Public Health Threats and Pandemics

Thomas J. Bollyky, the Bloomberg chair in global health, senior fellow for international economics, law, and development, and director of the global health program at CFR, discusses emerging threats to public health. Kate Wells, public health reporter at Michigan Public, speaks about her experience covering health stories in Michigan. The host of the webinar is Carla Anne Robbins, senior fellow at CFR and former deputy editorial page editor at the New York Times.  TRANSCRIPT FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Local Journalists Webinar Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. CFR is an independent and nonpartisan membership organization, think tank, publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. This webinar is part of CFR’s Local Journalists Initiative, created to help you draw connections between the local issues you cover and national and international dynamics. Our programming puts you in touch with CFR resources and expertise on international issues and provides a forum for sharing best practices. We’re delighted to have journalists from thirty-three states and U.S. territories with us today. So thank you for being with us. This webinar is on the record. The video and transcript will be available on our website after the fact, at CFR.org/localjournalists. And we will send it out to all of you on the call, along with any resources that are mentioned. We are pleased to have Thomas Bollyky, Kate Wells, and host Carla Anne Robbins with us today. We’ve shared their bios, so I will just give you a few highlights. Thomas Bollyky is the inaugural Bloomberg chair in global health, senior fellow for international economics, law, and development, and director of the Global Health Program here at CFR. He is the founding editor of Think Global Health, an online magazine that examines the way health shapes economic, societies, and everyday lives around the world. Mr. Bollyky also directed the first two CFR-sponsored task forces devoted to global health on pandemic preparedness and noncommunicable disease in low- and middle-income countries. Kate Wells is a Peabody Award-winning journalist covering public health at Michigan Public. She was a 2023 Pulitzer Prize finalist for her coverage of a Michigan abortion clinic. Ms. Wells also received the Livingston Award for Young Journalists for her work on the podcast Believed. And Carla Anne Robbins is a senior fellow at CFR and host of the Local Journalist Webinar Series. She also serves as faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. And previously she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. So welcome, all. Thank you for being with us for this conversation on public health. And, Carla, I’m going to turn it over to you to have a conversation with Tom and Kate for twenty minutes or so, and then we’re going to go to all of you for your questions. So get ready to raise your hand or write it in the Q&A box, but we would prefer to hear your voice directly. So, Carla, over to you. ROBBINS: Irina, thank you. And thank you so much for the local journalist people who support this, because this is really on top of the news—on top of breaking news right now, because the Senate bill just passed with the tiebreaker from the vice president. And we know there’s a lot of public health implications. And we will get into that. But, first, Tom, I want to turn to you. And, Tom and Kate, thank you so much for being here. We talk about the local journalist webinars as linking the global to the local. And the United States was a major funder forever of global health initiatives. There’s been a massive cutback in that, with the destruction of AID and other programs itself, and great fear of emerging health threats developing around the world. And there is no wall that we can build that’s going to stop disease from spreading to the United States. So what are the emerging health threats globally? And are they already threatening the United States? Are we going to have to be reporting on that and worrying about it for our kids? BOLLYKY: Great. Well, thank you so much to Irina and her team for hosting us. She has heard me say it many times but it doesn’t make it any less true, I really value the national program and its networks that it operates. They’re a great opportunity for us to learn, of course, also to speak with you. But it’s really one of the strongest parts of the Council. So I’m grateful to her and her team for doing that. It is nice to be here with Carla and Kate. In terms of thinking about the global to local, you know, CFR’s role is to inform U.S. engagement in the world. And that, of course, includes on health risks. But when we think about U.S. global health engagement, it is often framed as a product of hard security interests, you know, soft power, humanitarian concerns, geopolitical calculations, and machinations, divorced from the health concerns that happen here at home. But the reality is that health in the United States, including and sometimes particularly at the state and local level, profoundly shapes the way in which our country pursues health globally. And of course, the reverse is also true. The impact of U.S. domestic health on global health starts with the problems the U.S. takes seriously. And our understanding of which problems the U.S. takes seriously, of course, is being informed, as Carla said, in real time. We have a tax cut bill that has just advanced in the Senate that might affect Medicaid coverage, insurance coverage for eleven million people. But I want to really highlight two examples of this domestic-to-global intersection, and how it bounces back. The first is on public health emergencies. The administration, Trump administration, has cut $4.6 billion in grants related to pandemic response, both for COVID and for future pandemics. There have been significant cuts at the state and local level, in particular through our epidemiology and laboratory capacity program, that had distributed tens, in some cases, hundreds of millions of dollars to state and local public health authorities. You’ve seen just in the last month or so the president released his budget request for fiscal year 2026. And you’ve seen this de-prioritization of pandemic response occur in how the U.S. engages globally on the same issues. The news is a little grim for those of you that—for those of us that are concerned about the funding of such programs. The budget would eliminate the CDC’s Global Health Center and funding for most of its bilateral programs internationally, including on immunizations, TB, HIV/AIDS, polio, and so forth. Global health programming for other U.S. agencies, like the State Department, isn’t spared. It would reduce its funding of pandemic preparedness by 77 percent. So at a moment where we remain concerned about avian flu, Cambodia has just announced two more cases just this week, part of a spike of cases of avian flu that has been going on in that country. This intersection of what we’re seeing internationally, as well as our own domestic outbreak, is a real concern. And, again, indicative of this global-to-local connection. The other one I would just point out here, the second to last one, would be on vaccination. Secretary Kennedy, as all of you, I’m sure, know, has fired all seventeen members of the panel that produces the nation’s vaccine guidelines, and replaced them. He has also as part of that announced that the U.S. will forego its pledge to the Global Vaccine Alliance, Gavi. It had been committed to spending $1.2 billion to support global vaccination through that institution. Gavi is an institution the U.S. helped create. It vaccinates seventy million children annually around the world for pediatric diseases. And that’s been cut. There is some announcement of funding and people standing up this year some additional funding through that financing round, but it seems now, quietly, we’re getting a sense that some of that $9 billion that had been pledged to Gavi this week is repurposed funds from COVID, money that already existed. So it’s probably a little closer to $6 billion. If that’s the case, this is about 60 to 50 percent of what Gavi was seeking to continue its operation. So it’s a significant loss. The U.S. has concerns around—or, rising vaccine hesitancy in the U.S. is also reflected somewhat internationally. The Lancet released a study this week that twenty-one out of thirty-six high-income countries saw a decline in coverage for at least one of the major vaccines on the routine child immunization schedule. So you see this intersection happening there, where we see surges of pediatric diseases that might be—you know, that might foretell increasing episodes like this. In particular, the U.S. is likely to set this year a thirty-year record for measles cases. And we may see more of that to come. Let me pause there, having talked a little bit about this global intersection, and really interested in your questions in this conversation. ROBBINS: So if we were to be—obviously, we weren’t expecting COVID. And so it’s hard to predict something like that. But more traditional diseases that people aren’t getting vaccinated, either by choice or because they don’t have access to the vaccines because we’re not going to be funding them internationally, are there particular diseases that we have to worry about? Is polio going to come back? Is measles going to come back in a massive way? Are we going to start seeing malaria coming back in a massive way, that could potentially either come back to the U.S. because there are travelers that are going to bring it, and because people here are not going to protect themselves against it? BOLLYKY: Yeah. I think a classic example would be—would be measles. Historically, most of the U.S.’ measles cases that we would see were from travel, travel-related measles cases. We are now seeing a sustained spread of cases domestically. The U.S. has, sadly, imported measles cases to Mexico. So we are now a source of other countries’ cases. The U.S. has had—and this is more climate related, which is, of course, its own conversation—but the U.S. has had—seen spreading of malaria cases domestically. So we did have sustained malaria transmission last year. And then, of course, we’ve been seeing in Florida some Dengue case cases year-in and year-out, over the last couple of years. So you’ll see that as well. That’s a little less tied to vaccination, but it’s part of this broader conversation of what kind of surveillance we’ll have on a state and local level, what sort of lab capacity we’ll have, and how that feeds into our ability to fight diseases at home and abroad. ROBBINS: Thanks. So, Kate, how do local reporters monitor and get ahead of the story of a health crisis? WELLS: Yeah. So, I mean, I don’t have, like, fun news for you on this. But we—I think what I would—I think what I would preface all of this with is, we are hearing a lot about this crisis right now, but we—on the on a local public health infrastructure, in terms of whether it’s something like measles, we have already been seeing even post-COVID the local public health system be unable to handle what we were already seeing, post-COVID. I think there’s a feeling among the general public that our public health system, not just in terms of, like, you know, your local health department, but even in terms of, like, your hospitals, that somehow when COVID ebbed, that things went back to normal. And that just isn’t the reality, for a number of different reasons that we don’t need to go into too deep. But everything from the sheer number of pediatric beds that you probably have in your state, to how many maternity wards you have in your state, to how many people have left health care or are just entering health care and don’t have a lot of experience behind them. We have already seen—even before we started seeing measles rise in the last several months, in the last few years, post-COVID, we have seen childhood diseases just behave differently than the way we did before. And there’s some theories about why this is. But a few years ago it was this surge of RSV that completely overwhelmed children’s hospitals. And then this past year and the year before we really saw this increase in pediatric flu. And it’s less sexy than measles, but I say it because we need to understand that the system, as it is, was strained by COVID, but never went back to normal. And so already exists in this period of real strain. What is happening now that we have these changes coming from HHS and CDC is it means that your local public health infrastructure is really going to be on their own. The way public health works in this country is that, to a large extent, the way we monitor everything from, say, avian flu in the ag world, to norovirus and walking pneumonia, that that does happen at a local level and looks very different from state to state. We are going to be depending on these systems that, as Tom has said, just got a massive cut in funding. And also many of them, when I talk to these—to my sources, they are in a state of not just like uncertainty about what the future holds, but uncertainty about their own funding. So I think—I feel worried on a level that I don’t think I have for the last few years, really since COVID, of just a real uncertainty about what kind of system we’re going to have. And I think the importance of local—I mean, I realize I’m biased—but I think the importance of really good local health reporting is going to be more important than ever. And I think your audiences are going to really need clarity and be hungry for that kind of local level understanding, because there’s just going to be a lot of uncertainty and confusion. And people are—people’s kids are going to be sick. They’re going to get sick. They’re going to show up to the emergency room, and if they haven’t been to the ER in the last few years, be really confused as to why the experience that they’re having is not what they expected. Why are they being boarded for three days? Why can’t their kid get a room? And part of what we’re going to be able to need to do is explain to people why that is, and be in really good touch with our local health officials. Which, I know, is easier said than done when you’re dealing with a million different deadlines. But it’s why I’m glad we’re talking about this. ROBBINS: So, Kate, I’d like you to talk a little bit more about stories and about how you do that what you’re talking about. You’ve talked here just on a basic sets of stories about capacity, and particularly pediatric capacity. There’s some really interesting stories that are there. There’s the post-COVID story, and what bounced back and what didn’t bounce back. There’s the story about the coming cuts and what they’re going to do about capacity, and how—and depending on whether you’re in an urban setting or a rural setting, you know, how these Medicaid cuts, all of these things, are going to happen, and how that’s going to affect hospital capacity, and particularly pediatric capacity. Which sounds—those sound like great stories. I’m really interested on the—just the basic—because I’m sort of a numbers geek—on the basic ability to monitor what’s happening in my town, my region, whatever it is that I cover. I mean, I loved it and—I mean, it was awful—but I loved just the sheer fantastic work that Johns Hopkins did with that dashboard during COVID. I mean, you could go on every single day—now, the fact that it had to be done by a university and not by the federal government—(laughs)—but you could go on every day and you could look at that map, and you could look at the mortality numbers, and you could look at the infection numbers, and it could be for the United States, and you can look globally, and you could parse it, and all of that. If I want to look at what’s going on in my county, or in my city, or in my state for measles, or if I want to have some early warning about something that’s happening, how do I do that? WELLS: I wish I could give you an answer that was going to work for everyone on this call. The reality is, sort of like what we’re talking about here, the way that local public health works, and we really saw this during the pandemic but we’re going to see it a lot more now, is it is going to look completely different—not just state by state, it is going to look different county by county. And I’m going to say this multiple times, but, like, the importance of just having the phone number of who is your local public health officer, who is in there who tracks cases, and what cases do they track, what kind of contact tracing are they doing? Like, being able to establish this when there isn’t an immediate crisis is going to be really important, because the way—we’re going to be seeing fewer and fewer of the Johns Hopkins, because a lot of the researchers who have been doing this kind of work—where I am, it’s a lot—when we were in the pandemic, it was a lot from the University of Michigan. When I talk to those epidemiologists today, their departments are in hiring freezes, right, across the University of Michigan. They are not doing some of the work that they were doing previously because of this kind of funding uncertainty. And Michigan is one of the states that have been very active in some of these lawsuits, where there have been at least temporary injunctions against some of these funding blocks. But that doesn’t mean the money is actually flowing anymore. It is going to be more incumbent on local public health reporters to be figuring out, and also then showing people the really disjointed system that we have. It’s also not going to be just whoever your local public health officer is. And I’m sorry, to, like, give people a list of homework. You’re also going to need to know who is at your children’s hospital, and be talking with them ahead of time, because they are going to be seeing spikes and things before anybody else is. And there may not be the kind of tracking data that we had during the pandemic. I am not expecting that whatever the next big thing that we go into, that we’re going to have the same kind of data that we did during the pandemic. And I think we need to be preparing for that now as local public health reporters. There should be a good answer to that question that you’re asking, Carla, because it’s so basic. And I can tell you that there isn’t. Even right now in Michigan, when we are having more measles cases than we have in years, the amount of information that I can tell you about one measles case in one county versus the next is completely different. And that is because of local public health officers are trying to do jobs that you could not pay me enough to do right now, which is try and get and communicate information from people who feel resistant about sharing that information. But what that ends up doing, as a public health reporter, is you have to be really transparent with your audience. You have to tell them, the reason we know this much about these measles cases is because that’s what local health officers are telling us. And the reason I can’t give you the same answers about the same measles cases, you know, twenty miles away, is because everybody is kind of on their own right now, in a way that we just didn’t see during the pandemic. I don’t know if that’s a good answer. I wish I had a better one for you. ROBBINS: No, it isn’t it. This is hard. This is incredibly hard. And you add the politics of it, and the local politics, and the federal politics of it, and then you add to that the cutbacks that are taking place, it’s pretty scary stuff. WELLS: Yeah. I also think a lot of this, too, though, that we have to be really careful about, is we have to be honest and understand, like, the business of health care has changed, and has been changing. And that these changes that we’re seeing at the federal level and at the research level are going to be layered on top of that. The reason we are going to have fewer pediatric beds before, the reason we’re going to have fewer maternity wards already, the reason why I think it won’t just be rural hospitals that are impacted by these Medicaid cuts, I think it would be harder to see an ER doctor in Detroit and New York City and Minneapolis after these Medicaid cuts because the private equity staffing companies that run these emergency rooms are going to want to reduce the numbers of advanced practitioners they’ve got in these ERs. Like, we’re really going to have just a lot of different factors that are going to make it harder for your average reader to be getting the kind of health care that they’re used to. ROBBINS: So I want to turn it over to the group. I’ve got a million more questions to ask, but if you could raise your hand, would be great. And waiting for people to raise their hands. And while they—we wait for them, I will also ask Tom a question, while we do that. We have a question in the Q&A already. So, nope, maybe this—so L. Beveridge, would you like to ask your question, or should I read it for you? Q: Hi. Yeah, I can ask my question. ROBBINS: OK. Can you identify yourself? I apologize I don’t have a list in front of me. Q: Yes. Yes. Not a problem. Sorry. My Zoom is acting weird today. My name is Lici Beveridge. And I’m a reporter for the Clarion-Ledger and—Gannett newspaper in Mississippi—and the Hattiesburg American, a smaller version of the newspaper. We are seeing an awful lot of pertussis cases jumping up, in addition to the measles. We’ve had that, I would say, maybe the last ten years or so that I’ve noticed. But usually it’s been one or two cases. And, you know, nothing much comes of it. But I think this year and last year we had an awful lot of pertussis cases. And I think—I’m just wondering—you know, I think most of it is because a lot of people are opting out of vaccinating their children. And they’re saying it’s for religious reasons, but I really question that. And I’m just, you know, wondering if that sort of thing is happening elsewhere, and what is the potential impact of just parents refusing to vaccinate their children, even if it is available. ROBBINS: Tom. BOLLYKY: I’ll just weigh in quickly a little bit. Absolutely it’s happening elsewhere. You know, of course, our measles outbreak is being driven primarily by—at least initially by a religious community in West Texas and New Mexico. You saw increased cases there. We did look at some states post-COVID and their rates of religious exemptions. Florida being one where you’ve seen them go up. It’s been a while since we’ve looked at that national data, but I’m going to suspect you’ll see that in more places. States have historically taken different stances on how—whether to permit religious exemptions and for what, and with what documentation. But a lot of that has been disrupted, of course, by some of the politicization of these issues after the COVID-19 pandemic. I wanted to build a little bit on the data side, though. Like I said, it’s relevant for this conversation. I would—for myself, at least, I completely agree with everything Kate said. But I think one helpful distinction to have in mind is there’s the issue of funding and resources at the state and local level, and how that information goes to the federal level, and what’s being reported for threats on which there are existing surveillance systems. So most people, colleagues of mine, still rely on the CDC’s weekly report for measles. So that has all the shortcomings that Kate just described, but it is a—it is a credible source. What I think can be difficult is surveillance on emerging threats. So we did not have any reporting on new H5N1 cases for a significant period of time. It’s hard to believe that’s because there are none, given how many farms have reported infected dairy cattle, how many farm workers are in that area, combination of are we still looking, or—and also the issue, of course, around immigration, and how that might affect the willingness of farm workers to report. So I would—I think one challenge here is there’s—how are we going to work in a more resource-constrained environment with the existing surveillance networks, but in an area where there are both political and economic interests. And how new cases are being reported for an emerging outbreak, what is that going to look like? And I think they’re distinct. Other entities to put out there that I think are useful for you all to think about, depending on what you’re reporting on, National Association of County and City Health Officials, NACCHO, I think is a very useful data source, particularly for structure, funding and workforce issues. Association the State and Territorial Health Officials, ASTHO, also a really good data source. We do a lot of work with the Institute for Health Metrics and Evaluation on retrospective analyzes of states. And we’ve done a lot of that together with them on looking at the drivers of differences at the state level and county level, for instance, in COVID-19 and other threats. So in trying to understand what’s happened in the past, they could be a good resource too. But, again, my fear is surveillance of novel threats and what that’s going to look like, as being a distinct concern from these resource-based concerns. ROBBINS: So you’re saying that we don’t know what the avian flu status is in the United States at this point? BOLLYKY: I don’t think we have a good idea of what the spread of cases—I mean, we didn’t have that great of an idea last year either. But I think we really don’t have a good idea over the last six months how cases have spread in this country, because I don’t know if our surveillance has been quite as robust as it should be. And I think there’s—of the population of individuals most likely to have been infected, I think there’s a lot of reluctance to get tested and report, given the push on immigration status. ROBBINS: Kate, are you reporting on that in Michigan? WELLS: Yes, very much so. I think Tom said it well. And, Lici, I do want to just—I want to just circle back to your question too. Yes. Tom’s absolutely right. We are seeing this across the board right now. I think one change in particular with these—the rise of vaccine-preventable diseases, especially in kids, is one thing that we’re seeing now that we didn’t, especially in your neighboring state of, like, places like Louisiana, where you are seeing the health department literally start—the state health department—literally start to back off of promoting vaccines. That kind of thing is going to—you know, we need to be asking the questions as local public health reporters of, like, what is that doing in terms of not just are they having vaccine clinics, but then how are they counting cases? What does the reporting system look like? I think there’s a lot that we can be doing in there. The thing that makes—the thing that made avian flu reporting already particularly difficult to begin with, even before we were in this period of different types of approaches to immigration enforcement, is a lot of this was happening with work between the ag departments at a state and local level, your national vet labs, and then also with how good of a cooperation system did they have with public health. Michigan, we were lucky in that, like, we have a pretty good surveillance system. Where you run into problems, even with a really good surveillance system and really good collab between your ag department and places—land-grant universities like Michigan State University, the vet labs there, those places are all dealing with funding issues now too. Places like these national vet labs. But then also, what you’ve got is there’s just a major resistance—not even among necessarily farm workers themselves, but among farms themselves. You know, these are—these are massive businesses. And this is not—if we—if you are imagining that there’s, like, good testing happening in a dairy parlor, or even the availability of PPE, or if that were some sort of, like, a practical thing to be wearing while you were working in a dairy parlor, it just isn’t. Tom’s right. We don’t—this is the—he’s absolutely right that, like, we have these major gaps around some of these emerging risks. The problem is that we already know we don’t have the health system capacity to deal with the risk that we are already tracking. ROBBINS: Ariel Hart, health policy reporter at the Atlanta Journal-Constitution. Ariel, would you like to ask your question? Q: Hey. Thank you so much for doing this. So, if I could ask you to pull back, I report in a state that—I mean, they call it purple, but it’s really very—there are a lot of rural areas that will be deeply affected by the One Big Beautiful Bill Act. And even though we did not expand Medicaid, and so our coverage losses will be somewhere between the tens of thousands to the hundreds of thousands. But when you talk to folks in those areas—so, for example, if you drill down into the research of the four rural hospitals likely to close in Georgia if the bill passes, three are in Republican voting districts. There’s a great deal of comfort in the Trump administration of trust, of relief. And I think that there’s a sense that they’re finally being heard and tended to. And there is not—I mean, the level of concern I’m hearing on this Zoom for the people who might be more likely to be impacted by it, that’s just a world away. And so I wanted to ask Mr. Bollyky specifically, you know, given your kind of broad experience, for those folks, both the voters and the representatives, the policymakers, who they just really have a sense that the speed we’re at is the speed we will always be at, and it’s only getting better, where are we as a nation right now? Is there anything that I should be explaining to them, that you could explain to them, or thoughts that you have about this moment? BOLLYKY: Yeah. So really such an important question. So thank you for it. You know, to start on the big and then move more narrow, on where we are as a nation, I mean, I think it’s fair to say the United States is failing at its fundamental mission of keeping people alive. U.S. life expectancy, long regarded a benchmark of a nation’s success, has declined over the last eleven years. U.S. life expectancy is now lower than any other high-income country, of course, worldwide. So that—we’re not making progress. I think the dynamic you describe happening in your state I think exists in a lot of rural communities, where there is a feeling like government hasn’t delivered sufficiently on health. People run on a platform of, you know, cutting through all that government red tape and delivering better outcomes. So you see further cuts and further health declines, which, of course, alienate people even more from government services because they feel that their health outcomes aren’t good. And you have this spiral. We’ve spent a lot of time specifically on COVID-19, of course, because what happened. And we did this big study in the Lancet looking at the interstate difference in COVID-19 outcomes. And, you know, even when you control for age and relevant biological factors, there was a fourfold difference in how states performed, with the best U.S. states performing akin to countries in Scandinavia and the worst performing—U.S. states performing like some of the worst-performing countries in the world. That’s not normal. On most population health issues, you do not see that extent of a divide. And the relevance I drew from that, and my colleagues that worked on this study drew from that, is that we can do—even in—we didn’t see a divide between red and blue states in this study. Our top ten were five red states, so to speak, five blue states. We can do this. The U.S. can respond to its health challenges, even health emergencies. And we know that because some do, and some have. And we really worked very hard to get this message out because I think it’s a quite hopeful one. I worry that coming out of the pandemic, in particular, people have taken the opposite lesson, that somehow our health services are underperforming, we’re doomed. And instead of looking to the examples where we’ve done this well and trying to import them in states that aren’t doing well to address our health challenges, including those driving our poor life expectancy numbers, we seem to be cutting down the system. And I think state and local journalism has a key part in making it clear that the picture is actually a lot more complicated. There are some real success stories of communities and states standing up and really performing well under these threats. And I do think it’s important to get some of those messages across, because there’s just a lot of despair on public health, or the notion that somehow what we did didn’t work, that people aren’t delivering for populations. And I really think you all play such an important function in trying to get the information out there on what the reality of that picture looks like. Q: If I can ask a follow up. So to put a point on it, are we possibly at a global turning point as a nation? ROBBINS: I’m sorry, Ariel, can you talk—can you speak up? Q: Can you hear me? ROBBINS: Yeah. Q: Yeah. All right. To put a finer point on it, are we possibly at a global turning point as a nation? BOLLYKY: I worry that we are, because most U.S. health gains, when you dig down on it, are about prevention and public health. That most of the improvements that have happened on our broader health indicators, like life expectancy, are really driven by the public health side, not advances in the new fancy drug and the best machine at the hospital. And I worry a little bit that this moment, particularly coming out of COVID-19, has been—really undermined the infrastructure on which our health system truly relies on, at a population level. And I think it’s incumbent on all of us to do what we can to try to address that. And, again, I think what’s fortunate in this case is I actually think the data supports that conclusion. It’s just not getting across to people. And, you know, that’s something you all can help teach us in terms of communicating to your readers in local and state levels of how to do that better, because we’ve clearly not gotten it through to people. People have a very different impression on what’s happened in the utility of these services. And it’s absolutely essential that we do something to address that, because otherwise we will be at that inflection point you’ve described. ROBBINS: Great. Ariel says, thank you, in the Q&A. So just I’m going to quickly sum up what Tiffany asked the same question, but—somewhat of the same question that I asked earlier, for either Tom or Kate. Are there any national dashboards right now that we can be looking at? Because she, like I, was quite dependent on Johns Hopkins and the University of Washington. Is there anything out there that’s being maintained that one could just—obviously, they should be going to Think Global Health every day, which is actually really an incredibly well-designed website, by the by the way. And I’m—(laughs)—having come from the web world originally, I admire your design there. But anybody else out there doing a national go-to. Kate anything you look at every morning before you jump out of bed? WELLS: I mean, particularly for measles? Or which—when you say dashboards— ROBBINS: Anything that’s going to alert you to a story that you got to jump on? WELLS: Yeah. I mean, I think those national dashboards are great. I think if—going back to a little bit to what Ariel is saying—I think one of the things that we can be—when it comes to, like, sources to use for ways to communicate what’s happening right now, especially with some of these cuts to people in language that they—yes, there’s a lot of good resources. One of the things that I’m using a lot right now are both whatever your state health department has been able to put together in terms of estimates about what some of these Medicaid cuts will look like, but not just Medicaid cuts. SNAP as well. There’s also, if you haven’t been able to check them out—I’m biased, because I worked for them—but KFF Health News has great— ROBBINS: Kaiser Family Foundation. OK, go on, yes. WELLS: Yes. They actually—they’re no longer called the Kaiser Family Foundation. They’re KFF now. ROBBINS: OK, sorry. WELLS: That’s OK. They do a really, really good job of—they will not only have—let’s say we’re talking about Medicaid and SNAP cuts here, or, say, like the implications of work requirements, which have just been passed. They will be able to break down for you by congressional delegation, what some of these impact estimates look like in your local area. And they will have really good experts who can talk to you about that. The Urban Institute does as well. Those are just two good go-tos who have done a lot of local resources. I would definitely talk with your state health department. They will probably have information on that as well. I think one of the things that we can be doing for people right now when we talk about some of these cuts at the local level is make sure we are talking to them in the language that they use. Most people who are on Medicaid don’t think they have Medicaid. Like, you know, in states that did do expansions, you know, most people just think that they have the—whatever their card says, you know, whether that’s Blue Cross, or Anthem, or something. So we need to be, as local health reporters, talking to people not just about Medicaid, but we need to be talking specifically about the—we need to be using the terms that people understand in their day-to-day lives, because that’s what they use. So KFF and Urban Institute won’t be able to give you those. The state health departments will. And they are a really good resource right now. ROBBINS: And I know that when I get—for me in the morning, when I get up, I know that I have my basic go-to newsletters that I read. Like, I’m addicted to Punchbowl, which is, of course, about what’s going on on the Hill. And since I’m a national security person, I have my list of national security. Are there particular public health newsletters and websites that you go to, the people who are—do more general reporting, but if they want to get into this right now, that you would recommend, beyond Think Global Health, but in addition to? WELLS: Is that for Tom or for me, Carla? ROBBINS: For both of you. WELLS: Tom, do you want to take that? I’m happy to jump in. BOLLYKY: So I will tie a little bit to the—to the global side. I want to endorse what Kate said. I think KFF on budget reporting, particularly coming out of Congress, does an amazing job. And I want to really, on the global side, highly recommend my good friend and colleague. Jen Kates’ group on the global side does really fantastic reporting. They also do good reporting on racial inequities in health care provision. There’s a lot of great resources there on budget and congressional initiatives. So that’s certainly useful. For machinations in Geneva, the Geneva Health Files does a nice work—nice job of having some local-based reporting of what’s going on, on the global side, that I think is worthwhile to highlight. You know, again, on existing health concerns rather than emerging health concerns, I do still use a lot of the weekly reporting coming out of CDC. Another good resource that I’ll recommend in addition to our own is my good friend Mike Osterholm’s group, CIDRAP, in Minnesota does—he’s also a council member—does really good weekly reporting on outbreaks that are happening out there. And they do a digest. That’s a useful site that I’d recommend to folks as well. ROBBINS: Right. And we’ll push all this out to everybody after this is over with. So if you’re scribbling or typing, probably typing, we will do this as well. Debra Krol from the Arizona Republic asked questions about: Is anybody in particular taking a look at the impact of the cuts on the Indian Health Service? BOLLYKY: We’ve done a couple of stories looking at some of the cuts, as well as the measles outbreak, and how that’s affecting. This is on Think Global Health. And I’m happy to include those links. I was also one of the senior authors on a study we did last year on the ten Americas. That actually just came out in December. That looked at us life expectancy disparities, again, in the Lancet, by race, geography, and income. And the one thing I will point out on American Indian and Alaskan Native populations in the U.S. is this is a health crisis that predates COVID. They are the one group that both pre-COVID and, of course, post-COVID had a decline in their life expectancy from twenty years ago when that study was first performed. They are the bottom side of the headline figure that came out of that study, that the divide between these Americas, these groups, by race, income, and geography, has grown to twenty years. They are, unfortunately, on the bottom end of that spectrum. And that is from twelve years when we first—when that study was first conducted in 2005. So you’ve really seen, unfortunately, a—there’s a crisis going on in those communities. And, you know, COVID was certainly one area that should have highlighted it to people, but it both extends beyond that and predates it. ROBBINS: Diego Lopez with—is it the Cibola Citizen? Q: Hi. ROBBINS: Diego, great. Thank you. Q: Hi. Diego Lopez with the Cibola Citizen newspaper here in Grants, New Mexico. I really appreciate hearing you guys talk about how this is going to affect indigenous communities. We cover seven indigenous communities. And the Albuquerque Journal recently reported that several of our rural hospitals across the state are going to be closing as a result of these cuts. Could you talk a little bit about how is this going to impact funding for our indigenous tribes? I don’t quite understand how this is going to impact their hospitals and their health services. Thank you. WELLS: So I could maybe speak a little bit to this broadly. I am not going to have great answers for you on that specific part of it. Was this an estimate that came out of the health—your local—your state hospital association? Q: Yes. Thank you. Yes, it was. WELLS: So they’re going to be able to give you the best possible answer. I, in normal times where we are not slashing Medicaid, have a lot of skepticism, and think we all should as reporters, towards what your local health and hospital association, which is an industry trade group, is telling you is going to happen. I think right now they are a very good tool. And they will, because they are so well funded, have some very good communications people who will answer—one, answer your call very quickly. Two, be able to connect you with local providers on the ground who will be able to walk you through this. And three, also be able to give you specific funding mechanisms, because it’s going to look a little bit different everywhere else. I would also—I know this is difficult right now—I would also ask them to explain how they are making those calculations. We’re going to hear a lot of fear about entire hospitals closing right now. We need to be careful how we talk to people about that. Because it’s entirely possible that the hospital won’t close, necessarily, or not each of these hospitals will close but, say, two years from now their maternity wards will close, or 30 percent of their advanced practitioners will decide to move out of the area. So I would be—I would—I think they are really good resource right now who will be able to talk to you specifically about the funding mechanisms in each of your areas. I would also then ask them to connect you to local providers about what they are seeing and hearing, because they will be able to talk to you about how this is going to impact direct community services. If it is an estimate about closures that is coming from your hospital association, I would just bear in mind that as truly, like, generational as these cuts are that we’re talking about, this is also a trade group that is trying to make a—make a sales pitch right now. And so I would just—I would take whatever they have with that grain of salt, and use their resources well. I would also then find additional sources in your area who can talk to that. Now for emergency rooms, that can be places like ACEP, your American College of Emergency Physicians. They’ll probably have a state chapter. Your state medical board will be hearing from folks. These are—definitely talk with your state health association and your hospital association right now, just understand that they’re not public health officials. They’re a trade group. I don’t know if that’s helpful. ROBBINS: And is the impact separate? I mean, as what Debra—the question that Debra asked. And, hi, Debra. Debra does quite wonderful and just great reporting. Is the impact different in hospitals based on reservations? I mean, these are—that’s a different public health system, or is it not? WELLS: I don’t know the answer to that. But your health association—your hospital association, will be able to point you in the right direction of somebody who has those answers specifically to your area. And also, I would call the tribes. I mean, this is—these are—like, you know, I would talk to that local leadership. And there’s also, at least in—certainly in our areas, like in the Upper Peninsula—a lot of them also share community health departments, right, with non-tribal organizations. And a lot of the funding that they’ve been operating off of has been shared. If there is massive funding cuts there, that’s going to impact people who are outside of those tribal reservations as well. A lot of them share maternal and infant health funding or substance abuse funding. Like, the impacts will go beyond just whether or not a specific hospital closes. ROBBINS: Diego, does that help? Q: Yes, very, very much. Thank you. Thank you. ROBBINS: Great. Diego, I have Acoma relatives, if that’s covered in your group. Q: Yeah, absolutely. Not far from here. Great. Thank you. ROBBINS: So I was just going to quickly ask Debra Krol, if she’s still on, Debra, can you give us any help about how to do reporting on this? She may not still be on. She does great reporting on this. So I was just going to turn back to Tom and Kate in the remaining time. And, you know, this one big beautiful bill is enormous. I suppose two sets of questions. One is, like all legislation, particularly health legislation, you know, it’s been—it’s so big and so—and so incredibly technical, and so—there’s so many interests that have been—and deals that have been cut at the last minute, and specific carve-out deals. And we don’t even know what’s going to happen when it goes back to the House. But, first, what are you reading and who’s doing the best deconstruction of it for you to—if you’re interested in the impact of Medicaid on rural hospitals, or if you’re interested in the impact on SNAP, or if you’re interested in the impact on local public health spending, or whatever? Who’s doing a deconstruction that you—at least to begin to understand the playbook? How are you getting your information, Kate and Tom? WELLS: Tom, I’m happy to jump in there. You want to take the first swing? BOLLYKY: No, go ahead. And then I’ll fill in. WELLS: I mean, it’s going to—it’s going to sound like a retread of what we said. I would say two things as just, like, closing thoughts here, and then also some resources of who I think is doing this well. This has passed the Senate. Our job as local reporters is not to communicate this to people as if this is a done deal. Like we should be honest to people about the fact that this is happening very rapidly. And we should be honest with people about what the intentions are for that—why this kind of thing is happening so quickly. We should be clear with people about that. We have a period of time right now in which our main job is to communicate to people about how this would impact their lives as clearly as possible, in stakes and language that is clear and not hyperbolic, but uses all the resources that we have. The two orgs that I mentioned, KFF, Urban, they’re going to be really good at being able to—you can call KFF and say, like, listen, talk to me like I am five years old and explain this to me and what I need to be talking. Tell them your area if you have a specific metro area. They may even have specific polling. They’ve done a more recent polling about the popularity of some of these measures in congressional delegations. But then your state health department has probably done its own estimates, if they’ve done a pretty good job. I would be reaching out to your state, the people who are running Medicaid and SNAP, who can talk to you about estimates of here’s how many people we think would lose coverage here, potentially. Because our job right now is not to talk to people about this in broad political terms. Our job right now as local reporters is to talk to people about what this means for their lives, even if they are not on Medicaid. If you lose a maternity ward, that is your maternity ward that’s no longer there. ROBBINS: Tom, quickly? BOLLYKY: Great, the only thing—I’m sorry, Carla, did you have a follow up? ROBBINS: No, no, no. Just quickly over to you. And because I’ve neglected to ask one final question, and I want to get to that too. BOLLYKY: I’ll be very quick then. I do think NACCHO and ASTHO are still good resources on these issues in terms of reporters that do great work, particularly on public health. Not that she needs it, but she deserves it, Helen Branswell is always terrific on understanding these issues, and is somebody I often talk to and rely on with these kinds of questions. So just to put that out there, in addition to the sources Kate mentioned. ROBBINS: Great. And last question, thank you. And Helen Branswell writes where? BOLLYKY: I’m sorry, STAT News. ROBBINS: So Rick Berke. Is Rick Berke still the editor of STAT? BOLLYKY: Yes. ROBBINS: Former colleague, yes. And former congressional reporter. So he has the Washington side of it. Rachel Schnelle. Rachel, can you ask the last question? From KRPS? Q: Yes. It’s Schnelle, actually. Yeah. ROBBINS: My apologies. Q: (Laughs.) No, it’s OK. I was wondering, I’m covering issues in Missouri and Kansas. Our station kind of covers the Four Corners. And we work with Kansas News Service. And there’s been eighty total measles cases in Kansas as of last month. I come from a rural area so I know there’s sometimes speculations around vaccines. And I was wondering, is there a correlation always—I guess, is there a correlation between rural counties having low vaccination counts and also religious exemptions? Like, are those often one and the same, where they’re in the same area? Or is there a throughline between the two? So, yeah. I’m not saying that vaccine misinformation and rule exemptions are the same thing—or, religious exemptions are the same thing. ROBBINS: Kate, you were shaking your head. WELLS: There could be an overlap, though. I think when we measure religious exemptions we’re talking usually specifically about a specific waiver. A lot of the reasons we started to see pediatric vaccinations fall off was just it was harder during the pandemic for people to be able to access some of the basic care that they were regularly getting to. If you are in an area where there’s, like, fewer pediatricians than there were before, or what things may look like after Medicaid cuts, there can be a number of reasons why it’s just harder for you to be able to get your kid in on a regular basis, as you used to. I would not—we want to—sometimes, people will—I want to be very succinct about this, because now we want to go—sometimes, depending on where people are, they may get a waiver that classifies as, like, religious or philosophical waiver because they show up to school and their kid doesn’t have their vaccination, right, have their vaccines ready. And so the school just slots them in that way. It looks different, but I would just take the time to sort of talk to whoever your local public health department is about those differences so that we’re not conflating those two incorrectly. But there’s certainly overlap. Like we’re seeing— Q: Yeah, sorry, I meant to say overlap. (Laughs.) WELLS: Yes. I think there can definitely be overlap. I would just make sure that I talked to my local health department about what the specific process is for these waivers when people are getting them. Do they have to seek them out and go through a series of, like, talking to their public health nurse to do that? Or is it like they show up to school, you know, in August and their kid didn’t have this, so they’re—the school just signs them up for one, and they just sign a form. Because it looks different, different places. ROBBINS: Tom, final word. And I’m going to ask a totally uninformed question that’s related to this. And keeping in mind that I grew up in the generation in which everybody got measles. So is eighty cases a really high number? And is it—I mean, do we get to the point in which it just shoots up? You go from eighty to 500, and suddenly you really, truly have an outbreak? I mean, when do we start—when do we have to start getting really nervous about something? Like, what numbers? BOLLYKY: Well, we’re at—I’m sad to say, we’re at 1,227 cases nationwide. So that is just fifty short of a thirty-year high. Twenty-one percent of those cases have resulted in—or, required medical treatment or hospitalization. So that’s—of children, I should say, five and under. Of the cases involving children five and under, 21 percent of those have required hospitalization. So we should be alarmed. There have, of course, been three deaths also. Those aren’t great numbers. The thing to put to what Kate said before is that vaccination—there are three sets of barriers. There’s administration, supply, and demand. This issue of religious exemption gets at the demand issue, but there are absolutely what Kate was referencing to, administration barriers. And, for instance, this issue of multidose vials is an access issue also. There are going to be a range of things like this that people should pay attention to, particularly given the cuts and some of the guidance that’s coming out. ROBBINS: Well, thank you. I want to thank Tom. I want to thank Kate. This has been a great conversation. I want to thank everyone else for great questions. And I’m going to turn it back over to Irina. FASKIANOS: Thank you, Carla. And thanks to Kate Wells and Tom Bollyky for a terrific conversation, and to all of you for your comments, questions, and the work you’re doing. We will send a link to the video and transcript. We will round up the resources that have been mentioned during this call. Also some were dropped into the Q&A chat, so we’ll gather those up as well. You can follow our speakers on X at @TomBollyky, at @KateLouiseWells, and at @RobbinsCarla. And, as always, we encourage you to visit CFR.org, ForeignAffairs.com, and the online magazine that Tom Bollyky founded and runs, called ThinkGlobalHealth.org, for the latest developments and analysis on international trends and how they’re affecting the U.S. And, of course, please do email us with suggestions for future webinars or how we can further serve as a resource to you and your reporting. You can email us at [email protected]. Or if you want to be connected to a CFR expert, such as Tom or others, we’re happy to make that connection as well. So, again, thank you all for today and for the work that you’re doing. ROBBINS: Thanks, guys.

Panelists discuss the international implications of the current avian flu outbreak, how the virus may continue to evolve and spread, and how the United States and other countries should address the crisis. This is a virtual meeting through Zoom. Log-in information and instructions on how to participate during the question and answer portion will be provided the evening before the event to those who register. Please note the audio, video, and transcript of this virtual meeting will be posted on the CFR website.

Thomas J. Bollyky, Bloomberg chair in global health at CFR, discusses recent changes to domestic and international health policies and the implications of a U.S. withdrawal from the World Health Organization (WHO) on global health programs and international health coordination. Manisha Juthani, commissioner of the Connecticut Department of Public Health, discusses how state health systems might be affected by changes in federal policies, trusted resources for public health data, and how state and local officials can respond to promote health and safety in their communities. A question-and-answer session follows their opening remarks. TRANSCRIPT FASKIANOS: Thank you. And welcome to the Council on Foreign Relations State and Local Officials Webinar. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. CFR is an independent, nonpartisan membership organization, think tank and publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. Through our State and Local Officials Initiative, CFR serves as a resource on international issues affecting the priorities and agendas of state and local governments by providing background and analysis on a wide range of policy topics. We’re delighted to have you with us for today’s discussion. We have more than 580 state and local officials confirmed to join us from forty-nine states and two U.S. territories. So, again, this webinar is on the record. The video and transcript will be posted on our website after the fact, at CFR.org. We are pleased to have Tom Bollyky and Manisha Juthani with us to speak on recent changes in public health policy and implications for state and local governments in the United States. We’ve shared their full bios with you, so I will just give you a few highlights. Thomas Bollyky is the inaugural Bloomberg chair in global health at CFR and director of CFR Global Health Program. He is also a senior fellow for international economics, law, and development, and a senior consultant to the Coalition for Epidemic Preparedness Innovations. Tom Bollyky is the founding editor of Think Global Health, an online magazine that examines the ways health shapes economies, societies, and everyday lives around the world. And prior to working at CFR, he served in a variety of positions, including at the office of the U.S. Trade Representative and as a staff attorney at the AIDS Law Project. Manisha Juthani is the commissioner of the Connecticut Department of Public Health. Commissioner Juthani previously served as a professor of medicine and infectious diseases physician at Yale's School of Medicine and currently serves as an adjunct professor there. During the COVID-19 pandemic, Dr. Juthani was a leader in the COVID response at Yale, which led to her appointment as commissioner of the Connecticut Department of Public Health in 2021. So thank you both for being with us today. Tom, I’m going to first turn to you to talk about the most significant changes that we’ve seen to U.S. public health policy in the last month, and what you see is the implication of these changes for future international health coordination and data collection efforts. BOLLYKY: Great. Thank you all for joining us. Thank you to Irina and her team for coordinating this. The state and local network that her team operates is really one of the most useful, I find, resources at CFR, particularly on public health where battles are won at the state and local level. And it’s a privilege to be able to engage with you and learn from what you’re hearing on these issues as well. There's a lot going on, of course, on U.S. public health. So there's a good bit we could talk about. In my initial remarks, I'm really just going to focus on three areas. To start, I'm going to talk about vaccination. And there has been an unfortunate consequence, the cumulative effect of some of the early actions taken over this last month to perhaps undermine the support for vaccination, at a time where we have a quite a large measles outbreak ongoing, the potential emergence of dangerous avian influenza. These are risks not just for a loss of life. On measles, of course, it's also just a huge expense if it shows up in your part of the country. This is new. Vaccination for decades—U.S. immunization efforts provided immense benefits for health and had broad bipartisan support. Underlying these efforts were policies rooted in science that have been adapted and improved over time. Support for that vaccine policy framework is just as important today as it has been ever before. But it really has taken a hit, particularly after the COVID-19 crisis. To see how far we’ve traveled on measles, it was just in 2000 that measles was officially eliminated from the United States—meaning there was no measles spreading in the country. That was driven by vaccination. Typically, you need about—vaccine coverage of around 93 to 95 percent to have a sufficient level of population immunity to prevent outbreaks. There are currently, out of the forty-nine states reporting vaccination rates at the kindergarten level, thirty-one states are below the lower band of that threshold of 93 percent for coverage for the MMR vaccine. In terms of the outbreak, I’m sure most on this call are aware. Yesterday the tragic news was reported of the death of a child from measles in west Texas. An unvaccinated child is the first death from measles in the United States in ten years. Officials have reported, by last count that I’ve seen, 124 cases in Texas, mostly west Texas, since late January. Nine cases in the neighboring New Mexico county. Eighty percent of these cases involve children, who are more susceptible to this vaccine-preventable disease. Vaccination rates in the most affected county, rural Gaines County, at the center of the outbreak, are quite low. We've seen cases in seven other states—Alaska, California, Georgia, New Mexico, of course, New Jersey, New York, and Rhode Island. The total number of cases being just over 130 cases actually is more than we've seen in eight of the last fifteen years. And that's just in the first two months of this calendar year. There are probably more cases than that than we know about. We don't know how large this is going to get, but the rate of increase or the force of infection, as you might say, is strong. For reference, the last major measles outbreak we've had in the United States was in New York in 2019. That hit over a thousand cases. This could be worse. Now it is not too late. With the—with the potential for vaccination, behavioral shifts, tireless work of public health teams we could slow the spread of this outbreak. But it is concerning. At the federal level, we've not seen the type of support one would typically see for vaccination. The CDC has—itself, has been quiet on these issues—relatively quiet. We've had a number of important vaccine advisory committees postponed. The National Vaccine Advisory Committee was meant to discuss the strategic plan for national vaccination in February. That's been postponed. The Advisory Commission on Childhood Vaccination was meant to discuss the vaccine Injury Compensation Program. That's been postponed. There's been questions coming out of—at the secretary level about potential conflicts of interest among the Advisory Committee on Immunization Practice, that considers clinical information on immunization practice. Its findings influence the compensation program. Their credibility has been put in question. We had a Cabinet meeting yesterday at the White House where a reporter afforded an opportunity both to the president and the HHS secretary to speak on this, and although they did, we didn't see the call for vaccination that you would ordinarily see. We also saw in the early days of the administration an executive order restricting any federal funding to states or schools that required COVID-19 vaccination. So a broader—the cumulative effect of these actions, intended or otherwise, diminishes support for vaccination at a point where it's more critical. The second thing I would highlight is the firings of U.S. public health officials as part of the broader reduction of government workers. We’ve seen the National Institutes of Health, the nation’s premier biomedical research agency—we’ve seen an estimated number of a hundred—oh, I’m sorry—1,200 employees, most of them promising young investigators slated for larger roles, have been dismissed. Many of them have specialized knowledge that can’t easily be replaced. The CDC has seen a reduction of around 1,100 individuals. Four hundred of those are people that took the voluntary retirement in response to the request from the Office of Personnel Management. About 750 have been fired. There had been views that we might see a reduction in the Emergency Intelligence Service. Not yet, although that’s still possible. But we have seen significant decreases in personnel in the Laboratory Leadership Service Program, the Public Health Associate Program. And these are linkages between the CDC and states and locality that provide important resources in emerging outbreaks and crises. The last thing I will say is these, of course, also link to what's been happening at the international level, and the information sharing that can go on there. On the first day in office, the president, as many expected, withdrew from the World Health Organization. He did so in a manner that he renewed the withdrawal notice from 2020, suggesting it may be immediate. U.S. officials have already stopped participating in many of the networks that exist around surveillance of emerging infections and around influenza. USAID last night had 580—I’m sorry—5,800 out of 6,200 contracts terminated, in terms of its programming. There’s an expectation that the workforce there will be reduced from around 10,000 to 1,000. And, of course, they provide our eyes and ears with other countries in terms of emerging infections, as well as the good work that USAID does around HIV, malaria, and other concerns. What this boils down to is, you know, frontline public health workers here in the U.S. and abroad provide our network that we detect emerging diseases, prevent and respond to these threats, and protect everyone. That system may be unraveling. The risk of doing so is that we create blind spots, where emerging health threats incubate beyond our knowledge and provide an illusion of safety in public health that we don't—that we don't have. And that is our greatest threat potentially moving forward. So let me stop there. Lots more we can talk about. Looking forward to this exchange. FASKIANOS: Thank you, Tom. And we’re going to go to the commissioner to talk about how you are adapting your health systems in Connecticut to the federal public health policies that are obviously shifting, and the challenges that you’re facing, and where you see the opportunities, so we have a little bit of optimism. (Laughs.) So over to you. JUTHANI: Thank you very much, Irina. Thank you for the opportunity to speak with all of you today. And thank you for laying that foundation, Tom, so that I can speak to how we are dealing with things at the local level and at the state level. So what I would like to start with is that, as we entered these last few months and have seen a number of different orders and actions come through, it has been a time period of uncertainty and a time period of unrest, a bit, in terms of staff in a public health department, and state government writ large. So for us in the Department of Public Health in Connecticut, we have 154 different grants that we receive, largely from the federal government, spanning potentially up to seventeen different agencies at the federal government. And I believe that almost all of them received some sort of cease order in terms of work, initially. Half of my department is funded through federal dollars. And so where we are right now with different temporary restraining orders that have been put in place is that, in fact, at this moment, right now today, we do not have any specific grants that have been given specific terminations or reductions. We also have CDC employees—for example, the EIS officer, CEFOs, which are epidemic field officers that have been positioned in Connecticut—we had threats that they would be fired but they have not, up until this point. So what this has created, though, is a lot of uncertainty in terms of where we are going to be able to move forward, where we are going to potentially have to cut back, and where our work will continue. I think the second point on uncertainty is that, as with all administrations, there's an opportunity to decide what communications should go out, what needs to be paused, what can be resumed. And there was a lot of uncertainty in the first several weeks in terms of what information we would be able to get. And for example, there was the Morbidity and Mortality Weekly Report. The one that was put on pause in the first week after Inauguration Day had three different reports on H5N1 or avian flu. Since then, those have all been published, and we do have that information available. Today another MMWR came out as expected. So that is hopeful, that we have been able to see some resumption of communication that had been paused in the first several weeks. I would also comment that we’ve had a few emergent situations where we’ve had to call the CDC for emergency input in terms of how to deal with potential threats. And we were able to get in touch with officers who were working on the ground and be able to help provide us with guidance. As Tom mentioned, a lot of public health—good, old-fashioned public health is done at the local level, at the state level. But where we do really rely on federal partners is for expertise in areas that maybe we only interact with or have exposure to on a one-off basis and not on a regular, standing basis. And that is one of the challenges that we have seen, that we anticipate, and then we worry about in terms of where that is going to take us going forward. Tom mentioned a little bit about vaccinations. I mean, this is a foundational component of our public health advances over the last century. I’ve been talking for the last several months about a Morbidity and Mortality Weekly Report, MMWR report, from 1999 talking about the ten landmark achievements in public health over that previous century. And many of the things that are in there, with vaccinations being one of the top of the list, are the types of things that we worry about every day. If you look back to the early 1900s, influenza was a leading cause of death in this country. Today, we look at diseases like heart disease, and stroke, and diabetes, and cardiovascular disease taking a higher standpoint than influenza. But that is something that can backtrack very quickly. Something that gave me pause today was when I heard that VRBPAC, which is the federal committee that meets to determine which strains of influenza will be in the next season’s flu vaccine, that meeting was canceled. I hope that it is a postponement. I hope that we have an opportunity to see that those particular candidate selections of what should be in next season's flu vaccine are determined pretty quickly because this takes time. When the flu vaccine is identified what should be in the next season, that has to be done in the spring. It takes time to manufacture these vaccines. And this could be threatening to our pharmaceutical industry. This could have impacts on people showing up for work. The impacts of health are so vast. They impact business every single day. They cannot be separated. Health and business go hand in hand because in order to be thriving members of society we need to be healthy and we be able to—we need to be able to live, and work, and participate with each other. So these are some areas of concern, but I am hopeful that we’ve seen some changes where, for example, MMWR did resume. I am a member through the Association of State and Territorial Health Officials on the ACIP, which is the immunization practice committee that evaluates all—you know, all vaccines that come forward to be able to help create that schedule of vaccines. That meeting was postponed. I am hopeful, again, that ACIP will resume and that we will have an opportunity to be able to resume those types of, really on a regular basis, meetings that help inform these things. In Connecticut, we have been fortunate that vaccine uptake is something that has always been strong in our state. Going back to 2014, since we were talking about measles, the measles, mumps, and rubella vaccine, we had a 96.65 percent uptake for kindergarteners with the MMR vaccine. We hit a low during the pandemic in 2020 of 95.28 percent, with 95 percent often being a quoted number for achieving herd immunity. But now in 2024, we are actually higher than we were pre-pandemic, at 97.7 percent. And so we have a lot to, at least, hope that, at least, we’ll be able to, hopefully, avoid a measles outbreak. But we do have under-vaccinated populations, even within that—within our state. Which is true across the country. And so this is something we worry about, and we prep for, and we try to be ready for. The other thing I want people to just be aware of is that vaccinations are a critical thing, but there are so many areas of public health that we often don’t even think about. And I often say this comment that was said to me once, which is that public health saved your life today, you just didn’t know it. So, for example, safe drinking water. If we take our foot off the gas on regulations for drinking water, whether it be toxins, whether it be chemicals, whether it be infectious agents, these are foundational things that we maintain safety in our country. That is something that is under our purview in the Connecticut Department of Public Health. Another example would be food safety. We’ve heard some concerns that there may be less oversight or regulation in terms of food safety. We know right now, for example, there’s a listeria outbreak that’s going on around the country. This is particularly concerning for women, for babies. And we’ve had two cases here in Connecticut. But this is true at our restaurants and at our distributors of food, right at the ground level. For example, our state health department has secret shoppers that go out and buy different types of meat, or dairy, or produce, and do testing to ensure that food that is out in the public that people can purchase is safe. And we get funded, often through collaborations with the federal government and with our state partners, for that type of safety. These are basic things that public health does. And so I'm hopeful because I've seen some things improve over the last several weeks. But I have areas of concern. And it is our goal to work with our federal partners, that we rely on to be able to help provide us expertise and make these broad decisions that implicate all of us and have potential impacts on all of us. And I really hope that going forward we'll be able to continue to work together with federal partners to ensure the safety in our states. Thank you. FASKIANOS: Thank you very much to you both. Let's go now to all of you for your questions and comments. And you can also use this forum to share your experience and your best practices. (Gives queuing instructions.) And nobody’s put up their hand yet. Oh, we do have the first hand. Jennifer Herring. Q: Good afternoon. I’m Jen Herring. I’m from Doylestown Township, Pennsylvania. I’m the chairman of the Board of Supervisors there. My question is, generally speaking we know that there’s—it looks like there’s some limitations on communication between the federal authorities and state and local authorities, as far as health is concerned. And I’m fearful that it’s going to increase—or, actually, decrease—less communication. Where would you recommend we get our information from, if we don’t have access to the information such as, like, a department—the CDC? JUTHANI: I can start with that, at least. I would say that I would lean into your state public health department. One of the challenges that we all face is that state public health departments and local public health departments often rely on the CDC for more expert guidance. But, you know, we're doing the best we can with the information we have, at least at the local level, for what we can communicate out. And so I think as it relates to what's happening right in front of you, and in probably your day-to-day life at a local level, your state health department is probably a good place and a good resource to be able to lean into. One of the challenges we have, to Tom’s point earlier, is we don’t know what we don’t know. When you don’t have eyes on what’s happening on a more global landscape, or potentially even at the federal level, we just may not know it. But one of the things that I would say is that a number of us, as state health officials, do get together on a weekly basis. We do share information with each other. And we may need to do that a little bit more organically. We have sent out statements as we’ve received them. I’ll give an example. Today's MMWR did comment on severe influenza in children resulting in encephalitis and more severe neurologic complications. Before I heard that in the MMWR, I had heard that from some other state health officials. And so that was something we actually also ended up sending out a notice to providers in Connecticut to let us know if they had children who were manifesting with those types of symptoms. I was glad to see that it showed up in the MMWR as well, and I was able to get a better sense of what is the CDC seeing right now in terms of how that relates to what's happening now as opposed to historically. And some of the information shared there is that right now it seems to be 13 percent of children who died from influenza this season had that presentation, historically that was 9 percent. Again, is that outside of the range of variation? We don’t really know, but that was at least helpful for me to be able to read and understand that that was something they were able to share with us. But I would very much lean into, at least from a day-to-day standpoint of your life, leaning into your local and state health departments. Now, if you’re traveling somewhere else often we might have relied on the CDC to be able to see are there certain health advisories or other things like that that may be out there. I have not seen that that is not there. So that may still be available. But I would say also looking at those specific countries and seeing what they may be reporting out on—and, you know, WHO does have a website, it has information out there. Those would be the types of things I would lean into. FASKIANOS: Tom. BOLLYKY: Great. In the arena of more positive developments, after a few weeks where much of CDC’s website, in terms of data and pages, were shut down, there has been a return of much of that information. Now, depending on the area looking there are some concerns that some demographic information has been stripped out, which, from a public health standpoint, is not always helpful. But a lot of the data that had been missing, and some of the advisories that are posted on the CDC website, have returned. So that is, depending on your area, a resource. So, for instance, when I was looking for how many states are below the threshold, at this point, you can get that information from the CDC website, whereas just a few weeks ago you could not. So you’re starting to see some of those resources come online. The only thing I'll say on the WHO side, there are concerns—leaving aside the issue of collaboration with U.S. officials and, you know, a significant number of U.S. public have health staff had been seconded to the CDC—or, to WHO, so it was a real resource there, this will be—the United States was the largest donor to WHO, representing around 16 percent of its overall budget. So they have stopped international travel by most staff unless you're locally there. So to get back to the point that we don't know what we don't know, there is going to be some diminution of the international information we have, simply by reducing the reach of the world's health agency. So that will come at a cost. And part of that cost is the collaboration and the movement of staff. FASKIANOS: I’m going to take the next question from council member Barbara Leary from Folsom, California. Q: Yeah, I’m wondering if there’s—and I don’t know what can be done about this—any movement to reinstate a lot of the research? I know, you know, that you’ve talked, you know, about the MMWR being re-released, but I guess I’m concerned about a lot of scientists and other people who have been let go or who are not being able to pursue their interests in research, tracking problems, et cetera. And does anybody have any idea about how that might be addressed or changed? I think we’re in uncharted territory at this point, so just looking for some other thoughts on that. BOLLYKY: So just a little bit, and then—I'll start. I think there has been some effort for them—in terms of the cuts—at the federal level to U.S. public health employees because it was done largely around probationary employees—so less in a targeted manner and more where there might be the legal flexibility to pursue those reductions in force—you've lost a lot of people with particular expertise. So this was famously, has been reported, you saw that at USDA that the office that they had assembled around tracking the avian influenza outbreak had been gutted. You saw that at parts of the FDA, where, you know, we had brought in—or, the FDA had brought in, rather, people with particular areas of expertise that they've had to now try to hire back. EIS is an area that had been on the chopping block and, at least as of yet, given the outcry about the important role that that program plays, that has not happened. So I do think, in terms of communication, particularly from the state and local level, the importance of programs to the good work that you all do can have an effect when people have a greater appreciation of the value. I do want to point out one thing, though, that I am concerned, particularly as this has largely fallen on probationary government employees, that we are really eviscerating our next generation of public health experts and scientists. And that will have an effect not only, of course, on these people’s careers, but also on people who are considering entering the field. And it comes at a time where state and local—the state and local public health workforce has already been under stress due to the pandemic and is at low numbers. So really, the combination of this disincentive, losing potentially a generation of people, with some of the fatigue that is going on at the state and local level is really quite damaging. So again, you’ve—if you value these programs and particular areas of exchange with the federal government that are important to you, then don’t be quiet about it. JUTHANI: If I can just add one other piece to that, which is in my former role in academia the cut to indirect rates in terms of NIH funding, which funds many different types of support of research in academia, it has also had a chilling effect in the academic world where some academic institutions are not taking on graduate students in a variety of different areas. And in terms of the pipeline you talked about, of people doing research and not being able to pursue that research, some of that is because academia is feeling the pullback, whether it be from NIH dollars, a little bit different than some of the other public health funding that we’ve been talking about, more about scientific research. But really, this is an ecosystem and a continuum where people train in academia and then enter the private sector, enter the public sector, and really continue great scientific work. And it has been the stance of the United States for many, many decades that we wanted to invest in science, and scientific development, and that scientific pipeline. And so I do have concerns and worry that not only are we taking a hit to the public health workforce and generation of public health workers, but also to the scientific workforce writ large. BOLLYKY: Irina, I'm just going to add one quick thing, if I may, on that point. I have a particular concern about infectious disease research. One change, that there's proposed legislation in Congress but also apparently some support of the incoming team at the NIH, is to split NIAID, the portion of NIH that focuses on infectious diseases, into three subgroups—infectious disease, immunology, and autoimmune diseases. The thought is that this might build on some comments made during the campaign to defund or decrease funding to infectious disease research. And it really couldn't come at a worse time, given the range of things we're following. But it is not a lucrative area of medicine, to begin with, and to limit the research opportunities for people in this field is going to be a real disincentive to people pursuing it. FASKIANOS: Thank you. JUTHANI: As a—I’m sorry if I could just say one other thing. FASKIANOS: No, go ahead. JUTHANI: As an infectious disease doctor, I can attest to the fact that it is not one of the most lucrative areas of medicine. But I can also say that when we talk about public health we often think about communicable diseases, and infectious diseases being a large part of that, and the noncommunicable diseases. And we—because we've been able to have great scientific advances on the communicable diseases—in our vaccine programs, and antibiotics, and treatments, and antivirals—we've been able to focus on the noncommunicable diseases, meaning heart disease and cancer, and the things that take many, many decades to get worse in order to then cause worse morbidity and mortality. But if we don't have control of the communicable diseases that generally have morbidity and mortality more immediately, we will be losing decades of progress that we've made in public health. FASKIANOS: Thank you. I’m going to go next to Bill Taupier, who’s the director of administration and safety, in Massachusetts. Q: Oh. Thank you for having me. My question has to do with a little bit about USAID, and where it has been essentially eliminated, for all intents and purposes. My question is about, you know, outbreaks overseas, and how we can—you know, we learn a lot from those to fight diseases at home. But what is your opinion going to happen now with outbreaks of things like Ebola or Hantavirus, or other places—other diseases that could go unchecked? BOLLYKY: We’re going to be at greater risk. I think there might be a perception among some in the U.S. public that because of the struggles we saw around the COVID response, not just in the U.S. but other countries as well, that we really don’t know or are unable to contain—prevent, detect, or respond to outbreaks of dangerous diseases. And it’s not so. If you just take viral hemorrhagic fevers, things like Ebola or Marburg, you think about the Ebola outbreak in West Africa in 2013 to 2015, a little bit in ’16, that took 20,000 lives, or more. It costs billions of dollars in terms of the response. With each subsequent outbreak of Ebola virus, as well as other hemorrhagic fevers, we have gotten much better, even in low-resource countries, in containing this. The reason why you do not hear about these outbreaks in the same way that we heard about that particular West Africa Ebola outbreak is because of the build-up of these systems. USAID funding is responsible for the identification of the first COVID case outside of China. It is responsible for the development of the vaccine that we now have against mpox, and the world uses. I mean, the list just goes on and on and on of how these have kept us safe. And I do have concerns in these environments that—with the cutting of these programs, that we may not see that persist. If you had asked me even at the start of yesterday I would have told you that I think that some of the treatment programs around HIV or malaria, around in terms of the use of insecticide-treated bed nets, that those programs will probably survive in some form, even at the State Department. But we did learn overnight, with the cutting of these programs that I mentioned, or these grants, that many of the programs that had received waivers, the grants supporting those programs have been cut anyway. So I don't—I really can't say what's going to happen, but your question raises a real concern that gets at the heart of safety for all Americans and people worldwide. FASKIANOS: A question from Laura Bellis, Tulsa City Council member. Q: Hello. Yeah, I'm a Tulsa City Council member here in Oklahoma. And I also work in maternal-child health. And obviously, just geographically proximity-wise, too close to Texas for comfort. And our vaccine rates are also, as anyone can imagine, low, relative to where they should be. And so I'm curious if you all have any advisement, when we look at—whether it partnership, as Manisha has mentioned, with, you know, our state or local health departments, just what we can proactively do, acknowledging that we are likely to see a measles outbreak here? That we are in a certain type of policy and health environment that is not always very pro-public health. And just curious if there's anything you all would recommend trying to proactively do in the time we have prior to an outbreak. JUTHANI: Yeah. What I would recommend is, first, getting some knowledge with your local health department and state health department on areas that may be under-vaccinated right now. They should have eyes on that. They should know where those pockets exist. And, you know, like you said, proactively doing some of those interventions. And we do get funding to do this type of work, where we go within communities, identify what some of the barriers to vaccination may be, try to do that type of ground-building and communication with communities in terms of helping to overcome whatever vaccine hesitancy may exist, and then have vaccination campaigns to be able to, in fact, allow increases in vaccination rates. That’s some proactive work that could be done right now. Of course, you know, many health departments are stretched thin as is. Of course, we are dependent on our funding to be able to do that kind of work. But right now, I would say that that type of work is possible, and I would encourage you to connect with your local and state health departments. You know, every state is a little bit different. Connecticut is a home-rule state. We have fifty-nine local health departments and/or districts. I know that there are states like Massachusetts that have many more. There are others that have county-level government, and so there is a lot more economies of scale. But that's where I would really lean in and start there, to try to prepare yourself for what you've identified as a potential risk. FASKIANOS: Tom, do you have anything? BOLLYKY: Yeah. The only thing I would say here is part of what’s been hard about this first month is that, you know, vaccination rates have gone down. I think there is an important national conversation to be had. The part of the secretary of HHS confirmation hearings that resonate with me is being transparent that vaccines have a balance—all medical products have a balance of benefits and risks, and talking in those terms. I think it’s important that we engage in populations in a respectful way. I thought the advice that was just provided is very useful in that regard. I think there is work to be done. I think the fact that we did see a death, tragically, yesterday, hopefully provides an example of what the cost of under-vaccination might be. And there may be more receptivity to these vaccination campaigns than we might otherwise find. So I think looking for a way to have respectful, transparent conversations at this moment, given the national attention to this issue, is important. So I thank you for worrying about it. And, you know, the support you might be able to—or, the partnership you might have with your state and local officials. FASKIANOS: Great. I’m going to go next to Destini Cooper. If you could identify yourself, please. Q: Can you hear me? FASKIANOS: Yes. Q: Hi. This is Destini Cooper. I’m a policy analyst at the Legislative Council here in Nevada. And we're actually in our legislative session right now. I have a public health background. And I kind of want to know what you think the kind of pushback on public health will be when we're already in the world of vaccine hesitancy and things of that nature? And I just feel like in a world where we're trying to restore health—trust in the health care system or in the public health world, do you think that this will have some type of backlash? Because, as we know, as funding goes down or funding is taken away, then we lose services and we lose—you know, vaccine accessibility goes away, and people get sicker because we have more uninsured. And then the blame is, oh, well, vaccines don't work. Now we have more sick people. And now things that we made great strides in are now going backwards. So do you think that public health will kind of get the blame again when, how do I say it, basically options are taken away? Like, when we have to pull back on services and stuff, do you think the increase in health outcomes and, well, the lack of health outcomes—I guess, the decrease in health outcomes, do you think that public health will get the brunt of that again? Because COVID was our fault, right? Nobody believed in public health until COVID came, and then it was, oh, public health is here, and it’s terrible. So do you think that it’ll kind of be our fault again when we lose funding and we have to roll back these programs and the world gets sicker again, for lack of a better term? FASKIANOS: Who wants to start? (Laughs.) JUTHANI: I guess I can start. You know, I—Destini, I appreciate that comment. I don’t know that I would have thought of it that way, but I guess anything is possible. I would not have predicted the way the COVID pandemic happened and the divide that we ended up in after seeing a remarkable development of a vaccine that has saved millions of lives. So, you know, I think, to your point, is there a narrative or dynamic that has been set up that that could happen? I guess it could. You know, I guess I would have liked to think that with a reduction—and more health care problems, with a reduction in public health and preventative measures, that people would see that difference. But, you know, I guess we don’t know. My perspective in general is to try to work within my circle of influence, figure out where I can actually try to make a difference, and make a difference there, in that circle of influence. Because otherwise these questions become existential and feel like we’re never going to be able to make progress. But if I can look at—for the state of Connecticut, can I try to show people that I genuinely care, that I have read the science, and that, in my medical opinion, this is their best path forward, and try to bring people along and meet them where they’re at, then I’ve done my job for the day. And I think that that’s all we can each try to do. I hope we don’t end up in a place like you’ve outlined. Is it possible? I guess it could be. BOLLYKY: Two things, just to say quickly. We do a lot of work—have done a lot of research here on the drivers of differences between countries, how they did during the pandemic, controlling for relevant biological factors, and at the state level. And what a lot of that research has shown—and I’m happy through Irina to circulate the Lancet studies we’ve done on these things—is that, you know, trust—social trust, how communities interact with one another, played an outsized role in the differences between outcomes. There is actually a fair amount of research on how to engage with people who may not be trusting of public health or more inclined to blame public health for the problems. It is leveraging local—the people that are more trusted in those communities, physicians and nurses, the people that you engage with every day, the institutions you engage with every day, maintaining those relationships even in between crises, I think, is honestly one of the major lessons of the COVID pandemic for me, at least. And I think one that is going to be important in this moment. The second point I would make is I read an op-ed by a former Democratic political operative in the New York Times that talked about one strategy around this moment, from that political perspective, is waiting for the consequences of some of these actions to manifest, and therefore pointing out the folly of them. And I will say, from a public health standpoint, I don’t want that. I don’t want to wait that long. (Laughs.) I think we really need to be clear about what the consequences might be and try to engage with communities in an open and transparent way up front. And, you know, I think it’s really incumbent on all of us to do as much of that as possible. FASKIANOS: Thank you. There’s a raised hand, a number begins with 856, no name. So you’ll have to really help us identify yourself, your name and affiliation, please. Q: Yes. This is Laurie Lehmann. I’m City Council, Cape Coral, Florida. And I just want a clarification. You know, obviously, no one has mentioned Florida. Would my best bet be to talk to the county-level or the state-level public health departments to find out where we are lacking and what we can do about things? JUTHANI: Your local health department is always the group that is the most close and proximate to the conditions of what's going on, on the ground in your situation. So I think that that would most certainly be what I advise anybody, honestly, in any state, because they really know what's going on, on the ground most close to you. They can reach out to experts, whether it be at the state level or at the CDC level, to get additional information should it be necessary. So I think your instincts are correct to lean on the people who are closest to the ground where you are. FASKIANOS: Great. There are no more raised hands, but just a question about sources of good data. At the state level are there other organizations who are compiling the data that you could commend to people? JUTHANI: I would say that I think that this is a fluid and evolving situation. I think, to Tom’s point, we know that a number of CDC websites came down, and then now are back up. There are other things that are coming down and are—look to be permanently down in other agencies, as he mentioned the most recent changes that we’ve heard from USAID. So I think we’re going to need to keep on evolving and reassessing as time goes on. You know, I think there is the opportunity that maybe there will be other organizations, whether it be foundations, whether it be independent organizations, whether it be philanthropy, whether it be academia, whether it be partnerships of the like, who may try to fill voids that may develop, but I think we really don’t know what those voids are just yet. And trying to figure that out is, I think, where we are right now. FASKIANOS: Great. And, Tom, how would you say that other countries are beginning to fill the void of the leadership role of the United States in the global public health space? You know, with the exit from WHO, I mean, what is on the horizon here? BOLLYKY: Great question. I think, unfortunately, the events of the last month have had several knock-on effects. One is that governments who might be more politically aligned with the White House at the moment, some of them have—Argentina withdrew also from the World Health Organization, to emulate the action taken by the U.S. Reportedly, Hungary and Russia are considering doing the same. So this may spur, among some governments, emulation. In terms of the broader conversation about the Ukraine conflict, and indicating a potential need for more of a European role on defense on the European continent. This week, the U.K.—which outside of the U.S. is the largest government donor to global health—announced that it would decrease its foreign aid budget from 0.5 percent of GDP to 0.3 by 2027, so that it could invest more in the military, in response. Germany just, of course, had an election. There's enormous economic pressures going on in Germany right now. Germany has historically been a supporter of multilateralism, in the World Health Organization in particular. The World Health Organization has an office in Germany that does surveillance, data surveillance. I think there is some risk that you will see a pullback there as well. In terms of in-country, I think there have been some moves by aid-recipient countries to assume more of the burden. You've seen that in South Africa and Ghana, some conversations for that. But right now, the average government in sub-Saharan Africa spends $92 per person on health, which is less than a fifth of what it is in the less—the next lowest region. And their ability to assume some of these programs is going to be limited, outside of a handful of countries that are better resourced. Where we do see some governments responding has been China, particularly in countries where the U.S. has—or—and China has been grappling for influence, Southeast Asia and some Latin American countries. You've seen China offer to pay for some of the programs. I think in those strategic countries you will see that. I think overall China is not likely to assume the burden for U.S. programs in less strategic regions, or focusing on cross-border health threats. They tend to focus more on infrastructure projects. So we will see less of the focus on global health security and infectious disease or mother-child programs and more focus on healthcare infrastructure and products. FASKIANOS: Great. Roberta Smith from Routt County Public Health asked about programs like the polio eradication programs and Peace Corps, assuming they are also in danger. And then there's another question from MaryAnn O'Connor, who's the Massachusetts director in the city of Medford. Who's on the ground working on the outbreak in the Congo? So maybe you can just put those together. BOLLYKY: Yeah. So just quickly, on polio eradication, the U.S. provided money to the World Health Organization in two forms. One, like all governments, it pays assessed contributions, effectively membership dues. And then the other way is voluntary contributions. We, the U.S., historically provided significantly more in voluntary contributions. Much of that money went to two areas—the emergency program of the World Health Organization and polio eradication. So the withdrawal from the U.S. from WHO is going to have a consequence. Another major funder of polio eradication has been the U.K. government. So I don't know what will happen there in this area. It has been a priority for the Gates Foundation, so you may see them step up somewhat. But you may see some consequences. I have not seen anything in terms of the Peace Corps program. And maybe that will continue, but it’s difficult to know if they just haven’t gotten to it yet or if that’s more of a decision. I just haven’t seen any discussion. FASKIANOS: Great. Manisha, I wanted to give you a minute just to wrap up, and then I wanted to go back to you, Tom, just to say a few words about Think Global Health, because I think this community, this group could really benefit from it. So, Manisha, over to you before we close. And then we’ll go to Tom. JUTHANI: I think I would just make a plug to everybody that a lot of public health is local. And we do rely on federal partnerships and, obviously, international partnerships. But all of you are on the ground in your local communities. Advocate for public health locally. Press on and support the public health people that are doing that hard work and getting a lot of, potentially, counter messages to the work that they’re trying to do. And support them. Support the young people who are trying to do this work in that space in your local communities. And don’t be silent if you value public health, because I think that is going to be helpful not only in your state legislatures but at the federal government as well, to be able to show how public health has helped in terms of our society. FASKIANOS: Tom. BOLLYKY: Great. Thank you for the kind opportunity just to put in a plug for Think Global Health. It’s our online magazine that looks at how—tries to take—much focus on health is how things affect our—other things affect our health. This website looks at how health shapes economies, societies, and everyday lives. It looks from the other way. It’s a form of investment. I think we saw that in the pandemic. I think some of the political upheavals here are also related to what happened in the COVID pandemic. It is a multi-contributor site, so we do have a fair amount of domestic coverage of what’s happening in the U.S. So I would encourage you all to read it, but also, for those that are looking to write on these areas, we have that opportunity as well, and we welcome that. FASKIANOS: Wonderful. Well, thank you both for this hour. We really appreciate your taking the time and for the work you are obviously doing. And to all of you on the call for the work that you’re doing in your communities. It does take a village. We will be sending out the video and transcript. And we can put together some of the resources that were mentioned during this call. And, as always, we encourage you to visit CFR.org, ForeignAffairs.com, and, of course, ThinkGlobalHealth.org, that Tom just mentioned, for the latest analysis on international trends and how they are affecting the United States. And we welcome your suggestions for future webinars. You can email us at [email protected]. So, again, thank you to Commissioner Juthani and Tom Bollyky for this conversation. And we look forward to continuing it down the line. So thank you all.

In When the World Closed Its Doors:The Covid-19 Tragedy and the Future of Borders, Edward Alden and Laurie Trautman tell the story of how nearly every country in the world shut its borders to respond to the pandemic threat. The book details the enormous human costs of the travel restrictions and argues that governments are becoming overly reliant on borders to address external threats from terrorism to drugs to migration. This wide-angle view of a singular shock to the international systems of travel and migration highlights why those living across borders need better protections and governments more robust guardrails. The CFR Fellows’ Book Launch series highlights new books by CFR fellows.

Dr. Mandy K. Cohen reflects on her time as CDC director, highlighting the progress of the Biden administration both domestically and globally, as well as the public health challenges that lie ahead at the state and federal levels.Please note there is no virtual component to the meeting. The audio, video, and transcript of this meeting will be posted on the CFR website.Members may bring a guest to this event.