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Coronavirus Update From the WHO

Soumya Swaminathan, MD, DNB, Chief Scientist at the World Health Organization, discusses the global coronavirus pandemic and the WHO response. Recorded August 5, 2020.

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>> Howard Bauchner: Hello and welcome to Conversations with Dr. Bauchner, and it's a real, real treat today. I'm joined by Soumya Swaminathan, Swaminathan, sorry Soumya, people know I'm terrible on names, I apologize, who has remarkable position. She is a scientific director for the World Health Organization, and she's currently in India. Soumya, welcome. Thank you for joining me today.

>> Soumya Swaminathan: Thank you very much, Howard. It's a real pleasure to be with you.

>> Howard Bauchner: So, Soumya, like me, you're a pediatrician. So, you've been at the World Organization for about five years. You've had two positions. You're Chief Scientific Officer now. What did you do before you came to the World Health Organization, Soumya?

>> Soumya Swaminathan: So, I was a researcher in India. I worked at the Indian Council of Medical Research, which is sort of the equivalent of the NIH in India, and the ICMR has both intramural and extramural institutes. So, I worked for about 25 years in one of the intramural institutes, the Tuberculosis Research Center, which is actually based in Chennai, and then in 2015, I was appointed the head of the Indian Council of Medical Research, the Director General, and I held that position until 2017, when I then went and joined Dr. Tedros soon after he became the Director General at the World Health Organization, initially, as his Deputy Director General. And then last year, we had a reorganization, what we call a transformation of the organization, and this new science division was created, and he offered me the position of the first Chief Scientist of the World Health Organization, which I, of course, very happily accepted [inaudible].

>> Howard Bauchner: Congratulations.

>> Soumya Swaminathan: Thank you.

>> Howard Bauchner: Soumya, before we get into the World Health Organization role in the pandemic, which is what will be the focus of our conversation, you know, I don't think many people know how the World Health Organization is organized. And could you say a few words about that? I mean, the home base is in Geneva.

>> Soumya Swaminathan: Yes.

>> Howard Bauchner: But could you talk about in general how it's organized.

>> Soumya Swaminathan: Sure. So, the World Health Organization was formed in 1948. It's headquartered in Geneva. It's made up basically of the member states. So, we have 194 countries that we call member states that come together and basically are the organization. And we call ourselves really the secretariat. And the way it works is there's a headquarters in Geneva where we have about 2500 or so staff, and much of the normative work of the organization at headquarters. We then have six regional offices including one in Washington, DC, the Pan American Health Organization, the southeast region, western Pacific, eastern Mediterranean, European, and Africa region. So, there are six regional offices and six regional directors who are actually elected by those countries of the region. So, the director general as well as the regional directors are connected. And then you have, we have country offices in about 150 or so countries where you have the head of the country office and then the staff, and the size of these offices can vary from, you know, five people in some of the more developed countries, to over, you know, 500 people in conflict region or other countries which have a lot of health problems where WHO is more operational.

>> Howard Bauchner: Soumya, how does the World Health Organization relate to GAVI or UNICEF, the other big players in global health?

>> Soumya Swaminathan: So, that's a great question because obviously I think when the World Health Organization was set up in 1948, it was the only global health organization, and it has in its constitution, you know, several functions, and it had, as in fact its mission and vision early on the health for all principle, delivery of health for all people regardless of where they live in the world. So, that's very much enshrined in the philosophy of the organization. And research is part of it, but so is guideline standards, data, and working with countries and then more recently leading to national health regulations, which directly deal with surveillance and response to outbreaks. UNICEF is another UN organization, obviously, that deals with children's health and education. We work very closely on many areas including immunization and children and adolescents health as well as some of the other UN agencies like UNFBA on sexual and reproductive health, violence against women, with the Food and Agriculture Organization on issues related to food safety and zoonosis, antimicrobial resistance, and so on. So, we have these relationships with many or most of the UN organizations, and then there are organizations like GAVI, the vaccine alliance, and the alliance is really GAVI, WHO, and UNICEF, which together form the alliance and which are responsible really for distributing millions and millions of vaccines to children in the developing world, mostly in the lower middle income countries and over the last 15 years or so has really resulted in huge increase both in routine immunization of already existing older vaccines but also an introduction of newer vaccines like the pneumococcal vaccine, rota, and HPV, and so on. Last year, actually, we launched a program called the Global Action Plan for sustainable development goals, where WHO and 12 other agencies came together and said we need to work together if we have to achieve the STGs both not just at the global level but also down at the country level, you know, much more effective coordination and delivery of services, less duplication, more efficiency, and the idea was to accelerate the achievement of the sustainable development goals by 2030.

>> Howard Bauchner: Who creates the sustainable development goals?

>> Soumya Swaminathan: So, again, it was created by the countries of the world coming together at the United Nations, and then, you know, you had the millennium development goals which ran from 2000 to 2015.

>> Howard Bauchner: Right, yeah, right.

>> Soumya Swaminathan: And then 2016 to 2030 are the sustainable development goals. And, of course, SDG3 is all about health, but there are other goals, you know, on gender equality, on water sanitation, on environment, many of which are, of course, very closely related to health. So, WHO is a lead agency responsible for SDG3, and so when we, or when Dr. Tedros took over as the Director General, we launched a new five-year strategic plan that was very aligned to achieving the SDGs, and that was divided into three pillars, the first pillar being universal coverage.

>> Howard Bauchner: Right.

>> Soumya Swaminathan: Achieving that, because we've been seeing that for a long time, but we really want to achieve it by 2030. The second pillar is in fact devoted to health emergencies, and it's about prevention, detection, and response. And we have seen now clearly how many countries have been hit so hard and have found it difficult to respond to this pandemic. So, the second pillar is really about building those capacities and those functions. And we say there are two sides of the coin, universal health coverage and protection against health emergencies go together. And the third pillar is very interesting because it's to do with healthy well-being. So, it's not to do with disease, but really it's to do with well-being. So, it's to do with all of those risk factors and determinants of disease, like the social and environmental determinants, which have a huge impact on health, but which are not in the mandate of the health ministry. So, a good example is road safety. For example, we know millions of people die, you know, due to road traffic accidents every year. But the health ministry is not in charge. So, but it's the health ministry's role to be a steward and to be an advocated for road safety so that less people, you know, get injured and die. Similarly, you know, it's water sanitation, it's nutrition.

>> Howard Bauchner: Right.

>> Soumya Swaminathan: It's things like air pollution, which, again, is a major killer today in the world, where you have to work with other ministries like environment and food and agriculture. So, that's the third pillar. It's all about well-being. And so, we have geared ourselves up really to deliver in all the three. Of course, last six months everybody has been working flat out on the Coronavirus pandemic. But we are also very focused on measuring results and focused on delivery. But we have to do this with our partners, and our major partners are the ministries of health. They're the ones who implement in the countries, and WHO works with them in many different ways.

>> Howard Bauchner: How, Soumya, the world changed in December and January, January of this year, the world fundamentally changed. We've had pandemics before, but I think, I've come to think of it as the great pandemic of 2020. It's just easier for me to think of it that way, so the great pandemic of 2020. Did Dr. Tedros call you, or did you call Dr. Tedros and say, we have a problem. There's a big issue. When did you first know that this was going to fundamentally change the world?

>> Soumya Swaminathan: So, it was actually the WHO office in China that picked up the news of these atypical pneumonias in Wuhan and got in touch with the headquarters, and our emergencies program, which was actually completely revamped after the 2014/15 Ebola outbreak, which is a very strong program now, they have, they deal with the network of the international health regulation focal point. So, there are national focal points in every country who work with the WHO on anything to do with the international health regulations. And so, they were actually alerted, you know, very early in January, and then, of course, the WHO worked with the Chinese government, and they confirmed very soon, within 24 hours, that this was going on. So, really, on the 31st of December, the 1st of January, we knew that there was something serious happening, and from then on, it's been a nonstop, you know, dialogue and interaction with the authorities in China, with our China office, obviously there, but then also interacting with all of these IHR national focal points. I think they first met on the 4th of January. So, the alert was sent out to all countries on that day that something very unusual was going on that would need to be watched, and from then on, it's been a daily affair of learning more, finding out, sharing the knowledge with everyone, and then, of course, we started doing the press briefings also fairly early on, and that's been, we kept that up over the last six months to make sure that we inform the world as soon as we have anything new. So, it was happening daily, I think, until the month of July, and then it's now gone to twice a week.

>> Howard Bauchner: Soumya, when did you have a sense, or the WHO have a sense that this was not going to be confined to Wuhan and that this was going to be a world problem?

>> Soumya Swaminathan: So, again, because of our experience with the previous outbreaks of other Coronaviruses like SARS and MERS, our technical experts within the WHO, who worked on Coronaviruses for a long time, actually used that knowledge to make some predictions, including the fact that they could be human-to-human transmission and that it was very possible that this virus could travel, you know, through people and go to other parts of China as well as to other countries. So, I think by the middle of January or so, it was clear, and of course there were also reports coming in from other countries of travelers from Wuhan who were being reported to be sick. The one thing, I think, that helped initially was the sequencing of the virus by Chinese scientists.

>> Howard Bauchner: Yeah, right.

>> Soumya Swaminathan: And the fact that they put it out in this public database, like I said, on the 11th of January --

>> Howard Bauchner: Right.

>> Soumya Swaminathan: So that everything has happened. Diagnostics were almost within 48 hours of the diagnostic tests that were available. The second thing is everybody knew what this virus was and could start working on things even like vaccines, for example, based on the whole genome sequence data. So, I think that's been a big difference this time around. Of course, we didn't know a lot of things about the virus at that point, you know, about asymptomatic people, that there could be such large numbers of asymptomatic people, that they could transmit it, that it could be transmitted before people had symptoms in the presymptomatic state. And then the various modes of, you know, how, when, and where this virus transmits, I think we've learned a lot over the last couple of months. But I think the basic principles of the respiratory viral outbreak and how this could turn into a much more serious global pandemic, that alarm was launched, and of course, we officially called it a public health emergency of international concern on the 30th of January. You know, we have an emergency committee that meets that's called to meet and advise on these kind of things, infectious disease outbreaks to the Director General. So, they met on the 22nd and 23rd of January, and at that point, they did not think that it constituted a public health emergency of international concern, because it was still very limited at that point. And even on the 30th of January, I think there was something like 82 cases outside of China and no deaths had been reported outside China. But at that point, there were enough countries that had reported cases, and so it was called public health emergency. So, that was on the 30th of January, 2020.

>> Howard Bauchner: When the WHO declares a public health emergency, do countries react in a particular way? I mean what's the ramifications of the WHO making that type of announcement?

>> Soumya Swaminathan: Yes, so when the WHO makes that announcement, it's basically alerting all countries to this disease and the fact that it could be a risk to them and that they need to ramp up whatever the systems, which, you know, are already all laid out in the international health regulations about, you know, surveillance, putting in place surveillance, making sure that you have the laboratory capacity and the diagnostic capacity, making sure that you have your public health measures in place for isolating cases for contact tracing, for quarantining the contacts, and of course making sure that you also are able to take care of patients who get sick. And so, you own hospital capacity and everything that you need, oxygen, you know, other drugs to take care of people, to provide standard of care, ventilation, of course. And then in the month of February, you know, we saw very early on that there was a complete collapse of global supply chains for many of these essential items including personal protective equipment for healthcare workers, and sadly, we've seen huge numbers of healthcare workers, I think 10% of all infections are among healthcare workers. Oxygen, ventilators, you know, many of these things were in short supply, and it took a while to sort out. So, WHO actually then started procuring and dispatching diagnostic kits to countries. You know, in Africa, in the whole continent of Africa, there were only two countries that had the RTPCR capacity at the beginning in early February, Senegal and South Africa. And within a matter of three weeks, WHO trained people in all the other countries in Africa, made sure that there was at least one lab in each country that could perform this test and shipped kits over there so that they could start testing. And, of course, then over the last few months, the testing capacity has increased, but in many countries still in Africa there are not as many labs as there should be. What is good is that there's been a lot of also innovations and diagnostics so that we know have different kinds of tests that are becoming available, and hopefully we have the high sense, high specificity of antigen detection tests, which would make life a lot easier, especially for remote areas.

>> Howard Bauchner: What do you think, I was going to ask you, what was January and February like, and you've just said what January and February were like. It was perfect. What were the really early challenges, Soumya. When you look back, it may feel like it's a decade ago now, but when you look back to February and March, you know, you're watching what evolves in China. They're extraordinary in, you know, circling the wagons around 50 or 55 million people. It's just extraordinary. I mean they've had very little disease in the centers of Beijing or Shanghai. They've had some, but not much. And then, obviously, the focal point in Europe becomes Italy. You know, I do a live stream with Mauricio Ciccone, who says, you have no idea what's going to happen. It's been seen well over a million times, and I think it alerts the rest of Europe and the U.S. to this is a pandemic of just epic proportions. So, when you think about March and April, what's the role for the WHO? Is it really to focus on low- and middle-income countries or just enhance communication? What really is the role in March and April? What are the great challenges.

>> Soumya Swaminathan: Sure. No, there were many challenges, and I think the biggest one was staying ahead of the science or at least trying to stay updated with the evolving science. And, you know, you've seen this, the output, scientific output has been amazing.

>> Howard Bauchner: Yeah.

>> Soumya Swaminathan: Initially, of course, from China, and we have to be really grateful to those Chinese doctors and scientists who took the time to write all those papers in the midst of what they were going through. We really tried, you know, got a lot of information about both the clinical and the epidemiological features of this disease, and it was things that other countries then used. And then we, late February, early March, you know, started in Italy and Europe and then started flaring up in other countries, and you saw this huge impact, particularly on the elderly, you know, hospitals getting flooded. You know, healthcare workers really being burnt out and so on, and then we started seeing this mortality going up. At the same time, you know, the health system was then focused really on taking care of the sick, but we knew that in order to do the basic public health measures, you need to go out there and do the painstaking work of tracking and tracing and quarantining people, which really requires a lot of workforce. And I think that was one of the gaps, even in the high-income countries, it was lacking.

>> Howard Bauchner: It certainly has been in the U.S. It still is in the U.S.

>> Soumya Swaminathan: In many countries, it's a challenge, and I know that now people are being recruited in many of these countries, to take on that function. The other challenge, as I mentioned, was the shortage of supplies, all kinds of supplies, diagnostics, PPEs, oxygen, ventilators, and so on, and that's one area we worked with our Un partners to set up a consortium that could take care of the supplies and the supply chain. So, on the science, we decided early on that research is going to be important, that science is going to play a very major role in the new virus, and so we convened scientists, researchers in early February to debate on what we know, what we don't know, and we came out with a research roadmap. And that then led to the formation of about nine working groups, you know, like on animal reservoirs and zoonotic transmission, the one on diagnosis and on the virology, another one on epidemiology, and we launched several protocols, core protocols, and we called them the solidarity protocols.

>> Howard Bauchner: Right.

>> Soumya Swaminathan: There was on sero epidemiological studies that countries could use. On therapeutics, on vaccines, in infection prevention and control. So, these working groups were all made up of international experts from all around the world.

>> Howard Bauchner: Right. So, not just WHO -- sorry, just not WHO employees.

>> Soumya Swaminathan: Yeah.

>> Howard Bauchner: This is a collaboration between the WHO and scientists around the world?

>> Soumya Swaminathan: Yes. Yes. So, that's one thing, which is very important, is that everything WHO produces is actually done through our expert advisory committees. So, it's not just the WHO staff who sit and write guidelines. I think this is very important, and the new science division that I head, in fact, one of our departments is on the Quality Assurance of Norms and Standards, and one of the things we are trying to do is to really make sure that the evidence base on which we do our guidelines is absolutely exemplary, that the way we do our guidelines is more digital, 21st Century, you know, forward looking, that it's updated more frequently and things like that. So, our expert advisory groups and all of these groups of experts have been debating and coming out with these guidelines that we've been, you know, putting out from time to time. And we update them whenever there's new knowledge that's available. So, it's been an incredible experience to work with these people, and we brought them together again in July, and 1300 people attended this time, because it was virtual. And we had it over two days, and we had it in two sections, what are the lessons that we've learned, what do we now know about this virus, and where are the big gaps, and where is the research needed and what kind of research questions. So, let's have another research prioritization exercise. We've discovered you need interdisciplinary research in many areas, like transmission, for example. You know, you need the engineers to work with the virologists and the epidemiologists to really figure out where does transmission most occur, when does it occur, what kind of patients, and of course, what are the public health interventions that are most effective.

>> Howard Bauchner: Soumya, so at the time that you, you know, you're Chief Scientific Officer, but then you have the whole public health response in low and middle income countries, so that's occurring in parallel. Can the WHO actually facilitate the movement of PPE, oxygen, ventilators around the world, or can they only, are they somewhat removed from that? How can they assist countries in obtaining the materials that they need to care for patients?

>> Soumya Swaminathan: Yeah, that's a good question. In normal times we don't do a lot of that logistical work except in emergency situations. So, in Yemen, for example, where we've been really helping the country with the health services, because everything there collapsed in the war. So, in conflict situations, we do provide those kind of services. And this time around, we had to because we reached a point where countries were asking for help, and they were saying, WHO, you've got to help us. So, that's when our emergencies program actually got together with, you know, with [inaudible] program, with UNICEF, with the Red Cross, with those agencies that are used to, you know, to doing more of this kind of work, set up a consortium that is now actually doing this work of procurement and of delivery to countries that ask of it. This can be a long-term function. WHO normally doesn't do that, so we're looking for alternatives, but until then, we will continue to do that. But I wanted to mention another function of ours, which is very important, which is the prequalification and the emergency use listing. So, that's another way we help countries, because many countries that don't have very strong regulatory systems of their own or institutions which can, you know, assess test kits and so on, rely on WHO's advice. And so, when we put out an emergency use listing of a diagnostic test, for example, or a medicine, then countries know that they can go ahead and buy those, procure them, and similarly for prequalification. Global agencies like GAVI and UNICEF that procure vaccines will only buy those which are WHO prequalified, which is basically a quality assurance certificate. So, that's the other way which is a more routine function for us, but the emergency procurement is something we had to get into.

>> Howard Bauchner: Soumya, you know as well as I do there's, I think I've heard 150 or 190 vaccine candidates. Some are moving along quite crisply. I think probably there's half a dozen to a dozen phase three trials that have been started. China, Russia, the United States, many different countries. There's very interesting financial relationships, for example, between the U.S. and some companies, UK and some companies, Germany and some companies. Sure, WHO and GAVI are beginning to think about this. You know, a vaccine gets approved late Winter, late fall, early winter, early next year. There's a limited number of doses. How is the WHO beginning to grapple with that? I'm sure you're trying to think about it now and not when the vaccine is approved.

>> Soumya Swaminathan: Absolutely. So, we did start thinking about this because we've have previous experience in the 2009/10 H1N1 pandemic. It was not a pretty situation because a few high-income countries had basically cornered the market for the vaccines and the drugs and later on agreed to spare some for low income countries only when the pandemic wasn't as severe as, you know, it could have been. So, we don't want to be in that situation now, and member states are worried. Basically, countries are asking us to do something. So, in April, we launched what's called the ACT Accelerator, which is access to COVID technologies accelerator. It has a diagnostics, therapeutics, and vaccines pillars. On the vaccine pillar, we're working with GAVI and CEPI, the Coalition for Epidemic Preparedness and Innovation. And the goal is really two-fold. One is to accelerate the development of as many effective and safe vaccines as possible, but the second one is to ensure the equitable and fair access to these vaccines to people who need them all over the world regardless of their ability to pay. So, we, so the idea is you fund the R and D, and you know, support biotech companies and others so they can proceed much faster, invest in advanced manufacturing capacity, because this is another, you know --

>> Howard Bauchner: Right. Right. You can't approve the vaccine and then start the manufacturing. You'll be another six months or a year behind, right.

>> Soumya Swaminathan: Exactly. It takes a year.

>> Howard Bauchner: It's been a big issue when I've talked to various people, that the plants are up and running, actually.

>> Soumya Swaminathan: That's important. Exactly. So, even if you're investing and you're not going to use it ultimately because a vaccine turns out not to be the right one.

>> Howard Bauchner: Right.

>> Soumya Swaminathan: You still have to do it because you save so much time. And then we have what we call the COVAX facility, which will be managed by GAVI, and what it is, is it's a risk pooling and a procurement pooling mechanism. So, let's imagine the whole world is divided into two halves. There are high income and upper middle income countries are about half the world's population. The lower middle income and low income countries constitute the other half. So, let's say, you know, 3.7 billion people each. Now, the idea is that those who can afford to pay, the upper income and the high income countries, they actually pay for the vaccine, and they pay a little bit of a premium for the speed at which they're going to get it. And so, they pay a little bit of up-front money, let's say 15 or 20% of what they would pay eventually for their vaccines, and then once the vaccines are in the facility, they can purchase them. And at the same time, for the other half of the world, which is not going to be able to pay, we would have to do it with, you know, overseas development aid funds, the way that GAVI raises funds normally for their other vaccines. We would have to raise several billion dollars to pay for vaccines for those countries. But what's also important is that we are developing in consultation with all our member states a fair allocation framework and a mechanism, which basically says, okay, if we have limited doses of the vaccine, let's say we have only 100 or 200 million doses, how are we going to distribute this around the world? Can we say that we would give three percent of the country's population to each country so that they can vaccinate their frontline workers, healthcare workers, the ones who are at most risk.

>> Howard Bauchner: Elderly, frail elderly, if there's enough doses.

>> Soumya Swaminathan: And then, as you get more doses, you then start vaccinating these other groups, you know, which are more vulnerable. So, you go up to 20 percent of the population, and everyone should reach the 20 percent before you can then distribute the remaining, but the end of 21, 22, probably, there will be, you know, larger supplies, let's hope so, especially if we have more than one candidate that's successful. So, the idea is that everyone agrees in this framework that it will not be a situation where one or two countries are vaccinating 100 percent of their population and the others are basically just waiting and waiting. And so, the risk is that some countries are not doing a lot of bill deals, and it's been called vaccine nationalism.

>> Howard Bauchner: Yeah.

>> Soumya Swaminathan: While other countries are saying, hey, you know, let's be fair about this.

>> Howard Bauchner: A lot of resources needed. Without doubt, I think the Bill and Melinda Gates Foundation consistently over the last two decades has provided just an enormous amount of support for GAVI and the World Health Organization. Obviously, funding from the U.S. has become problematic because of President Trump's feelings about the WHO at the moment. Do you have a sense of how the funding will evolve? Is the expectation that a number of countries, foundations, particularly the Bill and Melinda Gates Foundation, will help GAVI and the WHO in terms of procurement and then distribution and administration of the vaccine? This is a massive vaccination program, which takes a certain infrastructure. Where is your sense that the resources will come from? I'm sure Dr. Tedros is already involved in these discussions, but what's your sense of it, Soumya?

>> Soumya Swaminathan: Absolutely. So, Dr. Tedros convened these heads of state actually. So, we had the President of the European Commission and President Macron from France along with Melinda Gates and Dr. Tedros, who launched this ACT Accelerator on April 24th, and since then, several countries have expressed their interest to join. In fact, at last count, I think we had over 78 countries, high income and upper middle income countries, that had expressed an interest in this COVAX facility that GAVI will host, indicating that they would be willing to put funds in. So, they have until the end of August, actually, so that's when we will know how many of these countries that expressed interest then invest funds in it and walk the talk. But obviously this is going to need a lot of resources. We roughly think it would need at least 17, 18 billion dollars between now and the end of 2021 to be able to get 2 billion doses of the vaccine. That's the goal.

>> Howard Bauchner: Okay. So, you have an estimate of 15, 16 billion to get 2 billion doses.

>> Soumya Swaminathan: Billion dose.

>> Howard Bauchner: Yeah.

>> Soumya Swaminathan: Which would be just enough, you know, to protect this vulnerable group in every country, and then, of course, beyond that because we don't know. We think most of the vaccines that are being developed now probably need two doses.

>> Howard Bauchner: Yeah, that was going to be the next issue is, we don't have enough science yet. I mean the critical issues, there's many, efficacy, safety, but the critical issue is how long is, if it's effective, how long will it last and how many doses?

>> Soumya Swaminathan: Exactly.

>> Howard Bauchner: It's critical because it has enormous implications for infrastructure and cost.

>> Soumya Swaminathan: Yeah. And that, we have to wait and see. The other thing that we're planning is what we call the Solidarity vaccine trial, which is basically an endeavor to bring, again, all countries together and say, can we accelerate the testing of as many vaccine candidates as possible so that we ensure success, because, you know, the big companies that are developing vaccines, they have the wherewithal and the resources to run their own phase three trials, you know, which need tens of thousands of people. But there are many smaller companies and bio techs that are doing this for the first time and have not done this kind of thing at scale. So, the Solidarity vaccine trial, which is similar to the Solidarity therapeutics trial that we did and we have a lot of confidence now having done that, would basically work with countries and with sponsors and with funders across the world in a sort of partnership in an adaptive trial design where we could keep on bringing on new candidates as they become available with some very strict scientific criteria obviously for, you know, stage gating those to see which ones should really go into phase three, but then put them into these sites around the world where there's high transmission happening so you can answer the efficacy question relatively early. So, that's again something we're working on with CEPI, with, you know, other partners. Gates Foundation has been very much involved in all of this, and, you know, they've been investing in candidates, the second generation of vaccine candidates, but also in advanced manufacturing capacities, and they're also very keen to support clinical trial sites in the developing world. Africa has developed their own network of --

>> Howard Bauchner: They have.

>> Soumya Swaminathan: Yes. And they want to also, you know, play a leadership role here in not only testing vaccines but also then going into manufacturing and supplying their own populations.

>> Howard Bauchner: A couple more questions we've been going on, but I love chatting with you. Sometimes I feel like Latin America is the forgotten continent. So much of the focus is on North America, Europe, and then Africa. What's been the experience in Latin America? I mean I'm well aware of what's gone on in Brazil and Chile and Argentina, but I'm just curious of what your sense about the WHO's relationship with Latin America has been.

>> Soumya Swaminathan: Actually, the Pan American Health Organization, which I mentioned, is the regional office for the Americas, North and South. They play a very important role in Latin America. They have very strong relationships with most of the countries, and their challenge, of course, has been that they also have large populations that are, you know, that live in poverty, that live in, I think they have something like 100 million people who live in urban slums. In many of the countries, they have a lot of migrant workers in labor, and in some of the countries, they've had, you know, challenges over the last few years, which have really weakened their health systems. So, I think they've faced a problem like all the other regions have faced where this thing really came in surreptitiously and then sort of exploded, particularly in the urban areas, and it's been testing their public health system. But most of the countries in Latin America actually have, or many of them have strong social support systems and a very strong public health corridor and a public health system, and many of them have invested, actually, in universal health coverage and also in social protection schemes over the last two decades. And so, they have been able to really, you know, garner their forces and try to do the best they can. But it's been overwhelming, actually, for the health systems of many of these countries. And essentially, again, it boils down to having enough foot soldiers to do the hard work of, you know, actually tracking people and testing them and making sure that they're taken care of, especially if they're poor, and it's hard to physically distance. Because I come from India, and I know how difficult it is to practice physical distancing in many of our cities, particularly amongst the lower income groups, who live in urban slums, who have to share toilets. They have to go and queue up for water facilities. So, in large parts of the developing world, you know, it's impractical to advocate physical distancing, and that's why I was very happy this time to come to India and see almost universal masking, everybody out on the streets is wearing a mask, at least in the city of Chennai, and I think it's true in many of the other cities. So, things like that, and I think behavior change has happened. I can see that over the last two months in Europe, but I'm also seeing it now in India, and I believe that this behavior change is what is going to see us through the next few months of this pandemic until we actually have enough vaccines. Hopefully, we'll have a safe and effective vaccine, and then vaccinate enough people to break the chains of transmission.

>> Howard Bauchner: When you look back, this is the last question until I have one final question, when you look back over the last six months, which since I've read 10,000 papers that have been submitted to JAMA, it's been a long six months, but I've learned a lot. What were the two or three really great successes of the WHO, and what were the two or three real challenges that, you know, perhaps you could have done differently?

>> Soumya Swaminathan: Well, I think, you know, one of the things we're committed to doing is actually looking back and having a review, and you might have heard Dr. Tedros has appointed a review committee, which is headed by the ex-President of Liberia, Ellen Sirleaf, and Prime Minister Helen Clark from New Zealand. They're going to head this committee that's going to look at the world's response, WHO's response but also how did the world respond to the pandemic. So, I think that could be a very good learning experience, and everyone is going to learn from this. I think the way we have approached it is to be, is to work with the data that we have and use the data as well as possible and use these networks of scientists and advisors from around the world, get people from every country, every continent, the best experts in that respective area to advise us so that we are guided by this collective set of huge intellectual bar and not just by a few people sitting in Geneva. And we started these health leaders calls, and almost on a daily basis, we have calls with experts. So, I think that's been a huge learning experience for everyone, and it's also made sure that we put out information based on the best available evidence. And I think the other thing I would say was a success is harnessing the scientists. I talked about the research forum we had in February. I think that unanimously everybody agreed that it sort of really helped to focus on the important issues and also to kick start a lot of research. The research funders, there were 25 research funders who came to that meeting and put funding into some of those projects. We have, I think, made a lot of progress with diagnostics, working with other agencies like FIND, you know, on pushing innovations, on making sure that we have quality assured tests that we are asking countries to use and on these standardized protocols. We've also made sure that we have these past evidence reviews done. The one that's coming out soon is in corticosteroids. I understand it will be in JAMA, and that will go hand in hand with our guidelines. And we'd like to do similar things. Whenever we have a guideline, we want to make sure that it's actually based on peer reviewed solid, scientific evidence. We did the same for infection prevention and control. I think the challenge has been the rapid pace at which things move and the fact that a lot of it is out in preprints, and the media and the public are already talking about things even before we've had time to really see is this really true? Has it been peer reviewed? Has it been, you know, accepted by the scientific community? That's the way scientists normally operate. But in this case, we have been constantly challenged to respond to stuff that comes out either in news, in news reports or in press briefings or in preprints and then challenge as to why our guidance hasn't been keeping up fasting enough. And as I mentioned, a lot of countries really depend on WHO guidance. So, it's a huge responsibility for us, and like I said, we do it based on the available [inaudible], which is then reviewed by experts. So, I think that could be the one challenge that perhaps we can do even better at, which is putting out the guidance even faster than we've done in the past. But I think this is something that we've all been, you know, learning in this journey together. It's incredible how much we learn every day. On immunology, for example, we still don't understand the differences between asymptomatic people and those who get really sick between children and adults.

>> Howard Bauchner: Right.

>> Soumya Swaminathan: You know.

>> Howard Bauchner: Even though, yeah, the last week, the reports, you know, where people thought, well, I don't like when people say children because children go from 0 to 19, and the 17-year-old is very different than the 2-year-old. So, when we finally looked at it by age, it really looks very different between a 5-year-old and a 15-year-old. I do have one final question. People who listen to my livestreams know I always usually end with more of a personal question. You have a relationship with a very, very famous person, the father of the Green Revolution of India. Could you talk about who that person is?

>> Soumya Swaminathan: Howard, you've done some research.

>> Howard Bauchner: I have.

>> Soumya Swaminathan: So, yes, my father is Dr. M.S. Swaminathan. He is a well-known and a well-respected agricultural scientist who ushered in what was called the green revolution by introducing the high-yielding dwarf varieties of wheat in Punjab, you know, in the 1960s, working with another very famous agricultural scientist, Dr. Norman Borlaug, and American scientist who then went on to win the Nobel Peace Prize. And the two of them introduced these dwarf varieties of wheat, which increased production so much that India then went from a begging bowl to a bread basket. You know, India was importing food in the 1960s, and we are now in a situation of surplus food. So, I think his work very early in his life made a huge impact on millions of Indians because he was moved by the mass famines of the 1940s and '50s, and he said he never wants to see a famine again in his life. And that's why he took to agriculture. He is going to be 95 very soon, Howard, and he runs his own research foundation. He's been, of course, he's had a long career including as head of the International Rice Research Institute in the Philippines. But his whole life was devoted, basically, to making sure that science serves society, and then after retirement, he set up the M.S. Swaminathan Research Foundation in Chennai, which bridges science, society, and sustainability.

>> Howard Bauchner: Well, very, very few people in the world get to really say they've saved the lives of tens and tens of millions of people. So, wish your dad a happy birthday on behalf of JAMA. This is Howard Bauchner, editor in chief of JAMA. I've been talking to Soumya Swaminathan, who is the chief scientific officer of the World Health Organization. I can't thank you enough. I don't think people really appreciate in the United States what the WHO does and its extraordinary value to the world, and it's really been a deep pleasure to talk with you today, Soumya, and please stay healthy, and make sure your dad stays healthy at 95.

>> Soumya Swaminathan: Thank you so much, Howard. It was a pleasure, and I hope we can have more colleagues from WHO speaking with you.

>> Howard Bauchner: I look forward to it.

>> Soumya Swaminathan: Thanks so much.

>> Howard Bauchner: Bye, bye. Take care.

>> Soumya Swaminathan: Thank you. Bye, bye. Thank you.


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