Beyond Vaccines: How Can We Prevent the Next Pandemic?

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. This is our last episode for the season, so we’re going to spend it talking about how the pandemic, which has dominated our lives for so long, could finally come to an end. The United States and other rich countries are making strides toward vaccinating their people, but many middle- and low-income countries are facing their worst surges yet of COVID-19. So I wanted to know what it will take to vaccinate the entire world and how we can protect ourselves from a pandemic like this in the future. I’m your host, Shanoor Seervai. And my guest on today’s show is Sandro Galea, a physician and epidemiologist and dean of Boston University’s School of Public Health.

Sandro, welcome to the show.

SANDRO GALEA: Thank you for having me.

SHANOOR SEERVAI: So everyone in the U.S. is desperate for the pandemic to end, but there are still many Americans who are not vaccinated. President Biden says his goal is to ensure that 70 percent of the population is vaccinated by July 4th. Do you think that goal is too ambitious or is it not ambitious enough?

SANDRO GALEA: I think it’s good to have ambitious goals. It strikes me as a reasonable goal and I think we are on track to achieve that. Of course, vaccinating the people who are not vaccinated is getting harder and harder because there is now plenty of vaccine supply. And really the issue we’re having is with groups of people who are harder to reach, who do not trust the system, or who do not want to get vaccinated for a variety of different reasons. So it will become harder to achieve higher vaccination rates at this point. But I do think it’s reasonable to aspire to 70 percent. I think it’s a good ambition. I think it is perhaps achievable.

SHANOOR SEERVAI: So who are these people you’re talking about who are difficult to reach or perhaps don’t want to get vaccinated?

SANDRO GALEA: Well, I think there are different groups of people who are unvaccinated at this point and, in no particular order, I think I would start with the group of people for whom vaccine access remains limited. And that involves people who historically have not been connected to health care systems, who have plenty of good reason to mistrust health systems, as a result they do not want to expose themselves to systems that are going to deliver vaccine. As well as people who have a hard time getting to places, people who have disabilities, who are locked in, and these groups frequently are out-groups, people of color, people of few means and they’re difficult groups to reach. And when a group has had plenty of reasons, for example, communities of color have had good reason to mistrust the health care system for many decades. I think it’s a real stretch to all of a sudden say, “Trust us, you should get the vaccine and get it quickly.”

So in many respects, we are trying to overcome decades of underattention to these groups and asking them to get the vaccine quickly. So I think there’s one group and I think it’s a large group. I think there’s a second group which could have access to the vaccine and could get the vaccine if they wanted to, but for whatever set of reasons, do not believe in the vaccine safety or efficacy. And that group, of course, has a totally different set of issues because it involves convincing that group that the vaccines are safe, efficacious, and important, not just for them, but for everybody else around them.

SHANOOR SEERVAI: So how do we get to each group, those with limited access to vaccines, and then those who do not believe that the vaccines are safe?

SANDRO GALEA: I think the approach with the first group is really an honest effort to make vaccine as widely available as possible in a door-to-door way and acknowledging our past failures in meeting these groups where they need to be met, being honest about it, upfront about it, and making every effort possible to cross that last mile, to get the vaccine over the threshold. For the second group, I think it’s going to require a different approach, one of convincing, one of leading with the science, one of using influencers to convince that group that the vaccines are safe and perhaps as importantly, that they are important to protect them, but also to protect others.

SHANOOR SEERVAI: And the problems that you’re pointing to, you use the phrase out-groups. This is really because we’ve just allowed inequality to exist and deepen in our society for so long. And I can’t help but wonder, how did we get to this point where we have an excess supply of vaccines, but there are just all these people we’re not able to reach because we’ve excluded them for so long?

SANDRO GALEA: What’s happening now is we are reaping what we have sown for decades. The observation that there are out-groups, if I may use that term, these are groups that the dominant society has historically said, “Well, we’ll allow you to be around, but really you’re not one of us. And we don’t have the same access to health care for you.” Which then breeds mistrust over the decades. So what’s happening now with the vaccine challenges is really these issues that have been around for decades, all of a sudden coming crashing around us. I’m often asked, well, how do you build trust in communities, and you can insert community X, let’s say communities of color, communities with fewer assets, or immigrant communities, so that people can get vaccinated. And the answer is I don’t think you can. I don’t think you can build trust in an emergency; trust has to be built over decades.

So now we have the problem of we need groups to be vaccinated without that foundation of trust. The subject of my book that’s coming out in November is that if there is another pandemic, we will have equally catastrophic results unless we invest in these underlying issues, underlying issues, for example, of racism, underlying issues of exclusion, underlying issues of income inequality now. Because those issues come to a fore when there is a crisis, whatever the crisis, a pandemic, a war, a large natural disaster, and inevitably society does much worse than it would have done otherwise if we did not have these underlying divides.

So to my mind, I worry that what’s going to happen once the pandemic is over, and hopefully it will be over relatively soon in this country, is that the only lesson we take from it is what we need to do is invest in vaccines, invest only in having rapid vaccines, rapid diagnostics, and that will take care of everything. And I contend that does not take care of everything because the reason the COVID pandemic was as bad as it was in this country is because we had underinvested in population health and in the structures that keep people healthy, and when the pandemic hit, we were sitting ducks.

SHANOOR SEERVAI: In the U.S., more than 600,000 lives have been lost to COVID-19. Can you tell me why the pandemic has been so devastating here?

SANDRO GALEA: I would argue there are two main reasons why the pandemic was as bad as it was in this country. There are many, many reasons, but we’re just simplify it. The two main reasons are: number one, we were not as healthy as we should have been, and number two, we did not have the societal structures to protect us when a pandemic hits. So let’s talk about each of them. Why were we not as healthy as we should have been? Well, we as Americans live shorter, sicker lives than to all our peers. Now, why is that? Well it’s because all our money that we spend on health — and we spend a lot of money on health, much more than anybody else — goes towards medicine, towards treating us when we’re already sick. We do not spend money on making sure that we are not exposed to violence. We do not spend money making sure that the food that we have available to us is healthy and nutritious. We do not spend money making sure that we have opportunities to exercise. So we are sicker, sicker longer, and die younger. That has nothing to do with the pandemic, that was the case before the pandemic.

But when the pandemic hit, as you know, the greatest risk for severity of COVID was having underlying disease. So it hit a country where we had higher rates of underlying disease than we needed to have. And our task now, as we rebuild, is to make sure that we are not sicker than we have to be, so that when there’s another pandemic, we don’t have the same problem. So, that’s problem A. Problem B is that we’re not structured to deal with something like this. Now, what do I mean by that? Well, the greatest risk for rapid spread of COVID was people being in contact with one another. Higher-income jobs, you’re able to social distance. Lower-income jobs, you’re not. Essential workers, you’re not. So those jobs are people who are already in low-income occupations, predominantly people of color. And those groups, as a result, ended up having much greater incidents early in the pandemic of COVID, and then, of course, severity because of the underlying comorbidity. So we have underinvested in what makes us healthy and we’ve underinvested in the structures that protect all of us.

SHANOOR SEERVAI: So let me ask you this: If you were in charge of the money that we spend on health care in the U.S., or on health, how would you spend it?

SANDRO GALEA: Well, I don’t think that I would spend less on health care. I think when I have a heart attack I want the best possible doctors and nurses to look after me. So this is not a message against health care, far from it. It is simply saying that we need to recognize that our health is generated over our lifetime. And if we as a society do not invest in healthy neighborhoods, healthy places to live, work, and play, healthy food, opportunities for exercise, reducing violence, reducing the risk to all of us from things like guns, reducing the harmful effects of structural racism, interpersonal racism, misogyny, all these forces fundamentally shape a world around us that create our health.

And now COVID, of course, brings all this to light, but you and I could have been having this conversation in 2018. And I would have said roughly the same thing. And now one question which I often get is, “Well, you’re just asking for more spending and who’s got more money for spending?” But the data are actually emerging and pretty clear that that kind of spending returns a tremendous return on investment because healthier populations are more productive, returning more money, both to the private sector and public sector. So it really is a failure of our imagination that we do not more of that. It’s not really a failure of finances.

SHANOOR SEERVAI: Let’s talk about how structural racism impacts people’s health. You mentioned that Americans on average live shorter lives than people in other high-income countries, but people of color in the U.S. live even shorter lives than white people. What are we going to do about that?

SANDRO GALEA: I think we are in a tremendous moment of opportunity for a national reckoning with these forces. And for saying to ourselves we should not accept a world where any measure of identity should be consigning you to have better or poorer health, that everybody should have the opportunity to have maximal health so that they can flourish and achieve their potential. And that calls on us, I think, to say what is it about our decisions, about how people are treated from the moment they’re born, the opportunities that they face, how are those structured so that everybody could have access to resources that produce health? And I realize that saying something like that almost sounds utopian. And one can use words that are unpopular in American conversation, things like socialist and all that. I’m not really talking about anything like that. I’m not making comments about our broader systems of political structures and the extent to which we have a market-driven economy.

I think all of these things could be achieved within the dominant market-driven economy approach that this country has. They simply require an attention to fairness, to creating the social safety net, to having the conversation about how is the transportation policy going to be disadvantaging people of color who live further away from the city core who need to get to their jobs? What is that going to do to their lives? How is a particular set of policies around housing and zoning going to affect immigrants who now cannot afford to live where they used to live despite the fact that their jobs are in hotels downtown? If we ask ourselves that question, we ask ourselves the question how are policies that we’re implementing affecting people who are most influenced by these policies. I think we can structure our policy, structure our politics, in such a way that they’re health-generating.

SHANOOR SEERVAI: Let’s just take one of these examples. You’ve listed many things that you say generate health, could create healthy neighborhoods, you mentioned transportation, housing, food. So let’s just pick one, I leave it to you, and then walk through what it would actually take to invest in that.

SANDRO GALEA: So I’ll use an example from my last book, which was well, what we need to talk about when we talk about health. And I use an example of a composite person. I think her name was Paula in the book. And we used the example of Paula who is born to parents who really don’t have very much money and are working multiple jobs, and they live in an apartment in the city close to a bus depot. Well, the bus depot has a lot of buses spewing diesel. Paula’s asthma is exacerbated. So as a child, she grows up, she has asthma. Her parents are working two jobs because that’s really the only way they can afford to raise her. As a result, she’s at home alone often, and she eats the food that’s available in her neighborhood, which is calorie-dense, nutrient-poor food.

As a result, Paula is carrying more weight than she would otherwise. She’s also not exercising, because she’s by herself much of the time. So already you have a child who now has asthma and who is overweight. So she grows up and of course she’s carrying those into her adulthood. She doesn’t really go to college because her parents are not educated enough to know to channel her into the areas where she could go to college, gets a job working in the food industry, and she’s now on her feet all the time in the food industry. She gets to her early 40s, she’s now overweight, has had asthma for a long time, has been working on her feet for 20 years. And now she has knee pain. She has arthritis in her knees. She goes to see the doctor who says, “You need a knee replacement.”

Now, there is no question that the doctor is doing her best. The doctor sees a patient in front of her who has arthritis in her knees, the doctor says, “Well, it will make it better if you get a knee replacement.” Now we could keep investing our money only in the knee replacement technology, which as I said earlier, there’s nothing wrong with that, we want to make sure that we have the capacity to have knee replacement for people who need it, but wouldn’t it be better for all of us if we created the resources so that Paula doesn’t have these exposures to begin with, all the way from childhood.

I’m often asked, when I give public talks, “Well, what’s the one thing I should do to be healthiest?” And the answer is the one thing you should do to be healthiest is you should choose to be born to well-off, well-educated parents. And it takes people a while to usually say, “Well, wait a second. I can’t choose that.” Well, that’s exactly my point, you cannot choose that. But of course we should be living in a society where we don’t have to depend on the lottery of birth, where we are structured in such a way that everybody has an opportunity to live a healthy life. And that to me would be just.

SHANOOR SEERVAI: The point you make about the lottery of birth, obviously it has a huge bearing in the U.S. context, but I would also like to use that idea to talk about the rest of the world. Many people did not choose to be born in the U.S. or in a country right now which may not have access to vaccines, or which is experiencing a deadly surge of COVID-19 because a variant is spreading. So are there some countries that you’re really worried about which are not going to be able to vaccinate their populations and are really suffering in the pandemic?

SANDRO GALEA: I think the majority of the world falls in that category, it’s not just some countries. When you look at the data, first of all, the U.S. right now is ahead of the rest of the world, with the exception of some other small, fairly wealthy, tiny countries, in terms of its vaccination rate. We are on the brink of reopening as a society, which is terrific, but the majority of countries in the world are further behind, they are now experiencing their third wave. I think this calls for a new reckoning with the question of global health equity, and it’s a really complicated, really difficult discussion because if you were to extend my argument, it becomes, how do we make sure we create equity of opportunity for everybody to flourish around 8 billion people around the world? That’s a really complicated question. And what COVID is doing is it’s forcing these issues to the fore. What does it mean to have vaccine equity, for example? What does it mean to make sure that everybody has equitable access to vaccines around the world? How does one achieve that? How do you deal with manufacturing? Who bears the cost?

SHANOOR SEERVAI: Right. And again, in this context, global health equity is a big problem. It’s a big question. It’s complicated. Could take decades. We’re in an emergency. So how are we going to tackle global vaccine equity now?

SANDRO GALEA: Poorly. I don’t mean that at all, I hope you understand, to diminish the question. I think it’s a fairly critical question, but I think the honest answer is not dissimilar to the answer, when we’re talking a few minutes ago, about how do you get people to trust you in the U.S. that taking the vaccine is safe now? To which the answer is it’s really difficult to do these things quickly. So I think now we do what we can. I think now we should make sure that we’re investing in the global structures that are out there, things like COVAX, that are delivering vaccines to countries worldwide.

But there is no question to my mind that we are not going to perform nearly as well globally as we could had we thought about it, had we invested in efforts to create an infrastructure for global health equity before the pandemic hit. So I think now the best we can do, frankly, is muddle through. I think we need to have a demonstrable global commitment to making sure that every country has access to the vaccines it needs and provide the technical supports that particular countries may need or may want and push that as much as we can.

SHANOOR SEERVAI: And I mean, we are muddling. The U.S. has said that it will send millions of doses of vaccine abroad, but we’ve been saying this for a few weeks and we’re just seeing these doses go out. What is it going to look like for the U.S. to really demonstrate leadership when it comes to vaccinating the rest of the world?

SANDRO GALEA: Well, the U.S. is 4 percent of the world’s population, we can’t forget that, which means we’re a big country. We’re the third-largest in population, but ultimately we’re, I mean, a small piece of the whole global puzzle. I know this sounds paradoxical, but I think we also need to get over the notion of American exceptionalism that it is the West is going to solve the world’s problems. The U.S. needs to be part of broader global constructs that solve the world’s problems, and those global constructs need to be constituted with representation from governance, from people from countries all over the world. So again, I’m suggesting things that take time, I realize that, but in the present I think where we have been successful is in rapid manufacturing and delivery of vaccines, which strikes me as that’s where we can be most useful and doing that in global partnership is the right approach.

SHANOOR SEERVAI: And what do we do about the fact that pharmaceutical companies are involved in this process and may or may not want to be sharing their intellectual property with other countries that could have manufacturing capacity if they have the resources on the intellectual property end?

SANDRO GALEA: Right. And that, I think, all comes down to the resources, the monies that pharmaceutical companies feel they need, or they should have for their intellectual property. Now, of course, there’s again a longer-term issue which is how we structure the patent regulations, how we structure what we consider to be acceptable profit margins on things like pharmaceuticals, but leaving aside the long-term question. In the short term it seems to me like there is a cost to be borne, which high-income countries have a responsibility to help bear to allow low-income countries to have access to vaccines.

Whether that cost is borne by buying out intellectual property or by buying out large doses of vaccines, I think that’s more of a technical question that depends on the particular context and the particular vaccine. But fundamentally it comes down to there is a cost to be borne and high-income countries have a responsibility to pay much more to make sure that low-income countries get access to vaccine in much the same way, by the way, as high-income citizens of this country have a responsibility to pay more taxes in order to create the resources to make sure that low-income citizens have more opportunity.

SHANOOR SEERVAI: And in the short term or the medium term, do you think there’s a point that we will be able to say that at least this pandemic is over?

SANDRO GALEA: I think there will be a point where we’ll say this pandemic is over. I think the best thinking right now suggests that the virus, SARS-CoV-2, is never really going to go away, it will become perhaps cyclical, but ultimately endemic in society, but it will become like the flu that is with us the whole time. A pandemic being over means that we no longer have a disproportionate burden of cases and disease that disrupt how we live. So I do think we’ll get there. I think we’re going to get there as a country relatively soon. I think as a world is going to take a couple of more years and the world will move on. I think the loss of the past few years will be if we do not learn from the moment. If we do not learn from the moment it will be such a pity because so many lives have been lost, so many lives have been put on hold that surely the one thing we owe ourselves is to take lessons from this moment to make sure this doesn’t happen again.

SHANOOR SEERVAI: Thank you so much for joining me, Sandro.

SANDRO GALEA: Thank you very much for having me.

SHANOOR SEERVAI: That’s it for today’s show and for this season of The Dose. We’ll be back with brand new episodes in the fall. So if there’s a health care issue you want us to cover or a guest you want to hear from, please send us an email at [email protected]. You can also get in touch with me on Twitter, @ShanoorSeervai.

The Dose is hosted by me, Shanoor Seervai. I produce this show for the Commonwealth Fund along with Andrea Moraskin, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wang for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. Thank you for listening.