’ll get back there. But the effects of this are just dramatic. And what I – what I really worry about is – I mean, you mentioned some of the things the secretary has said. But it isn’t only the secretary. I mean, there was a tweet two days ago in all caps on social media that said, you know, children should not get MMR vaccine in the United States – statement in caps – they should get measles and mumps and rubella separately. OK, well, so that means you go from two vaccines to six vaccines. Of course, we talk about why we don’t want to jab kids too many times in all of this. But neither measles, mumps, nor rubella are available in the United States as single dose vaccines. So now what do you do if you’re a parent that is worried about your kid looking at this, and this is kind of advice from the – literally, the highest, you know, person in the land? Do you stop vaccines? Do you take the vials and divide them up into three and, you know, use it that – I mean, what do you do?

And so there’s – the amount of information, of disinformation, that’s out there is just shocking to me. And one of the things when I was going through the book and doing research, you know, misinformation, just by the way, the separation is misinformation is when your auntie tells you something that she read somewhere or doesn’t understand. And she’s not doing it nefariously. She just doesn’t know. You know, and you can correct that knowledge. Disinformation is intentionally spreading information that– that is wrong. And there’s a lot of disinformation out there now on vaccines.

You know, we think of Russian bots, and Chinese bots, and North Korean bots as ways of doing it. But, you know, one of the things I talk about in the book is the U.S. Defense Department putting out disinformation, you know, in some of its campaigns to discredit the Chinese vaccine. And, you know, I mean, we do that at our peril because this is all about trust. And if you don’t, you know, have trust, then you have a problem because, you know, one vaccine you don’t trust doesn’t mean you trust the others. It means you begin to have questions, you know, asked about all of these.

Dr. Bliss: So I want to just invite people to move to the mic. I have plenty of questions, but I certainly want to give people in the room who – many of whom worked with Seth, like, during the context of the pandemic. You know, feel free to stand over. Recently, just two days ago, I think you published – maybe it was three days ago – but you published an op-ed in STAT. And you also argued elsewhere, at Munich and other places, that that pandemic preparedness and global health security have to be considered matters of national security. And in the book, you know, you actually note the irony of, you know the taxpayers being willing to pay for a flotilla of nuclear submarines patrolling around the oceans in order to kind of find potential threats, but unwilling to kind of recognize the same kinds of vulnerabilities to pandemics in the same way.

I just wanted to ask you to reflect a little bit on why it can be difficult to – I mean, we’re sitting here in a think tank focused on foreign policy and security. And, you know, many people are convinced of that. But there’s a large sector of the national security establishment that doesn’t necessarily see things that way. Why do you think it can be challenging to make that case? And what do you think would be different if more people, whether policymakers or the public at large, really kind of adopted that view?

Dr. Berkely: I mean, that’s a great question. And I think we have to move there, unfortunately. And when I talk to military leaders, I mean, not uniformly, but most of them understand this and think it’s important. It’s a little bit of a, well, that’s not my job because somebody else is paying attention to this. And what I said in this op-ed, which, you know, I thought makes an important point, is, you know, to kill or cut all of the work on biosecurity – first of all, we are way overdue for a bioterrorism attack. There’s a lot of reasons why bioterrorism is a better way to do terrorism than is nuclear or other things, because of the lack of signals that you would have there. And today, you know, synthetic biology is everywhere, and AI is there, and so there’s an ability to do it. But also naturally occurring.

And I make the point that – you know, and this is a statistic that I didn’t know – but if you look at the number of people who died from COVID in the United States, that exceeds all U.S. servicemen who have died in all wars in the United States from the Civil War on. So, you know, beyond the Civil War, all of them put together. And I see somebody shaking their head. The statistics are, you know, in the piece. And it’s referenced there. And they’re official U.S. statistics, by the way, on both sides. But, you know, and the only point to make that is – and it’s a little bit of an apples and orange, you know, issue, but we’re increasing the military budget by 12 percent while we’re slashing this other budget.

And, you know, you can’t have global security without global health security. And I think that’s the message. And, you know, I know at some point there will be a bioterrorism attack. And then everybody will say, oh, my God, we got to do a lot more for it. But again, just like I don’t want to see kids die as a way to, you know, get people back to paying attention to getting high coverage, I would like to see the world focus on this. And so I think it’s an important part. The military understands surveillance in a different way and understands data systems and understands, you know, the need to have a global coverage in doing that. And we need to be having the same type of conversations in health as well.

Dr. Bliss: Yes. If you have a question, would you please use the microphone just so our online audience can also hear?

Q: Hi. Thanks very much for this.

I wanted to ask, with your global view, do you think the biggest challenge now – and, you know, maybe it’s hard to compare, is trying to message better or teach or whatever in the United States, to push back on the anti-vaccine moves that Katherine outlined and that you know? Or to move on the kind of problems that you mentioned with Africa, and the need to have a volume of production, and equity in a global sense?

Dr. Berkely: I mean, in a sense they’re connected. And you really, in a sense, have to do both. The problem with what’s going on in the U.S. right now is you can argue the U.S. is one of 200-odd countries and – you know, and so what? But the influence of the U.S. – I mean, not only the financial might, but the technology, the science, the policy that has been here. The FDA – I see a former FDA commissioner here – has become – was the global standard for the world. You know, those are things that people take seriously. So when the U.S. takes a turn and starts not using data and starts pushing conspiracy theories as a way to make policy, that has massive repercussions around the world because other people say, what do they know that we don’t know? You know, this is the question. And of course, with social media it moves literally at the speed of light. And innuendo and, you know, whatever influencers are the people that are that are pushing the agenda.

So I think we really have to do both. By the way, we need more distributive vaccine manufacturing, is the other thing you implied. You know, when Gavi started, there were five manufacturers. The majority were in industrialized countries. There were 19 before COVID, 24 after. And the majority are in developing countries. And so we need to continue that path of having high-quality vaccine manufacturers. But that doesn’t guarantee equity either, as we saw with the Indian manufacturers that, you know, were there. So it’s a broader question on how to prepare. But each pieces of these are important parts of the solution. My bigger point, though, is if we’re not asking these questions, if we’re not discussing it, if we just think it’s not an important priority, then we’re not going to have any of these conversations. Once we acknowledge that this is a priority and has to happen, then we can figure out what the best.

Q: Thanks very much. And it’s great to see you again. I’m looking forward to reading your book.

We’re actually working on some recommendations for senior leaders about how to mitigate risk from biological threats. And, as you’re well aware, and we briefly chatted about, there’s been a decision in the United States to withdraw federal funding from mRNA vaccine research and development. And Secretary Kennedy explicitly stated that the reason for that was his voluminous review of the literature, which showed that the vaccines were ineffective and unsafe if they used the mRNA platform. He then went on to make a number of other statements about the mRNA platform, which created even more doubt about whether we should continue investing in that platform.

As we look at what’s happening in other countries and their continued investment there, that’s creating a real dichotomy of opinion. And I wonder if you could share a little bit about your perspective on the role that mRNA vaccines played during the pandemic and the role they will play in the future, and what you would advise the United States leadership in that realm?

Dr. Berkely: Yeah. Thank you, Paul. And it’s a really important question. So, you know, I am not going to stand up here and say the mRNA vaccines are the be-all and end-all. You know, we don’t know – we didn’t do a lot of things like test head-to-head vaccines. And, for example, it may have been that other approaches might have had a longer duration of protection or other issues. But there is no other tool we have in our armamentarium that can move as quickly as mRNA vaccines. Now, in the pandemic I think the numbers were from the time the genome sequence was published to the first vaccine in a vial was 42 days. I think it was 63 days it was injected. You can’t do that with any other technology. And, by the way, that was a novel technology and it wasn’t a licensed product. So today you can do that even faster. So, you know, it’s the one you have to have if there’s an emergency. And if we have a fast spreading respiratory infection that doesn’t have a one and a half percent mortality rate, but has a 40 percent or 50 percent, you know, minutes count in those circumstances.

So if the concern is that there are safety issues, and I will point out that these vaccines have been used in billions of people and they’ve been looked at by, you know, regulatory agencies across the world – not just in one country, but across, you know, literally hundreds of countries. But if there are concerns, the way we deal with that in science is we do more research. We don’t cut the research and pull away from it. And, you know, the data on efficacy is quite clear on those vaccines. By the way, that data is still coming in. There was an excellent New England Journal article about a week ago done by, I think, it was somebody in the VA system looking at booster doses and showing 64 percent reduction in deaths, you know, now occurring in 2024 and in VA populations, and reductions in hospitalizations and emergency room visits, et cetera.

So I mean, you know, I think, again, I don’t know what voluminous literature have been looked at, but it’s not the literature that I’ve seen. And I will – I will also say that if we look at things like personalized medicine, if you have cancer we give you the standard care of therapy. If you want to give vaccines, personalized vaccines, you tend to give them a second line of therapy. You know what, you can’t wait six months to make that vaccine because the person will die. You need the fastest approach possible. So I am a great fan in trying to take the existing platforms, improve them more, increase the duration of protection, think about new ways to do them. And other countries will do it if we won’t. And, you know, I think it’s a – it’s a – you’re taking one of the most important tools out of the armamentarium, you know, by doing what they’re doing.

Dr. Bliss: So I don’t want to end this discussion, or get to close to the end, you know, without looking at the role of health workers. You dedicate the book to health workers. And, you know, you just answered in the question previously about the role that the importance of regional manufacturing, but, you know, the challenge of kind of keeping systems warm, as you say in the book. And so I just – I wanted to ask you to say a little bit about the role of health workers that, you know, really kind of appear at the end, but are a theme and dedication, and the role that a well-prepared cadre of health workers can play in really strengthening that outbreak response.

Dr. Berkely: Yeah. So I think I know a lot about vaccines. But if you had said to me, what do you think is going to happen – you know, before COVID – that we have a global pandemic, that the whole world shuts down, that it spreads everywhere in the world, and we need to deliver vaccines to old people, and to people with comorbidities, and the health workers, and to all of that. And what do you think is going to happen to routine vaccines? I would have said they’re going to get hit really badly, you know? And, you know, I don’t know, 20, 30, 40, 50 percent reduction. The number was in 2020 a 4 percent reduction. And this is on average, obviously. There were, you know, ups and downs. 2021, a 1 percent reduction. And so those were dedicated health workers that were doing that.

But here’s the statistic that blew me away. Those same people, and they were supplemented by others but that was the core – delivered three times the number of vaccines that had ever been delivered before. And so, you know, at great personal cost to them. Many people died. They were on front lines and, you know, did an incredible job, and exhaustion, and burnout, and all that was there. And, by the way, when health workers die in developing countries, I mean, it’s not – it’s not – it’s horrible anywhere it occurs, but it’s worse in a developing country because, of course, they don’t have the numbers that are in – that are in high-income countries. But they were able to deliver that.

So that’s why I felt so strongly that they have to be called out for what they were able to do. And it also goes back to the mention of, you know, the 90 percent. The 10 percent that don’t get vaccines, the so called zero dose, you know, that’s where – in that population – it’s half of the deaths are occurring in those populations. And two thirds of those people live under the poverty line. So this is a perfect statistical way to pick out people who really, you know, need attention. And what we should be doing as a world is extending those out, making sure there is a health worker serving those populations, bringing them into the surveillance system. Because if some weird outbreak occurs in one of these, you know, dark zones where there’s no health delivery, then they will be able to call in help, and we extend this system. So I think the strengthening systems and doing that is a really important priority, both for healthcare, but for pandemic preparedness as well.

Dr. Bliss: We’ve got two questions, and we’re coming close on the end of our time, so let me ask you to – three questions, OK. Let’s take all three, one at a time. And then give you a chance to answer. And then we’ll – I’ll ask for some final thoughts, Lora Shimp.

Q: Seth, good to see you. I’m Lora Shimp. I work at JSI. We’re a nonprofit, for those – Seth knows us because we’ve been a partner with Gavi since the beginning. But we were also part of the country readiness and delivery (crowd ?) as part of COVAX, and providing a lot of the support as the – as the rollout happened.

And to your point, around health workers – and this will get to my question – you know, we lost one of our best staff, Adelaide Shearley, two weeks before the vaccine would have arrived in Zimbabwe to have vaccinated her. She was also a key member of the Malaria Vaccine Advisory Committee and really helping with the processes for getting that rolled out. And she was a key member of the National Immunization Advisory Group and, you know, other advisory committees.

So that leads to my question. Which is, you know, the coordination was so fundamental. And we have learned a lot from the coordination on that. And we also know the importance of civil society in that true sense, the importance of Rotary for polio eradication, the importance of a lot of the civil society groups that helped with COVID. What do you feel now are the best learnings out of that coordination for us to move forward, particularly in light of getting private sector more involved? I’m thinking of International Pediatric Association and some of the other entities now that we can really bring more into confidence in being those voices around the importance of vaccination, because we know – like Tom Friedman is doing – to really be able to incite that sort of trust in the medical community and vaccines?

Dr. Bliss: OK, so we have one question on the lessons of coordination. Bill Moss.

Q: Yes. Bill Moss from Johns Hopkins.

So, Seth, I wonder, can you give us several examples of how we may be better prepared for the next pandemic now than we were before the COVID pandemic, based on the lessons learned – despite the complete change in global health and global health funding. I think diversifying vaccine manufacturing may be one example, but I’m wondering about, for example, the regulatory aspects. Are we better prepared than we were before the pandemic?

Dr. Bliss: OK. Thank you. And third, please.

Q: Thanks very much. Seth, it’s great to see you. Folake Olayinka, former USAID immunization team lead, and I worked extensively on COVID.

And all you describe brings a lot of – some PTSD, for sure. (Laughter.) Reliving many of those critical moments. But I think we’ve all had little time to reflect and think through how we can plow in, identify those lessons, but plow them in for the future. I have two questions for you really quick. One, one of the biggest challenges in terms of that global equity was really getting the systems to be able to be ready, but also to be able to carry out multiple interventions at the same time, particularly in low and lower-middle income countries. Talked a lot about Africa, where their, you know, burden of other infectious diseases were so high, at the same time dealing with COVID. What is your suggestion around resiliency in that aspect?

The second one, I’m really curious to understand, within the political leadership engagement, what was the main argument that really swayed political leaders to get behind increasing access to COVID vaccination and other medical countermeasures? Thank you very much.

Dr. Bliss: Thank you. OK, so there’s a question on the lessons – you’ve got them? All right.

Dr. Berkely: Yeah.

Dr. Bliss: All right. Good.

Dr. Berkely: So, the coordination question, to start with, is hard because I have a belief – I mean, one thing that was discussed and people talked about was should we set up a pandemic, you know, new organization, and that should do all of it. And I think every time we have a problem we shouldn’t set up a new organization. That’s not the way to do things. And I personally am biased, and I’ll say that, but the reason the Alliance works the way it works and was so successful is it didn’t try to repeat what WHO was doing, and UNICEF was doing, and civil society was doing, and the World Bank was doing, et cetera. It pulled from all of those, networked those together. And the advantage of that is it has the ability to expand and contract based upon the need.

So I think that’s the way to think about this for the future. But what you need to do in peacetime is exercise that muscle a little bit, keep people engaged. And so we actually put a fund together after – I didn’t get a chance to talk about some of the changes that had occurred after COVID. But there is a fund that allows the network to get together to plan, to, you know, do some test runs of things, and to try to keep some of the tools alive that are – that are there. And that is important. The question would be, to the private sector side and others, you know, what incentives do we have to put in place to engage them? And, you know, that’s always been a hard discussion going back and forth, because you have very different views, you know, on IP or on, you know, other issues that can affect that.

But I think that this can be done. And as – what I would do is I would try to have that. Now, the one other problem with that is we don’t necessarily have – we have Gavi for vaccines and the partners that are all working on that. We don’t necessarily have that for diagnostics and, you know, for MCMs and others – you know, I mean, PPE, and other things. So the question would be, how do you assign that to have a core nidus of people that are keeping these things alive, which would be really, really helpful.

Are we better prepared for pandemics? What might be some – you know, some lessons that could have made a difference? Well, first of all, we have a lot – an ability to produce a lot more vaccines, at least at the moment. So in terms of volumes we could do more. We now have new movements on regulatory that’s important. There is an – you know, there’s an African, you know, FDA that is – that is that is being formed – or African Medicines Agency – sorry, not FDA – African Medicines Agency that is being formed. It’s not yet, you know, up to snuff and where it needs to be, but this idea of trying to prepare in the future, it’d be very helpful to have one agency, like we do in Europe. I mean, there’s still individual agencies, but you can go to the EMA and be able to, you know, use it in different places. So those types of things, you know, really would be – would be better.

We do have a zero-day facility now that was put together. It has a half a billion dollars in it. And DFC, the Development Finance Corporation, and the EIB, and European Investment Bank, have a set of loan guarantees that will kick that up to about $2 billion, which I think, frankly, is enough. I mean, people say, why don’t you want the whole amount? No, I don’t want the whole amount, because you’re going to need the donors to kick the tires. And, you know, what you need is enough to get things started. And so that exists.

Now, my worry is, within two months of that being set up, donors are like, well, well, you know, the money’s sitting there. We’re not using it. Shouldn’t we use it for something else? And this is a problem because, you know, after whatever it is, 12 trillion (dollars), 14 trillion (dollars), whatever it costs, to me half a billion dollars was not a lot of money. But how do we think about that in terms of doing it? And one of the risk things – we didn’t have time to talk about here – but for the Bank, is if we could get the Bank to use its financial resources to help with this, that would be great. But to do it, they’ve got to either accept risk or they have to partner with those that will accept risks. And you have to do that in good administrations and bad administrations, because trying to deal with David Malpass and in terms of his views on these things, he was not happy because we talked to WHO. Well, I mean, hard to be in the middle of a pandemic and not talking to WHO.

You know, this issue of resiliency and, you know, the – you know, the global – the systems for global equity. You know, yes, health workers, unfortunately, have to do everything. And the right answer to that is build more resilient and stronger systems, invest more in your primary health care. I mean, in the developing world 70 percent of the interventions can be done through the primary health care system. What we need is – and I don’t like universal, you know, health care as a moniker because universal means everything. And what we need is progressive universalism, where we, you know, use the most cost-effective interventions, get them out to the most, then the next most cost – so that we can do the most with the resources we have. But we need more resources. There’s no question about it.

And that’s a – not a global problem. That’s a domestic problem. And the challenge is to get countries to think about these issues. You know, for every dollar you spend on vaccines, you get a $54 return. That’s what governments should be spending their money on. Instead, you know, Gavi pays for the vaccines, and they spend their money on tertiary hospitals, because politically they have to do that. So, you know, that that is a conversation. It’s hard to change that, but that would make sense.

And then your question on the political arguments for this. You know, first of all, there is the humanitarian argument. You know, and I don’t underestimate the importance of that. And, you know, here is a nation that says it’s a Christian nation. This is an important part of being a good Samaritan, of doing the right thing. But there is the self-protection argument we started with talking about this. And, you know, when big epidemics occur, they will spread unless there’s systems to stop them. And if you think about, we saw in Ebola in 2014 in West Africa, where ultimately the U.K. military, the U.S. military, I think French military, all had to come, and huge amounts that spread to countries around the world. What we need is a system in place that, you know, allows that to happen. So it was having those discussions with political leaders.

And, lastly, and this is a sad part. As I said, we didn’t think it was the right thing to give leftovers to countries as the way to deal with them. We thought they should buy doses. They should get whatever they wanted, as much as we could, best doses. But at the end, when there were – people had bought three, four, five times the number of doses for their countries, we started with dose donations. And that was important. But there was also an incentive there, because all of a sudden every country – and, again, I talked to the political leaders – nobody wanted to admit there was wastage. There was unbelievable wastage. We were getting criticized if there were 10,000 doses that got wasted but, you know, there were hundreds of millions of doses that were wasted in different places.

I asked the G-7 leaders. I said, can you make a statement and just say there is, you know, wastage everywhere, because if there was then the oppositions, you know, won’t have as much of a leg to stand up and attack people? But they didn’t do that. But, you know, Switzerland published the data. And you could see what the – what the numbers were. So there were all these weird things that were going on in the discussion. And I would get calls from political leaders saying, you’ve got to take these doses. And then I would say, we can’t take a dose that’s a week from expiration, because the country needs time to do it. And then, you know, the countries would say no. And then the prime minister would call the country leader and say, you don’t want to work with us? You don’t want our doses? They say, of course, send us your doses.

And, you know, and then that hurts our credibility, because, you know, we’re trying to protect them. So all of these types of lessons learned. But I think, you know, we need a world where people understand these are real problems and need global solidarity, and the solutions that can’t be done one country at a time. There needs to be a national and a global system in place.

Dr. Bliss: So I want to just end on a looking-ahead note. And, you know, right now it’s a challenging time. We’ve seen cuts to foreign assistance here in the U.S. and Europe. Countries are cutting back and diverting funds. There are multiple challenges.

Dr. Berkely: But they’re increasing their defense funding. So if we can get them to make that connection, that would help, because – yeah.

Dr. Bliss: OK, yeah. That’s a good point. There are – at the same time as all of that is going on, you know, there’s a whole group of new students, graduate students, you know, people who have entered this field either motivated by their experience in the pandemic, and having seen what you and your colleagues really pulled together and achieved. So, I guess, what’s your advice for people who might be feeling a little bit of existential dread at the moment, having gone into this career path of global health and kind of wondering what’s happening? And do you – what gives you hope as you – as you kind of look ahead, and you might share with that next generation?

Dr. Berkely: Yeah. I actually think, in a sense, the global health people are better off, in a funny way. I mean, the thing that really worries me are our next generation of researchers, you know, because, you know, here you are, dedicating your life, probably getting paid less, taking years to get, you know, your first NIH grant, and tenure, and all of that. And now all of a sudden everything’s slashed, you know, and labs are closing down. And, you know, how do you rebuild that, because, you know, people – there’s other things they can do. They can get paid a lot more money. They can have, you know, other careers. So I think it’s a bigger problem there.

I think the global issues will come back. I don’t know what they’re going to look like. They’ll be different. But the need certainly is there. And so the real challenges is how do we think about articulating it and getting the buy in, which is a little bit of what the questions were, and then how do we figure out how that gets financed? You know, I don’t think it’s industry’s job to pay for all this. I don’t think it’s necessary philanthropy’s job to pay for all of this, because a lot of this has to be government. But there are roles that everybody has to play. And I think that’s going to be the way to move things forward. And thinking about it, institutions like this play an important role because you’re a trusted institution that can, you know, have these discussions to get us back to a place where, you know, we’re talking about data, we’re talking, you know, about facts, and can be in a position to use that to, you know, create discussions that are the right discussions to protect populations.

And I think, at the end, that’s what it’s about. And, you know, and lastly, I would say that, you know, for the young people who are discouraged about what they’re seeing, you know, say something about it. Get active. Vote. You know, donate money if you have it. Volunteer. But, you know, we need – we need people. I mean, there’s too much silence on the things that are happening. You know, you talk to people individually, everybody says it’s terrible. But, you know, we don’t have enough of that voiced. And we need that desperately at this time, I think.

Dr. Bliss: Well, Seth Berkley, author of “Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity,” thank you for lending your voice to this conversation today, and really for taking the time to capture, you know, your thoughts on the history of that important period and sharing this book with us. I know this is the beginning of a whirlwind tour. So thank you for stopping here. And good luck to you. I hope we can continue the conversation.

Dr. Berkely: And thank you, Katherine, for your excellent questions. And in enjoyed the conversation.

Dr. Bliss: Well, thank you as well. (Applause.)

 (END.)