Tedros Adhanom Ghebreyesus: Global perspectives on public health

[music]

Michael Barr: Hello, I'm Michael Barr, the Joan and Sanford Weill Dean of the Gerald R. Ford School of Public Policy, here at the University of Michigan. It's a great pleasure to welcome you all here today, for our distinguished guest, Dr. Tedros Adhanom Ghebreyesus, Director General of the World Health Organization. This is a co-sponsored event between the Ford School and the School of Public Health, which we're excited to offer under our policy talks at the Ford School event series and the School of Public Health's, Ahead of the Curve's speaker series. On behalf of both schools, I'd like to thank Dr. Tedros for joining us. Dr. Tedros was elected to the Director General position in May, 2017, the first person from the African region to head the WHO. Prior to that, he served in the Ethiopian government, first as Health Minister for seven years, and then as Foreign Minister for five years.

MB: During his time in the health ministry, he led a comprehensive reform of his country's health system, built on the foundation of universal health coverage and provision of services to all people, even in the most remote areas. As Foreign Minister from 2012-2016, he elevated health as a political issue, nationally, regionally and globally. He also served as chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Chair of The Roll Back Malaria partnership and co-chair of the Partnership for Maternal Newborn and Child Health board. He sums up his ambition for the WHO this way, "Our vision is not health for some, it is not health for most, it's health for all, rich and poor, abled and disabled, old and young, urban and rural, citizen and refugee, everyone, everywhere."

MB: Dr. Tedros also has ties to the University of Michigan. After his visit to the campus in 2011, the university established a number of meaningful collaborations with universities in Ethiopia, including establishing the Center for International Reproductive Health Training, or CIRHTs, which works with 10 medical midwifery and nursing schools across the country. Programs have followed in surgery, internal medicine, pediatrics, GI, transplant and other specialties. Michigan Medicine doctors helped perform Ethiopia's first ever kidney transplants in 2015. We are grateful to CIRHT's founder, Dr. Senait Fisseha, who remains one of Dr. Tedros's Chief advisors, for help in arranging this talk. This event is part of the Gilbert S. Omenn and Martha A. Darling Health Policy Fund lecture series.

MB: Established in 2001, this series allows the Ford School to host distinguished speakers on the topic of health policy. Our thanks to Gil Omenn and Martha Darling, who are watching today, for their generosity in making this possible. Before we dive into the discussion, a couple of quick notes about format. We'll start with short remarks from Dr. Tedros, and then spend the majority of our time in a conversation between Dr. Tedros and Dean Bowman. Thanks to many of our audience members for submitting questions during registration. We've included themes from your questions in our discussion. We'll have some time at the event today for live audience questions as well. You can send questions using YouTube or Facebook chat functions, or you can tweet your questions to us, using the hashtag #PolicyTalks.

MB: And now, I'm happy to turn things over to my friend and colleague, DuBois Bowman, Dean of the University of Michigan's School of Public Health. A renowned expert in the statistical analysis of brain imaging data, Dean Bowman's research has important implications for mental and neurological disorders such as Parkinson's, Alzheimer's, depression, schizophrenia, and substance addiction. The two of us enjoy working together on the important relationship between Public Health and Public Policy, and here at the Ford School, nine of our master's students are pursuing joint degrees with the School of Public Health. Dean Bowman, let me turn things over to you.

DuBois Bowman: Hello everyone, and thank you Dean Barr and the Ford School for co-hosting this event. I also wanna extend my deep thanks to Dr. Tedros, for joining us today, and to congratulate him on recently being elected to the National Academy of Medicine. I know that this recognition is added to a long list of honors for him, but as it was just announced earlier this week, I'm gonna extend my heartfelt congratulations. We're honored to be hosting him, and I'm looking forward to our conversation.

DB: This is such a rare and important opportunity to hear from a public health expert, who's leading pandemic response efforts on a global stage, and I'm excited for the insights that Dr. Tedros will share, as well as the ways that we might be able to apply those insights in our own lives, as we have many people in our audience today who are involved in local public health response efforts, who are helping to drive public health policy, or are students eager to get out into the real world and make an impact on health policy issues. So with that, I wanna say thank you again to Dr. Tedros, and I'll turn it over to you now for some short remarks.

Dr. Tedros Adhanom Ghebreyesus: Thank you. Thank you, Dean. I'm really glad that Dean Barr started from telling the audience that I'm very close to University of Michigan. I'm very proud to be close, actually. As Dean Barr said, the first meeting that resulted in the establishment of a resident program in Ethiopia in St. Paul Medical School was actually done in 2011. I remember then meeting Dr. Senait, and my friends Dr. Joe Kolars and Dr. Tim Johnson. I have many friends, by the way, in addition to them, in the University of Michigan. And when we had a discussion in March, 2011, to start a residence program, that happened in nine months from the day we spoke about it.

DG: We discussed at that time, about the need for speed, to establish the resident program as soon as possible, and of course, our target of six months, that was very ambitious. But we did it in nine months, and the first graduate of the resident program was in July, 2016. So imagine discussing about residence program in 2011, March, and then having graduates from that school in 2016. So my partnership with the University of Michigan is very, very productive, not only the residence program, but also the support, helped in strengthening the newly established medical school, the St. Paul Millennium Medical School. So thank you so much. I would like to use this opportunity to thank the University of Michigan for that very successful partnership.

DG: And of course, the first kidney transplant in Ethiopia also, was a result of that partnership. So it's a very productive one. And that's why, when I meet colleagues, I always say, "Maize and blue!" [chuckle] And I'm very proud of that partnership which is very productive, and thank you so much, again, for having me today. For me, it's homecoming, and I consider the University of Michigan as my home. And thank you to Dean Bowman, and also, I already say to Dean Barr, and greetings to all members of the school, to students, the faculty, alumni, and the entire University of Michigan community. And thank you for having me today.

DG: And I have often said that health is a political choice. The COVID-19 pandemic has presented governments and public health institutions around the world with many difficult choices, which public health measures to recommend, what level of restrictions to impose to protect health systems while preserving individual freedoms, how to allocate scarce resources, and more. Many of these decisions are made under intense public pressure and with evolving information. But in fact, many of the most important choices that determine the outcome of a health emergency are made long before the crisis itself strikes. The choice to invest in primary healthcare and public health infrastructure, the choice to put science at the heart of public health policy, the choice to build trust with communities through a strong social contract, the consequences of these choices are now playing out around the world. Some of the world's wealthiest countries with the most advanced medical systems were swamped by this novel virus, even as countries with far fewer resources were able to limit the speed.

DG: The number of weekly reported deaths from COVID-19 is now at its lowest in a year, although we know the real number is higher. However, many countries and communities continue to see increases in transmission and death, especially in areas where access to vaccines or acceptance of vaccines is lowest. Low income people, minorities and other marginalized groups have suffered disproportionately. More than 6.6 billion vaccine doses have now been administered globally, but more than 75% of those have gone to high and upper middle income countries. Low-income countries have received less than one-half of one percent of the world's vaccines. Just five percent of the population of Africa is fully vaccinated. So the problem is more serious even in Africa. High and upper middle income countries have now administered almost half as many booster shots as the total number of vaccines administered in low-income countries. We are facing a two-track pandemic, fueled by vaccine inequity. This is not just ethically abhorrent, it's also epidemiologically and economically self-defeating.

DG: The longer vaccine inequity persists, the longer the social and economic turmoil will continue, and the more opportunity the virus has to mutate. No country can vaccinate its way out of this pandemic in isolation from the rest of the world. The fastest and most effective way to bring the pandemic to an end is to vaccinate 40% of the population of every country by the end of this year, and 70% by the middle of next year. Of course, the inequity we see in access to vaccines is the same inequity that lies at the root of so many global health problems. If a community is unable to provide essential healthcare services during normal times, how can it be expected to cope with a pandemic? That's why at the heart of WHO's mission and the heart of all public health is a conviction that health is a fundamental human right for all people, not a luxury for those who can afford it. So even as we respond to the pandemic, we must learn the lessons it's teaching us. Let me offer three.

DG: First, we must recognize that a strong health system is not the same thing as an advanced medical care system. For too long, too many countries have invested heavily in advanced medical care, while under-investing in public health and primary healthcare. When COVID-19 hit, they were overwhelmed. At the foundation of universal health coverage, primary healthcare is a vital first line of defense against disease outbreaks, but also for providing services for communicable and non-communicable diseases, including mental health, and for preventing and mitigating the impacts of social, economic, and environmental determinants of health, including climate change.

DG: Second, we need better financing for national and global preparedness and response. That includes a substantial increase in domestic investment, as well as in international financing to support low and lower middle income countries for surveillance, laboratory, miscommunication, and contact tracing capacity, and preparedness systems using a One Health approach.

DG: Third, we need better global governance that's inclusive, equitable, and accountable. The existing global health security architecture is fragmented, and voluntary mechanisms have not worked. At a special session of the World Health Assembly next month, WHO member states will meet to discuss the potential for a legally binding international agreement on pandemic preparedness and response to provide a much needed overarching framework for global cooperation. In the coming months and years, other crises will demand our attention and distract us from the urgency of taking action now. If the world continues down the same path, then we'll continue to get the same result, which is a world that's less healthy, less safe, and less fair. Health is a political choice. Now is the time for all countries to make the choices, to build a future that's healthier, safer and fairer for everyone, everywhere. Thank you again, and I look forward to our conversation. Back to you, dean.

DB: Thank you, Dr. Tedros. That was fantastic. I appreciate the really powerful words that you shared and really wanna dive into several of those topics throughout our conversation together. So we're appreciative of you sharing with us and grateful for the incredibly important work that you're doing, that you're leading, to keep people across the world safe and healthy. Now, with the remaining time, what we're gonna do is transition into some questions. Many of the themes that I'll touch on are questions that were submitted during the registration process for the event, so I know that our viewers are eager to hear from you. So if you're all set, let's go ahead and dive in.

DB: The first question that I'd like to ask really touches on things that influence leadership, and our audience today ranges from public health students, public policy students, to advanced career professionals, both within and outside the university. And for students, even early professionals, it's often challenging, to see themselves as prominent and influential leaders in the field, yet, what leaders bring to their roles is often shaped by experiences over the course of many, many years. And so to begin, I'd just like to ask you to reflect and maybe comment on any experiences that come to mind for you during your journey, whether personal experiences, educational or professional, that have influenced your leadership style and approach.

DG: Yeah, no, thank you. Yeah, I have probably wanting to share with you so we can move into other questions. This is in 1988, when I had the opportunity to get a scholarship in Denmark. It was a diploma training in epidemiology, and that was in 1988, a lot younger than now, of course. And I had my health insurance for the first time. I was there for four months, but I had health insurance that covers me for one year. I even asked them, "Why do I need a one-year health insurance when I stay in your country only for four months?" They said, "No, no, it's fine. If you want, you can come back to use it." So that triggered, actually, an interest to study or to understand the health system of Denmark. And from my observation, or of course, my understanding at that time, I thought Denmark had implemented what we now say health for all, or universal health coverage, because the whole community, all citizens were covered, including guests like me actually, and I was really surprised. And also, I was convinced that universal health coverage can be possible in any country. What is needed is a political commitment from the leaders of the country.

DG: And I had another opportunity to visit Sweden later on, and of course UK, the NHS model, all have a lot in common, mainly focused on public financing and cover each and every citizen. And I think the three observations made me to be a lifelong believer of universal health coverage. So all we do in WHO, and even before that, when I was Minister of Health in Ethiopia, I was working day and night based on that belief, that UHC is possible, what we need is political commitment. So I think all... Whatever leadership inputs I would like to make, or whatever inputs I would like to have, I would like to lead it into making sure that UHC can happen in the world, and I believe all roads should lead to universal health coverage.

DB: Terrific. And I think that reinforces one of the earlier points that you made in the non-equivalence of a strong health system and availability of advanced medical care for some, so I appreciate you sharing that. So now, just shifting slightly to talk about leadership during challenging times. One of the most vexing aspects of the pandemic stems really from the novelty of the virus. And you had to make many decisions with global implications in an atmosphere of uncertainty and ever-changing disease progression, and this started in the months leading up to March of 2020, when the World Health Organization first declared COVID-19 as a pandemic. And so, I'm wondering if you can just take us back to that moment and describe for our listeners what you were facing with your team and how you were able to make decisions in face of so much uncertainty.

DG: Yeah. No, thank you, thank you so much. That's a very good question. You know, I haven't taken any... What do you call it? Leave, or I haven't taken any rest until 2019, after I became DG. So I wanted to have a few days leave after more than two years and a half as Director General. And I was actually on a leave when I got a call on December 31st, and which was the New Year's Eve, that there is something going on and there is maybe a new outbreak which is serious. And then, that was a call from my colleagues. So we started following up starting from the eve of the new year, during the new year, so we started working, and by January 2nd, what we picked up from the website of Wuhan-based health department in China, actually to be a novel disease, something new, and it was confirmed by January 2nd. So maybe something about my team then is, you can understand, my colleagues took it seriously, although it was the eve of the new year, and continued working on it, although the following day was a new year.

DG: That commitment, to be honest, inspired me and gave me the energy probably until now, fighting the pandemic. Because you say, "Okay, I have colleagues who know what they are doing and who have commitment." So my team is good, and I say proud to be member of this team. So you function well when you have a functioning team. So I think that's the start of the trigger, that's when we had the first report, and my colleagues did their best, and I was happy. I didn't complain that I was disturbed while it's eve of the New Year and then the next day was the New Year. Then, of course, the first few days, the first few weeks, the first few months, our knowledge of the virus was really limited. And we decided with our colleagues to say to the world, "Okay, this virus is unknown. We don't know much. What we don't know is more than what we know. What we know is little, but we believe that this could be dangerous, from whatever we have seen so far."

DG: And that was the message from the start, and we started developing guidelines with the little we know, to guide the world on how to fight. Then by January, I think 22, by January 22, there were cases, although outside China, there were around 50 something cases, but in China, it was increasing significantly, so we called the emergency committee to deliberate. The emergency committee was divided and they didn't declare PHEIC, but they decided to meet after 10 days to deliberate again. Between January 22 and January 30, I had to fly to China to see things firsthand, and what we saw on the ground was really serious, and we had a chance also to get more information, and then we returned to Geneva. And the following day, we had the emergency committee meeting, again, ahead of the 10 days they actually planned to meet, and PHEIC was declared on January 30th. So the highest level of emergency was actually declared on January 30th, that's a month after we had picked the report from the Wuhan-based website...

DG: Health department website in China, when the number of cases outside China was less than 100, actually. And at that time, we said, there is a window of opportunity now, to control it, and countries should be aggressive. This virus seems dangerous, we don't know much, but we have to be very serious. And from then on, the principle we were following was, to really understand the reality, and understand what we know, understand what we don't know, and try to, of course, at the same time, take it seriously and communicate whatever we have at hand. So that's the early days.

DG: Of course, then we described in March, that the situation is now worse, and that it can be described as pandemic. By the way, there is no requirement from WHO to declare pandemics, because the highest level was already declared on January 30th as public health emergency of international concern. But between January 30th and March, mid-March, when we described the epidemic as pandemic, the actions of the whole... The actions of many countries, majority actually, was not really as desired. So we wanted to use the description as pandemic to wake... As a wake-up call, to say to the world that this is serious. It was serious even when we said it in January 30th, that was the highest level of emergency, but it's getting even more serious, and that it was a wake-up call. Between January 30th and March, mid-March, we were also telling the world that this virus is dangerous, and we used even phrases saying, "It's public enemy number one," and that the world has to do everything. Before even the description of the situation as a pandemic, we were trying to tell the world that this virus is dangerous and public enemy number one. And since then, we are here, but now we know more, we know better, and we believe that we can, with the tools we have, I think we can manage this virus, and we're a lot better and really better condition now.

DB: Terrific, so...

DG: Back to you, Dean Bowman.

DB: Yes, yes. So I'd like to ask of another question that's still kind of related to just challenging times and leadership, and that is, public health has been politicized during the pandemic in ways that we haven't really seen before. Public health workers at local levels, at national levels and even global levels have had incidents of mistreatment and even threatening behavior, offer working hard to protect the health of the public. And so as a leader, what have you learned about navigating this type of climate? And perhaps not even only yourself as being someone who's obviously very politically astute, but maybe even for members of your team or others who you've worked with.

DG: Yeah. No, thank you. It has been a very difficult journey, and still is, and it has been politicized throughout. Maybe at times, we were a bit starting to be frustrated, even. And I remember, in one of our [0:29:41.7] ____ pressers, when we had only 60,000 deaths, and when we saw politicization of the virus, we said to the countries, "Please, stop politicization." If you politicize this pandemic, the virus will have advantages, and we will have more body bags, and prepare more body bags. Because to be honest, saying it that way was really not something I normally say and I want to say, but the inaction of many countries and the politicization was so disappointing that I started using those words. And now, we have more than... How many millions deaths? Millions of deaths. I think 60,000 was really small, actually, compared to what we have now. So the politicization really hurt a lot, and it was a very good advantage to the virus.

DG: There were many good examples that we were saying then, please stop politicization. To fight this pandemic, you need unity, and it starts at national level. And we were bringing examples of countries, for instance, Finland was a very good example, when political parties, the ruling, the incumbent and the opposition, forming a joint committee and fighting the virus together, because they said it's a common enemy, and they could be more effective, and some other countries also have done the same thing. And that also influences the global solidarity, because when there is national unity to fight the pandemic, then the same approach can be used globally to fight the virus in unison. But because there was politicization at home, and especially some countries were using the virus or the pandemic situation to score points against their opponents, political party opponents.

DG: They were politicizing wearing masks, politicizing vaccination. By the way, it's still happening. And then, if people are told by some of their political leaders not to wear mask, which is very technical, and while the other political party members are saying you have to wear, or political leaders are saying you have to wear a mask, then some will follow their leaders, listening to not wearing a mask, and others, of course, will wear. But the result is a good proportion of your population will not be abiding by the technical guidance, and will be exposed to the virus, and the virus will get opportunity to spread. So that really created a lot of opportunity for the virus, and the high transmission that happened in so many countries was because of political problems. And when politics is wrong, the technical guidance is undermined, and the result is bad. When politics is right, technical guidance is followed and the impact is better.

DG: So, political intervention is surgical intervention, it changes the paradigm, for good or bad. So when there is clear and right political direction, then the technical guidance could be supported and the result could be better. So that's why we have been saying, please don't do it. And please, don't politicize, and please... You have many other political punches to use against your opponents, don't use this. This is a common enemy, don't. Just take this out of the table to use it against your opponents, and use other things to score points.

DG: Then personally, how did you manage it and my team? We focus on the issues. We had attacks, threats, directly. And many were throwing at us, a lot of rubbish. But what we do is, we focus on the issue, we say, "Okay, maybe we see a lot of rubbish thrown at us. But whoever is throwing it, they may have a point." So what's the point? So instead of focusing on the rubbish, or instead of focusing on the attack, what's their point? What are they telling us? How can we find the point and address it? Because some people may be frustrated and do that. But that frustration should not really cover the point they're trying to make. So we focus on the issue. It helps us in two ways: One, we stay sane, because we are focusing on the issue, we don't take it personally, and we don't let it in, the rubbish, so we can stay sane. At the same time, since we're focusing on the issue, we will identify the issue and solve it, because there may be something we can learn even from that rubbish or frustration.

DG: So that's how we try to handle, focus on the issue. Focus on what they're trying to say; let's not take it personally. Then to the health workers, as you know, early days, there was a lot of support and appreciation, and you remember many citizens in many parts of the world, evenings, from their balconies they were cheering health workers and appreciating them for their support. But at the same time, there was abuse. But health workers, they risk their life. By the way, the recent estimates of the deaths of health workers is unbelievable. We lost lots of health workers because of their occupational... It's because of occupational reasons, what you call occupational hazard.

DG: And we believe that health workers should be appreciated, not only the clapping or the cheering, but whether it's pay or better work environment and other things. I think we have to respect our health workers, they were heroes and still are, and many have lost their lives while saving others. And would like to use this opportunity, actually, to pay tribute and express my respect. But the harassment or the abuse is still continuing, which is not really necessary, and the global citizen should understand that health workers are actually risking their lives to save them. So that's how we were trying to handle, so we try to stay calm and try to focus on the issue, and work in good faith, to save lives, because people are dying. So we cannot complain, we just do our best to save lives, that's it, and focus on the issue.

DB: Great, great. And I know health workers, public health officials on the frontline, policy advocates will draw strength from your words of support, and others that I'm sure will draw some wisdom just from the tips that you left about how you approach things with your team. So I'd like to now move in and touch on some things that you mentioned in your opening remarks about equity. And if we can start really at the very beginning, and in terms of just the case for vaccine equity, and we've seen inequities play out not only between countries, but even within country. If you can just really underscore the case for why do we need vaccine equity.

DG: Why do we need vaccine equity? That's a very good question. As you know, even as speak, the whole world it is taken hostage by a virus. And it's affecting the lives, livelihoods of people, affecting their social life, political, and their economy. So, vaccine equity will help us to open up the world, give to the people their lives back, their livelihoods back. So that's the reason. Without vaccine equity, we cannot do that. Second, with vaccine equity, especially if we can speed up vaccine equity and vaccine coverage and vaccinate the whole world, the chances of emergence of new variants of this virus could also be less. So you have these two advantages, because if the emergence of new variants is less, then we can manage the virus, so lives and livelihoods will be back, back to normal. So that's why.

DG: Otherwise, if there is no vaccine equity, then it's like when your house is burning, if you hose it in one part and the rest you leave it, then it will continue to burn, so you will target to make sure that all the fire that you see is extinguished. So just the same approach. No country can be safe unless the rest is safe, or the rest of the world is safe. And it's in the interest, because no country can be safe, it's in the interest of each and every nation to stand for vaccine equity. It's not charity, it's actually opening the world... Will benefit even those who will be sharing the vaccines they have.

DG: Especially, when we say sharing, we can target the G20 countries, they own more than 80% of the global GDP, and they also own more than 90% of the global manufacturing capacity of vaccines as we speak. So, if the rest of the world is not opened up, even the G20 countries, I think will be... Will continue to be affected by the virus. So that's why we go for vaccine equity, not as a charity, but for the benefit of every human being and every nation on earth, and for our world to return to normalcy, because everybody is sick and tired, and everybody wants the whole world to really, really open up, so go back to normal. So see it as an individual, that's the only way out, by the way.

DB: Terrific, terrific, and I really appreciate you underscoring, sort of, moral and ethical grounds, but as... But paired with scientific considerations that are critical for us to actually effectively manage and control the pandemic.

DG: Exactly. And that's why, by the way, vaccine inequity is, I said also in the past, epidemiology clearly wrong, and economically wrong, morally wrong. So three, wrongs. And I don't think we should accept this. By the way, I would like to use this opportunity to appreciate President Biden, because from the 135 million doses delivered so far, 2/3 come from donations from the US, and I think that's a very good signal to really lead the world, and we hope this will motivate others, and we also hope US will do more, and President Biden and his administration will do more.

DB: Terrific. And, so I really appreciate your comments there. And wanna ask you also just to maybe elaborate on some things that you mentioned at the outset in terms of vaccine boosters, and just to open it up, I know it's an area that you've commented about previously, but just sharing your thoughts on vaccine boosters.

DG: Yeah. On vaccine boosters, we had a meeting with... We convened a meeting of more than 2000 experts some weeks ago. And there is nothing conclusive on the advantages or usefulness of boosters. So why do we waste resources when it's not conclusive? And the most senior scientists or experts we have have already looked at it and they're not supporting actually. So that's one. And second, many countries who are moving into boosters are those countries who have already done well on the first and second dose. So we felt it's really unfair and unjust to move into a booster, while in Africa we have only 5% coverage and the 5% coverage means... 95% doesn't have even the first round.

DG: So imagine when 90% doesn't have even the first round, moving, after covering 60% or 70% of your population to move into boosters, and which is not really conclusive, then it doesn't make any sense. Then again, it's a moral issue, it's also a sinus issue and other issues, and that's why I announce moratorium until the end of this year, at least, then we can have time to assess again on the usefulness of boosters, and whatever was allocated for boosters can be used to increase the vaccination coverage in developing countries, especially in Africa. And that goes back to what we said earlier, the equity issue. Unless there is equity and others are vaccinated, this virus cannot be beaten, so even those countries with high percentage or high coverage, 70% or 60% will not be safe.

DG: So it's in their own interest. And I have a good general called Dr. Mike Ryan, he says, "It's like having a lifejacket and then taking another one on top of that while leaving your friend next to you without a lifejacket." So, [chuckle] do we need to go that low? No. At the end of the day, it will be very important to use our mind and come back to our senses to do the right things, because this world cannot really survive without doing the right things the right way, and for the right reasons. So we need to really be serious about our common humanity. Thank you.

DB: Terrific. And I have one question that just came in from the audience that I'd like to ask, and it's, does the WHO and its regional offices have direct relationships with international biopharma companies to gain access to medicines, and influence R&D in patenting policies, and what are the prospects, for example, for any African country to establish a vaccine manufacturing unit? 

DG: Yes. To address the vaccine equity problems we're facing now, one of the solutions is investment in local production in as many countries as possible. And we have established a hub, manufacturing hub, transfer technology, of course, in South Africa, the first one. And we hope that we'll encourage investment in Africa and local production in Africa. And we are also supporting countries in each and every continent, actually, two or three for... To boost their capacity and local production. And we're advocating for technology transfer and we have a technology pool, of course on voluntary basis, and we're advocating also for intellectual property waiver, as you may know. We really appreciate the private sector. They have developed the vaccines in less than a year, and they need all the support, but at the same time, the manufacturer should think that this is unprecedented situation, and we have to use all the means we have in order to increase production and get out of this this mess. And also to countries that's what we're trying to help them understand.

DG: IP waiver, the provision was included during the negotiation on the TRIPS agreement, to use it for such a situation. So if we can not use it now, which is unprecedented, when do we use it? So we need to use all available means. Of course we have good relationship with the pharma, but at the same time, we have a very honest and candid relationship at the same time. And for them, if they have IP waiver for a limited period of time, for a limited number of products, like vaccine for instance, 2-3 years, I don't think we'll affect the incentives they get from the IP protection. It's limited number of products for a limited period of time, because we care for them also, because they have really helped a lot, and this cannot be under... Should not be undermined and we should recognize that, but at the same time, we need to use the available means we have.

DB: Terrific. So... Ask one last question, I'm mindful of time, but I... We're nearly two years into the pandemic, and for you, based on everything that you've experienced, the under-the-hood view that you have through the World Health Organization. If we take a long-range view, do you feel that we're ultimately headed toward endemic community transmission, or do you feel that elimination or even eradication are potentially within reach? 

DG: I think from what we see now, the virus is here to stay with us. It's going to be endemic from what we... The behaviors it's showing. It has already crossed all seasons twice almost, meaning two years means all seasons twice. So it can be transmitted any time of the year. So it's potent, and you see also the mutations. So what we expect is it will stay with us, and that's why, with high coverage of vaccination, combined with public health measures, then we know how to live with it, so we can go back to our normal lives without needing elimination or eradication. For the time being, that's what we think, but of course as we go forward, we will know more and maybe there could be more recommendations, could be elimination or whatever, like we do for other specific disease problems. But for now, I think it will stay with us, and we need to know how to live with it. When it started, by the way, as I told you, we were saying, "This is dangerous and it's public enemy number one, and we don't know, it may stay with us, so you have to do everything."

DG: But there were many countries who believed that it will just go away, like SARS, like MERS, like H1N1. I think that was one of the reasons for the surprise also. Instead of doing whatever they could, they were saying, "It will go away." It didn't go away like SARS or MERS or H1N1. So I think the message or the lesson going forward is, when there is anything new coming, I think, of course, comparing it with, if there are similar events before, or similar disease before, is important, but at the same time, it's always important to suspect that it may have its own behavior, and it could be more potent, and it could be more dangerous.

DG: So I think more precaution will be, I think needed for the future. But you remember that some people are using the exact word, it will go away, or it's like flu, or it's... And which is not. So that's what we believe. I think it will stay with us, it will be endemic, but we know how to live with it. It can be like the seasonal flu, and we can manage it that way, but we'll have vaccination and the rest. Then going forward, we need the pandemic treaty, or you can call it pandemic agreement, a framework that can help us to define the rule of the game, for the future, so we prepare in advance and we invest based on the treaty or the agreement on preparedness, because prevention is better. So we can invest in prevention, then we can invest in early detection, and then we can invest in response, but we need to have an agreement that really covers from prevention up to response, a rule of game for the world so the world works in unison when such a situation happens.

DB: Terrific. So, we're just about at the end of our time together, and Dr. Tedros, I can't stress how much of a privilege and honor it is for me to have this conversation with you. So on behalf of myself, the School of Public Health, the Ford School of Public Policy, both here at the University of Michigan, and everyone who's listening in today, thank you for joining us. This was an excellent conversation. We're so appreciative of you taking time to be here with us, but also really for your bold, yet compassionate and grounded leadership on a global stage. So thank you. I also wanna extend my thanks to everyone who helped pull this event together, including the team at the World Health Organization, Dean Bar, and colleagues at the Ford School of Public Policy. Thanks to everyone listening for joining, we hope to see you at another event again soon. Have a great afternoon.

DG: Thank you. Thank you very much. Thank you for having me, and thank you Maize & Blue! So, virtually today, hope to come in person soon.

DB: Terrific. Thank you.

DG: Thank you. Thank you, Dean Bowman, thank you so much. And Dean Bar.