CGD Podcast: Vaccines in a Changing Global Health Landscape with Seth Berkley

Rachel Glennerster: Welcome to the Center for Global Development Podcast. I'm Rachel Glennerster, president of CGD. Today, we're going to try something a little bit different. Recently, I had a conversation with Seth Berkley, who was the CEO of Gavi, the Vaccine Alliance, the world's largest immunization alliance, which buys and provides immunizations to many countries around the world. The conversation was recorded in the context of an event, which is why it's a little bit different. Seth played a very big role in the response to COVID-19 and getting vaccines out to low- and middle-income countries.

Seth and I have worked together on many different topics over the years, known each other for a long time, and he and I were talking in the context of his new book, Fair Doses, about everything from the benefit of vaccines, vaccine skepticism, what happened in COVID-19. We think very similarly on some things and quite differently on others. I think you'll find it an engaging conversation. Hope you enjoy it.

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Rachel Glennerster: Welcome to everyone here, and it's great to be here to introduce Seth Berkley, who is going to talk about his new book, Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity. Seth has been a really important voice on public health, in particular vaccines, for a long time now. He was a co-founder of COVAX, which is the mechanism that provided both a platform for all countries around the world to buy COVID vaccines, but also provided the mechanism to provide free vaccines to low-income and lower-middle-income countries. His new book offers an insider view into that whole process, as well as the science of vaccines, and various fights on vaccines across many decades. Seth, do you want to just give us a little introduction about the book?

Seth Berkley: Great, fabulous. First of all, it's great to be here. Thank you for having me. As all of you can probably imagine, I'm passionate about vaccines and the effects they've had. If you look at the history of vaccines, we've gone from, in the early 1970s, having less than 5% of people in the world receive even a single dose of vaccines to now being the widely, most distributed health intervention in the world.

I track that story. I try to bring us into what type of institutions, what type of mechanisms, a lot of the people who are interesting, and the stories that go with them. Of course, with that has been an unbelievable reduction in vaccine-preventable diseases, about a 70% reduction in vaccine-preventable diseases, which has contributed to more than a 50% reduction in under-five child mortality, which is the statistic we used to use to talk about development.

We've really seen this incredible change occur over time. Of course, then we moved into a set of different interventions on how to make vaccines, and we had new vaccines against cancer and vaccines against parasitic diseases. How did that happen, and what were the challenges? Then, finally, digging into the creation of COVAX. That was particularly important because when COVAX started, we didn't have a mandate. We didn't have any money.

We didn't have any people, but we knew, given the previous pandemic of avian influenza, that the West was likely to buy up all of the vaccines. There'd be none left for the rest of the world. The idea was, could we do something to try to change that dynamic? We had to create something out of whole cloth, COVAX. There was a lot of challenges, criticism, and the purpose really was to set the record straight, at least from my point of view.

Many of the stories that I tell in the book are stories that I didn't tell publicly. It's not that I'm shy, but we were trying to continue to bring pharmaceutical companies along to get political leaders to do the right thing, to make sure there would be good distribution. We were reluctant to be open on some of the challenges that were there. There are many stories of who were good leaders, who were bad leaders, which companies performed well, which didn't, which NGOs performed well, which didn't.

It really gives you a sense. That's why it's an insider view because it gives you a sense of what the challenges really were with the idea, of course, that at the end, we learned from this. It's evolutionarily certain that we will have more outbreaks, more pandemics. The question is, will we learn from the previous and do it better from time and time again as it moves forward? That's just a little bit of a summary of why I wrote it and what it covers.

Rachel Glennerster: Great. Thanks. As you say in the book, COVID vaccines and COVAX was both an amazing success, and then it got two billion doses into the arms of people around the world.

Seth Berkley: 146 countries.

Rachel Glennerster: 146 countries, and yet it also did not achieve everything that we wanted it to achieve as far or, more importantly, as fast as there was this big differential between how quickly rich countries got their people vaccinated and how quickly poor countries got people vaccinated. What lessons would you draw from that in terms of what would you do differently next time? Where were some of the barriers?

Seth Berkley: The first and most important barrier, from my perspective, really related to the fact that there was no financing available on day zero. When we decided to set up COVAX right at the beginning, we had no money, we had no people, so we had to go out and fundraise. We ultimately raised $12.5 billion, but that took a long time. It's not just it takes time to raise money and get political commitments, but even when you have those commitments at the end of 2020, we had commitments of close to $2 billion, but we only had $400 million in cash.

The board, of course, was saying, "The money we have in Gavi is to vaccinate children against very important diseases." If we use that money to buy COVID vaccines, then those kids will-- there will be epidemics of those disease, and they'll die. We ended up in this crazy risk period, and we ended up taking on enormous risk. We can talk about why we did that because other institutions couldn't. That would perhaps be the single most important.

One of the things that was done later on at the end of the pandemic was to set up a fund, a zero-day facility, that could jump-start this effort. A $500 million is sitting in it with a set of loan guarantees from the European Investment Bank and the Development Finance Corporation to bring it up to $2 billion. The idea is that on day zero, you can begin to prepare countries, you can begin to put orders in place, and you can begin to do technology transfers of vaccines as they move forward.

That, I would say, is one of the most important pieces. You would have thought there would be an infrastructure. There would be a way to deal with things like indemnification and liability, or people who had adverse effects, and we had to set all of that stuff up from scratch. Later on, when countries wanted to give doses, we did not start with those donations. We didn't think that's the way to do this. We should be buying for people, not just taking leftovers that people don't want.

Of course, so many vaccines had been bought by wealthy countries. We had a creative mechanism to do that. That created complex legal structures, et cetera, et cetera. I just want to say, though, not to be naive, because if we had that money on day zero, it doesn't mean that on day zero, we would have gotten the vaccines. As you would expect, every political leader in the world says, "My job is to protect my population."

There was a scramble. There will always be a scramble for doses for the wealthy countries. The challenge is, do you go from 0% to 100% of your population, or do you cover your high-risk population, your healthcare workers, your elderly, in this case, people with comorbidities, and then do you make sure that others in other countries have access to the technology so that you do your best to protect the world? Obviously, you're not safe unless everybody's safe.

That was really the discussion that we tried to have. Some political leaders were, "We're not going to have a single dose leave our country until everybody--" and by the way, it wasn't one dose. We didn't know if any of these vaccines were going to work. Let's buy three, four, five, six different vaccines. They ended up way over supply in the country, which meant there weren't doses for others.

Rachel Glennerster: Research has suggested that 60% to 75% of the delay in poorer countries getting access to these doses was because they put in the requests, the purchasing later than which--

Seth Berkley: There was no money at the beginning.

Rachel Glennerster: There was no money at the beginning.

Seth Berkley: It wouldn't have. That's just the point, being that it wouldn't have been equal. This time, 39 days after the first dose, first jab in the UK, we had our first dose in a Gavi country. That's the best it's ever been. Ideally, it should be the same day.

Rachel Glennerster: I remember the discussions about we should get every country to commit to-- as soon as you've covered your high-risk population, you should start getting doses to other countries. We debated at the time, but I think that's somewhat unrealistic. To me, one of the most optimistic scenarios or the best way to help solve this is to get more production as early as possible so that there's more doses to go around, and then there's less fighting. Absolutely. There were extremes in terms of the US not letting anyone have their AstraZeneca vaccines when they weren't using them at all. There were absolutely clearly extreme positions that made no sense.

Seth Berkley: Not allowing any export of American-made vaccines to other countries at the beginning.

Rachel Glennerster: Yes, but coming back to this point of how do you manage to get a lot of money early on. Again, we debated this at the time. We're now on a high-level panel for the G20 on pandemic preparedness, which is going to come out with recommendations for the G20 about what to do in the future. One of the recommendations there is to allow multilateral development banks to lend to middle-income countries to be able to make contracts on day one or very early in the same way that high-income countries did before a vaccine is approved.

They didn't do that last time. I've been optimistic that multilateral development banks are the source of very large amounts of money. Therefore, you have to get them involved. You've been quite critical about how slow they are, how cautious they are, and you worry about relying on them too much. Can you explain a little bit about why you think-- given that we're in DC, a few streets away from the World Bank, what is your concern? How do you think they failed?

Seth Berkley: First of all, the Willie Sutton principle of, "Why do we go to the banks? That's where the money is." I fully agree that is a logical decision. If we go back in history, every time there is a pandemic, the bank says, "We're there. We're going to do things." Every time, they haven't been able to. It's not because they don't care, and it's not because they don't have mechanisms. It is this risk issue.

Particularly with IDA, there is a sense that we can't lose a single dollar. If you're going to invest in vaccines before they're licensed, before we know that they work, you're sometimes going to invest in vaccines that don't work, and you're going to lose money. This is where we ended up, little David to Goliath, having to backstop the bank because they just said, "We have this money." We've made it very hard, by the way, for me to raise money.

Initially, they said they had $12 billion, then they had $20 billion. I was like, "Great." The board was like, "Great, it's problem solved. It's all done," but then countries were saying, "We can't get access to the money. We can't buy vaccines with it." At the end, we even had to provide funding for the health systems that would deliver vaccines because it wasn't as agile as it could be. If there is reform of the system and if the banks want to do it, that would be great.

Let me explain the risk that was involved, and I think it's important. We raised money, and then we started putting contracts in place well before any of these vaccines, any of them had shown efficacy. Now, it turns out the reason we were so lucky and the vaccines worked as well as they did, most of them worked, was because research had been done over the last 15 years on other coronaviruses.

We knew how to design a vaccine for coronaviruses. None of those had been licensed, and we didn't know large safety, et cetera, but we had that science. Again, that's important as we slash budgets for NIH, as we slash budgets for BART, as we do this. These were the things that allowed us to have the science that was in good place to do that. Imagine that I had taken development aid, and I had put all these contracts in place, and none of the vaccines worked.

I had taken billions of dollars of money. My head would be on a stake with people running around with it there. I make that point because this is inherent what is in a pandemic, particularly with a novel agent. It's different if it's a flu pandemic, and you know how to make the vaccines, et cetera. I think the challenge is you have to have that risk taken somewhere, and if you can convince people. At the end, I convinced the donors, I think. Although had that happened, I'm sure it would've been very different.

This is a mindset, particularly in development. It's a new world now. I know. In those days, initially, we have to do something for the developing world, but then there was, "Oh, my God, we heard that there were a few doses wasted in Country X." There was a reporter that said some doses were wasted. When I looked across the G7 countries, massive numbers of doses were wasted, but none of them were transparent.

Switzerland was. It wasted lots and lots of doses, which I talk about in the book. I said to the G7 leaders, I said, "Look, if you could just admit that everybody's got wastage because of buying all these different vaccines and doses expiring, et cetera, then it'll be okay." Everybody's afraid that the opposition party will say, "Look, they wasted all this money." Those are the reasons I'm so uncomfortable, and I document in the book.

I understand it was a particular political moment with David Malpass, who's not a particularly friendly leader because, at that point, we were still talking to WHO. We were trying to work with them with others, but he excluded us, even though we had all of the money to buy things. The risk from any of the discussions didn't allow us to work with MIGA for guarantees. That really was a challenge.

The first decision the board took, and the only reason we found out about it was because they called us and said, "Does this make any sense?" was that any vaccine the bank would buy should have approvals from stringent regulatory authorities in three different regions. Now, that excludes all developing country manufacturers, to your point, of expanding the base of manufacturing. Of course, that wouldn't happen for a period of time.

It would kneecap developing countries to not getting vaccines quickly at all. It really is about them getting to the place where they can move quickly and partner with people, which they eventually did partner with us. Had they partnered with us and brought the financial muscle along, we still could have taken some of the risk as we did, but it would've been a natural thing instead of just going on its own.

Rachel Glennerster: Yes. Just to reiterate that point and make it clear for maybe people who weren't as in the weeds as this as we were at the time, the first Trump administration was very critical of the WHO. The head of the World Bank is appointed by the US administration. There was this push, not for the World Bank, not to work with the WHO, which, in the middle of the pandemic, makes things extremely difficult and got in the way of these discussions.

Seth Berkley: The first Trump administration gave Gavi a 5% increase. It was the only health organization that got that. We had broad bipartisan support. Republicans have always been strong support of child survival initiatives and particularly things like vaccines. We had friends there. In September of 2020, Trump decided not to support COVAX because we worked with WHO. Now, imagine trying to put a global effort together and saying, "We're not going to work with WHO at all," it just doesn't make any sense because they have access.

They have engagement. We had, at that point, 193 countries working as part of COVAX. Only the US and Russia and a couple of small countries weren't there. We got a global consensus that something needed to be done, and we needed to move this forward. It was a real problem because, at that point, we were looking for US money and US doses, which we ultimately got. There's a really interesting story of how that happens in the book.

Rachel Glennerster: Your book isn't only about the COVID-19 vaccine. You've done a huge amount of work on childhood immunizations. Again, a huge success in that 90% of children worldwide get at least one vaccine, but there's that stubborn 10% who are not getting vaccinated. To what extent do you think that is vaccine skepticism, or is it simply hard-to-reach communities in fragile and conflict-affected areas? Are there cost-effective ways to get to that last 10%?

Seth Berkley: That is really a great question. That 10% we call zero-dose communities. Why are they important? It turns out that 50% of the child mortality is occurring in those two-thirds of them who are below the poverty line. I made the case when I was at Gavi that because it's measurable, it's a metric, it's something you can do, this is a great way to think about equity.

Now, I would make an argument. If you cared about pandemics and you cared about them, not for the rest of the world, just for the US, what you'd want to do is have a surveillance system that allowed you to know what was going on. These are, in essence, dark spots in terms of health. Because if you don't have vaccines, given that it's the most widely distributed intervention, you don't have anything. You would argue that if you could extend that supply chain out to reach that last zero-dose community, you then have some type of health worker.

You can report back. You get health interventions, vaccines, obviously, but others would follow. Now, what's changed is if you think about traditional development parlance, it's the Tukol in the distance in an African country, and you say, "This is the people you're missing and very hard to reach." Today, it's a little bit of that, but it's much more urban slums. It's displaced people. It's migrants. It's people who are intentionally put aside by the government.

You need completely different mechanisms to get to these populations, but it is certainly doable. I would argue that it should be one of the top development priorities. By the way, not just for global, but for local countries because, again, it's inevitable given the increase in climate change, the density of urban populations, the changing vector landscape that displaced people in travel that will have more epidemics and pandemics. Those are expensive, and they're risky. How do you do that? You reach these pockets that aren't there.

There is an effort at Gavi in terms of this zero-dose. The pandemic displaced it for a while, but it is moving forward. There's lots of things that have to happen. You mentioned the second problem now, and that is vaccine hesitancy. There's always been vaccine hesitancy, from the first vaccine of smallpox, where the wood cuttings from the time had people having cows' horns growing out of their heads because it was made from cows.

It's always been rumors. It was relatively easy to use expertise, to use local health workers, religious leaders to village chiefs, whatever, to educate and get campaigns going. It's different now. The misinformation is spreading and disinformation at the speed of light, literally, because of the internet. We have Russian bots, Chinese bots, North Korean bots, and by the way, the US government, which I document in the book as well, out spreading disinformation on vaccines, which is just unbelievable.

One of the challenges is as it becomes politicized, you end up with a situation where your local leader is trying to argue with the expertise, let's say, of the greatest country in the world, the most technologically advanced country in the world, et cetera, when recommendations get put out that have no basis in science and are completely driven by conspiracy theorists. This is a bigger and bigger problem. It isn't most of the reason for the zero-dose, but it is spreading around the world and a really big problem.

Rachel Glennerster: It's interesting. At least in the data, I've seen vaccine hesitancy as less of a problem in low-income countries. I work a lot in Pakistan, and there were rumors spreading at one point. You saw, in the data, a big fall in.

Seth Berkley: It turns out that before COVID, what happened was if you go to the developing world, people still see these diseases. Auntie's son died. There's somebody who's got a limp from polio. There's somebody who has a morbidity from one of these diseases. People, therefore, understand that these are important diseases. Then you go to wealthy communities, for example, in the US, who are going organic and green, and they're like, "Why are we getting all these shots?"

So many of them, and the babies are crying when they get them, and do they need them, and what's in them? It really was this lack of understanding of the diseases. That's even worse now, where people are saying, "Oh, measles, it's good for you." We saved 60 million lives in the first part of the 2000s around the world through measles of vaccines. The people who are saying these things have no idea what they're talking about. This is the problem. I think this intentional disinformation, particularly from political leaders, I don't know how we're going to get around that.

Now, I see in the US, everything is moving to the states. There's 350 anti-vaccine bills that are at state-level, anti-science bills. I know now some states that are forming their own recommendations because they don't trust the federal government, ACIP, et cetera. You're going to confuse people even more. It's important to have the right data out there. When you have recommendations, you got to look. Is it from the American Academy of Pediatrics, the Infectious Diseases Society of America, this state consortium? How do you tell?

Rachel Glennerster: There is now important work on how to combat misinformation, and I think we need to do even more on that.

Seth Berkley: Just to be clear, there's two things. There's misinformation. Misinformation is your auntie who tells you something that she heard somewhere, but she's not doing it nefariously. She heard it. Then there's disinformation, where people know it's wrong, and they're putting it out for a political reason. That is the big problem, though.

Rachel Glennerster: Or to make money from other supplements.

Seth Berkley: For a reason, yes. A lot of money.

Rachel Glennerster: Let's switch to vaccine innovation. We first met when you were working on the International AIDS Vaccine Initiative, IAVI, which didn't just work on the idea of getting a vaccine for HIV, but tuberculosis and other areas. There's huge potential for innovation in vaccines for other diseases that are important in low- and middle-income countries, but we didn't get a vaccine for AIDS. Why do you think it's taken so long, and why do you think we don't get as much innovation in vaccines as you would think we would need, given the huge potential benefits?

Seth Berkley: By the way, the licensing of lenacapavir is an important adjuvant for this type of stuff, but you still would prefer to have a vaccine that provides protection that you can give with people not having to go in and get this type of treatment. HIV is the most difficult vaccine. I think that's even what the chapter is called that talks about that. The reason it's so difficult is you get infected with one or maybe two strains of virus. After a month, you have a billion completely different viruses circulating.

It's not that the immune system can't provide protection against, but it's constantly trying to make protection against the new circulating strains. When we started, we didn't really understand all of this. As we began to understand the science, we changed our direction. It turns out that humans can make broadly neutralizing antibodies that cover many, if not all, of the strains.

We shifted to that focus. We were able to protect animals, for example, by doing gene therapy to put in these antibodies, or just even putting the antibodies in passively. There was a process to try to turn this into an immunization strategy. This was a long process because there's what's called post-translation modification. You have to put it the right way and get the right antigens, and you have to do different vaccines.

The research was underway, and it was making progress. Of course, it just got killed after years of work and data, both from funding from NIH and USAID and the cohorts that had been followed back from when I ran IAVI. It's really, from my perspective, quite tragic from a scientific point of view. Again, this is a lesson learned that may be important for other viruses. It's always the science, just like we heard when the COVID vaccine came, because we did SARS and MERS, and you use that science for it.

The thing that I talk about in the book that's important is there is a market failure in a way, but it's not really a failure. If you looked at Ebola, a very important agent in that it can spread. It can cause a lot of disease. First 26 epidemics were small outbreaks in very poor parts of Africa with, in essence, almost zero money. It's not really a market failure because the market says, "Who am I going to sell this to?"

In that case, you need some other mechanism to finance the development of that vaccine. We ended up putting together an innovative financing mechanism once the big 2014 outbreak occurred. We had a vaccine that was already there from bioterrorism side. Then how do we turn that from an experimental vaccine? We showed it had efficacy to ultimately turning it into a vaccine that would be licensed and made available. A lot of that is innovative financing mechanisms.

You're right. We're in the middle of a renaissance of vaccines. Science is unbelievable. We now have two cancer vaccines for liver cancer and cervical cancer. It's Hepatitis B and HPV. We have our first parasitic vaccine for malaria. We have a couple of them now. We're going to see soon, vaccines against cancer antigens. What that means is that we're going to have vaccines that primarily treat the cancer, not just treating the infections that are antecedent to the cancer.

It's an incredibly exciting time. We have all these amazing diseases that have been with us for millennia, parasites and other infectious diseases that are endemic to the developing world. We're going to need research efforts to do that. What do we have to do? We have to, first of all, I think, from a global point of view, prioritize these things. It doesn't have to be done in every country. Just has to be done. How do we do that? If it's not going to be done in the US, it'll be done elsewhere.

We have to continue to build up capacity. IAVI, one of the things I'm most proud of is we built amazing laboratories around the world and worked on doing trial design in countries. Those laboratories, those people are still there. They're still doing science. That's how we're going to move forward, but it's going to need public finance at the end, or philanthropic, but it can't be done through commercial for these rare diseases.

Rachel Glennerster: You've talked about the complicated science involved in HIV vaccines. Just to build on the economic challenges there, you said it's not a market failure that you might only have a few people who need the vaccine because you can ring-fence. If you're lucky and early, you can ring-fence, and then you're not actually selling many vaccines. You're absolutely right that it means that there's not a huge market, but there's a huge cost to the rest of the world if you don't do it. I would argue that's a market failure in that a lot of the benefit from a vaccine goes to people who aren't taking the vaccine.

Seth Berkley: Yes, but I meant for the companies. It's not really a market failure. Their analysis is right. You're not going to make money on this. In fact, people are going to say you should give it away free.

Rachel Glennerster: Yes, exactly. The companies are making a sensible decision in that they aren't going to make a lot of money for this, but the world benefits a lot. Therefore, we need to subsidize it.

Seth Berkley: What's interesting, just announced a couple of days ago, CEPI is setting up a stockpile for Nipah with the Serum Institute of India, and going to keep a hundred thousand investigational doses there. This is a new model that's coming up, and we'll see how this works because is it going to sustain over time? Will they ever green the vaccines? One of the things I talk about at the end of the book, in the epilogue, is-- the question is, are we better prepared after COVID?

The answer is, in some ways, a little bit better. In many ways, now worse. I give some examples of Ebola Sudan that occurred afterwards, and how we weren't prepared. That's an interesting case because Ebola Zaire, we had a stockpile. We had a license. We did all of that. The story's in there. Ebola Sudan, we knew about it. There's also Ebola Bundibugyo. There's a bunch of different strains. We had vaccines made, but they weren't in a vial ready to go.

It took 78 days to take the bulk, put it in vials, test it, make sure it was still stable and sterile, and da-da-da-da-da. Amazingly, for big outbreak, the Ugandan ministry got it under control in 74 days. At the end, you couldn't test the vaccine. Now, the good news is they got it under control. The next time it was in a vial, four days, they used the vaccine. The positive example is Marburg in Rwanda, where CEPI had done an exercise with the government on how to do this. It took eight and a half days for them to have the Marburg virus there, and they were able to use it. They had the lowest mortality in any Marburg outbreaks.

This is going to be about having that type of preparedness. To your point, the cost savings for the world are enormous. How do you explain that? Now, this is the challenge we have. The US government has stepped away from Gavi. It's not supporting Gavi at the moment. You can say from a humanitarian point of view, that's a terrible thing. From a self-preservation point of view, to protect Americans from these diseases that will absolutely come back as people move around the world, it's just, from my perspective, crazy.

Rachel Glennerster: You've touched on the cuts in aid in the US, but also, actually, in many countries around the world are cutting back on aid. The global health community is particularly being badly hit by those cuts. The Center for Global Development, we've been doing this series called Tough Times, Tough Choices. We can argue that the funding ought to go up. Given that we are facing these cuts, what are some of the tough decisions that have to be made?

In that work, a couple of the suggestions have been WHO, which is facing a huge cut, should focus on its core mission of this global mandate for doing things like reviewing new medicines and new vaccines and cut back on its country work, even though that's very important, and in Gavi, to protect the vaccines going to low-income countries and maybe cut back on some of the health systems work that maybe can be taken on by other people. Also, on the subsidies given to African manufacturing would be another place that it could cut back if it wanted to preserve the money going to the pure vaccines for low-income countries. I know these are difficult questions. Do you have views about--

Seth Berkley: I could make a slightly different argument. Vaccines don't deliver themselves. The reason we put a health systems approach in place wasn't to say we're a health systems agency. There was a short period people tried to say that, but not in my time. We're a vaccine agency, but vaccines need to be delivered, and you need health workers. The amazing thing during the pandemic is the routine vaccines went down 4% in 2020 and about 1% more in 2021.

That's a terrible thing because these are really important vaccines. If you think about what actually happened, these health workers are the heroes. I dedicate the book to them. They actually delivered three times the numbers of vaccines they had ever delivered before during that year. Actually, if you think about it, they should have gone down way more than that. Why is that? There was a system. There were cold chain points. There were trained people. There were supply chains for syringes and all of these other issues.

I think, in a way, it's a little bit cutting your nose off to spite your face if you kill that system's money. Now, should we be paying attention to other systems issues? Probably not. I think in that narrow way, you want to do that. I would argue, by the way, that if countries are really rational, they don't spend a penny on health until they spend on vaccines, because for every dollar you spend on vaccines, you get a $54 benefit.

It's the most cost-effective intervention. It has this public health effect. You could also make the argument to say, this should be their core expenditure. Forget about the teaching hospitals. Forget about other things. That would be the logical thing to do. Now, I understand, politically, you can't do that. We also are able to drive the prices down 98% from what it is here in the US by massive purchasing and moving to developing-country manufacturers.

I think a lot of those arguments have to come out. I think at the end, what the world is going to need is access to tools at reasonable prices of high quality, to your point, that WHO needs to be paying attention to that quality. We need to make sure that happens, and then we need to use domestic finance to be about cost-effectiveness. We need progressive universalism. I can't stand the argument that just says, "Oh, we need universal healthcare."

All right, yes, I believe health should be a right. We can't have teaching hospitals on every corner in every place in the world, given the cost. What do you do? You do the most cost-effective interventions when you get those out as widely as possible. You have more resources. You go to the next one, and the next one, and the next one. I think that's the type of discussion that has to happen. It is a tough time.

I do believe the US will come back. I think one other point I'd make that I think is really important is, right now, we're increasing defense expenditures. The US is talking about going up 12% to $1 trillion. Here's a little fact for everybody that may surprise you. More Americans died of COVID than soldiers died in all wars since the Civil War, American soldiers all wars since the Civil War from one infectious disease.

Is it smart to be slashing global health money and money towards these types of diseases at the same time we are saying military is going to make us a secure country? I think this is not a smart thing to be doing. We need a little bit more of that argument, and we need a little bit more of the defense thinking where they have multiple redundant systems. They pay attention to not worrying so much about waste, but paying attention to really what the threats are in trying to prepare for them. I think that's where we ought to be thinking.

Rachel Glennerster: Okay, I'm going to turn to the audience now for some questions. Who would like to start us off?

Jed Meline: My name's Jed Meline. I'm with Project HOPE. As the pandemic began to wind down, the Biden administration and other global leaders around the world were talking about establishing a multilateral organization for pandemics. The Pandemic Fund, that's hardly a Gavi or a Global Fund or a WHO or a UNAIDS for pandemic preparedness. In the end, nothing was created other than The Pandemic Fund. Was that a lost opportunity, or where would you think, should it have been at Gavi, should it have been Global Fund? Curious about your thoughts on that, and then what might be done about that now?

Chelsea Cherenfant: I'm Chelsea Cherenfant. I just graduated with my MPH from GW, and I did my master's thesis on vaccine hesitancy in Nigeria and Malawi. Really grateful to hear your thoughts on a lot of the various issues that are going on, and looking at vaccine access, delivery, and innovation, because all of those have an impact on vaccine hesitancy. Before my question, though, I did want to push back a little bit on the idea that vaccine hesitancy is not an issue in low- and middle-income countries.

The example of Malawi, it's had such a great historic record of immunization. Especially with COVID-19, we've seen that sliding. One thing that I wanted to ask in relation to that is what are some strategies to reverse that trend or keep up high immunization rates in countries that have that historic rate and have seen that slide? It hasn't just impacted COVID-19. We've seen that with routine child immunization as well as with HPV. How do you combat some of the narratives that are starting to seem repetitive when it comes to misinformation?

Seth Berkley: Thanks for the great questions. I worry a little bit about the idea that every time we have a need, we create a new institution, a new fund. In a sense, it's important. I understand why it's attractive, but I think my lesson learned, and again, I'm biased because of having run Gavi, but the lesson there was don't try to make everything yourself. The Gavi is an alliance on purpose.

We took the best of UNICEF and the best of WHO and the best of civil society and the best of the World Bank, and all working together to move things forward. It means your staffing is lower, but it also means buy-in from these institutions, and you can move this forward. That would be the model I would do going forward. When I left, one of the things we set up was a fund whose specific role was to keep the conversation going among all the partners to have them think through how they might keep ever warm some of the tools we created, and do all of that.

Now, at the end, if money won't flow and authority won't flow, then that's a problem. That's, by the way, the sensitivity with the bank because one of the easy things to do is say, "Well, the bank's big. It's got money. It's got balance sheet. Just give it to it," but that's only going to work if it's willing to take these risk issues on and work with everybody else. I think that is the better way to do it is to have networks, which can expand at time of crisis and shrink back down. I think that'll be the most cost-effective to do it because you don't know whether it's going to be next year or it's going to be 10 years away.

The one challenge with that is we don't have a good agency right now for diagnostics. There are some challenges with some of the PPE and other things. One would need to assign some of those things to agencies and figure out how to do it, but I think that's what should happen. By the way, the last thing I'd say is you can't rely on national agencies, as there was a big sense of, "Oh, BART will do it for the world," or whatever. Given politics and the way things shift, you can't do that. You do need to have something that is focused on the rest of the world that needs to go forward.

The question about disinformation, it's really hard because it isn't even a health question. It's a expert question. It's a institution question. I don't personally understand how you make America great again by killing the most prominent academic institutions that everybody in the world wants to go to where you're training people. You're in this awkward situation. To me, it has to swing back. A lot of the problem to me right now, and understand the politics around this, but a lot of the problem right now is we've all discovered social media as a way to get information.

Of course, on social media, any ideas, particularly if you're an influencer, can have an effect without necessarily the science to back it up. People don't have their own ability to understand that science. How do we return to a situation where you have some experts, and those experts, by the way, have to have some humility? I think this is the problem during the pandemic, because we said if you're an expert on day one, what do we do? You have to say something. You say, "Stay 6 feet apart." Where's the science that says 6 feet as opposed to 5'11" or 6'3"? There isn't any, but that's an educated guess.

As you understand the aerosol droplet transmission masks, you can adjust it. Part of having humility as a scientist is saying that science is constantly-- it's not meaning you're lying or wrong, you're just doing the best you can. We need to start there. I think at the end, and this gets back to the issue that the lady asked who's working in Nigeria and Malawi, I didn't say that vaccine hesitancy is not an issue in development. It absolutely is. I said prior to COVID, it was less of an issue in developing countries because they understood why vaccines were important, and we had not so much of that.

I think what we really need in those countries is to somehow separate this political disinformation from the facts and science. Nigeria has a fabulous health minister, who is very well-trained and understands science. How do we get that to be the trusted information that gets put out, and not the stuff that is being put in partially by American evangelists to provide disinformation? I think we've just given everybody in the world the tools to provide this disinformation.

On the question of US is doing it because other countries do it, two wrongs don't make a right. I thought the US had learned a lesson when they went to Pakistan and when they were trying to find Osama bin Laden. They had this fake campaign. That led to a lot of the attacks and distrusts on polio workers and all of that. I thought we learned a lesson. There was a period where people said, "Never again for vaccines." Vaccines are too important, and that trust is too important.

We ended up going to the Philippines and telling that the Chinese vaccines had pork products in it and the Middle East and that they weren't efficacious, et cetera. When you lose trust in one vaccine, you lose trust in more than that, and you lose trust in the system and the people that are doing it. I think we're in a difficult time, but it's going to come back to strong institutions. Strong science is the only way I know how to fix this.

Rachel Glennerster: You've talked a little bit about the international institutions need to be doing in preparation for the future pandemics, but there's a question online about what are the immediate steps that governments should be doing now to get us in a better shape for more equitable access next time?

Seth Berkley: There are a couple of answers to that question. First of all is I'm talking about vaccines. Mostly, that's my area of expertise. It is not definitive. We talked about HIV. Still don't have a vaccine today after 40-plus years of work. There's always going to be a vaccine as an intervention. What you need to do is also be prepared to have non-specific interventions. After the pandemic, we heard political leaders say, "We will never mandate masks, never mandate masks again." I'm like, "If you had a 50% mortality respiratory infection that's fast spreading in the country, you're not going to mandate masks?" "Never."

One, we have to be realistic, and don't ever say never. We have to prepare for where we have interventions, where we don't have interventions. Until we have the interventions, we have to use the non-specific interventions that are there. That's number one. We have to build out those systems so that we reach those areas that are dark and bring light to them and bring systems to them, and bring delivery. I think that's a real priority.

As I said, it can't be every country. This is the problem. If every country wants to make its own vaccines, it's not going to happen. The supply chains will be too complicated. We have to figure out how to have some centers that are doing that work, and then the supply chains are secure, and that the science continues. Again, if I use the US pulling away from mRNA, mRNA is not necessarily the best vaccines. I can say that. I can explain why I'm saying that, but they are the fastest, at least today.

If you have a fast-moving, highly fatal disease, or even if you were trying to treat a cancer patient with an individual vaccine, you want that fast mechanism to be there. If you don't think it's safe or you think it has problems, what do you do with that circumstance? You do research on it. You don't just slash the research because then you don't get the information. I think we're not necessarily logically moving forward, and that's what governments have to do.

I would hope that other governments would take on these issues, although the US had been a traditional leader of this. As I said before, maybe the Defense Department will understand the risk that we're at, and maybe they will step up, including one of the reasons that the cuts in the UK and France and Germany and other places are happening is because they're having to massively increase their defense spending. It may be even, as part of that spending, they can put some into surveillance. We are way overdue for a bioterrorism episode.

It's, in a sense, a much better way to do terrorism. I'm sorry to say that, but the reason is we're always worried about nuclear issues. There are footprints of the nuclear materials that you can figure out where they come from. You can't do that with biologics. It's very attractive. Synthetic biology is everywhere. The knowledge is everywhere. You have AI that can help you design things. It's really scary. Again, if people aren't thinking about this, then they are not living in a globally secure world. I just think if politicians aren't thinking about that, we need the people to remind them that this is important.

Rachel Glennerster: I'll just end with another question from our online audience. Given the geopolitical shifts, aid cuts, and the disinformation that you've talked about, can we survive the next pandemic?

Seth Berkley: I think it depends upon what the next pandemic is. That, I think, is the problem. We prepared previously for a pandemic. We had a system in place. We had some preparations, and that was supposed to be flu. Of course, lo and behold, it was COVID, novel agent. We don't know what's going to happen next. It might be flu. By the way, COVID isn't gone. We don't want to discuss it, but it can continue to change.

We might have a strain that comes out that is different enough that it's not going to be recognized with some of the protection and might have more lethality. It really is going to depend on what's there. Right now, we are not as prepared as we should be. To your point, we were able to produce 11 billion doses of vaccine in 2021. That's enough to vaccinate every person on earth because, in those days, we didn't have pediatric vaccines.

We could have vaccinated everybody. That was just an issue of where it went and over-ordering and all of that. From a supply point of view, we might be okay, depending upon what technologies that's there. I worry about the research and the diffusion of that research and, obviously, the equity issues. It's something we should be prepared for. You never can be say, "Yes, we're there," but we should be a lot better place than we are now.

Rachel Glennerster: Great. Thank you, everyone, for coming. Thank you for writing this book because I think we absolutely need to be taking some of these actions to better prepare if a next pandemic comes, but when.

Seth Berkley: Thank you.

[applause]

Rachel Glennerster: I hope you enjoyed that discussion. As came up in the discussion with Seth, I really think that the COVID-19 vaccine experience was both a huge success in that we managed to get a vaccine much faster than anyone had predicted, and also a failure or a huge tragedy, because millions of people died. There were a lot of deaths that we could have prevented. I think there's a lot of lessons to be learned from that experience.

There's recently come out a report from the high-level panel that both Seth and I were on, which tries to draw out some of those lessons and, more importantly, put forward proposals and recommendations for policy changes that we can put in place now to make sure that we learn those lessons, and we make sure that any future pandemics have much less impact. I, in particular, was pushing a lot for changes in how the World Bank and multilateral development banks can reform how they work.

Specifically, I think there is an important thing that needs to change in how MDBs cope with pandemics, which is that they need to allow low- and middle-income countries to borrow to purchase vaccines and other countermeasures at risk. What do I mean by that? Just like the UK and the US started investing in vaccines and buying vaccines in the summer, actually late spring and early summer of 2020, lower- and middle-income countries should be able to do the same.

They were not able to do that because they could not borrow money from the World Bank and other MDBs to buy a vaccine that didn't yet exist, that hadn't reached regulatory approval. That is why they were at the back of the queue when it came to vaccine. We really need to fix this problem. I think it's really interesting when I work with people from the health community, like Seth, that they are much more skeptical of these multilateral development banks or what they can do.

They were very frustrated at how slowly they moved on vaccines in the pandemic because they moved very fast on other things. I think it's really important that we try and understand across disciplines why economists are probably the multilateral development banks and think they're very important institutions, but yet understand the frustrations that other people have with them. Then places like CGD can help try and reform these institutions so they reflect those realities of frustration and areas where they're not working as well as they could.

Thank you for listening. I hope you enjoyed the episode. Please subscribe to our podcast and share it with friends. If you'd like to learn more about this event or about our broader work on global health and pandemic preparedness, please go to CGD's website. You can find lots of material there, including links to the high-level panel and a lot of proposals on global health and pandemics.