MS. STEAD SELLERS: Good morning, and welcome to Washington Post Live. I’m Frances Stead Sellers, a senior writer here at The Post. This morning, I’m going to be talking with Dr. Seth Berkley. He’s the CEO of Gavi, the Global Vaccine Alliance, that was launched two decades ago to jumpstart childhood immunization around the world. In those 20 years, Gavi has immunized more than 822 million children, and helped to reduce the childhood mortality rate by half in more than 70 countries--lower-income countries around the world. Dr. Berkley, a very warm welcome to Washington Post Live.

DR. BERKLEY: Thank you, Frances. Nice to be here.

MS. STEAD SELLERS: I’d like to start by asking you about the big picture. You, at Gavi, are one of the leaders of COVAX, the coalition that is setting out to vaccinate the world. Where do we stand with these huge goals in 2021 of 2 billion doses delivered and the more ambitious goals even of 2022?

DR. BERKLEY: So first of all, when COVAX was set up, we knew the previous history, which is when the swine flu pandemic happened in 2009, for example, vaccines were bought up by wealthy countries and didn’t get to the developing world, and we knew that would be a risk. But of course, we didn’t know whether any of the vaccines would work. And I think we’ve been quite lucky that this turns out to be an organism pretty easy to make vaccines. And as you’ve seen, we now have many, many successful vaccines that have been able to show protection. Right now, there’s 24-odd vaccines that are being used somewhere in the world. So that’s the good news.

So when we set our goals, what we realized was that mostly it was the elderly who were dying and it was people who had other co-morbidities. And so we looked at trying to get to that group and healthcare workers--because obviously they are the ones protecting the healthcare system. So the goal was try to vaccinate all healthcare workers, all of the elderly, and all of those at high risk by the end of 2021, and that’s where the number of around 2 billion came from, and that’s about 20 percent of those populations.

It turns out that we will probably not get there quite at the end of 2021. It may slip a little bit into January or February. But I think we’re on track broadly towards those numbers. But the challenge has been there are many barriers that have been put in place, export bans, vaccine nationalism. I’m sure we’ll talk about some of these. And it has made it very, very difficult. And as of today, low-income countries are not well-covered. High-income countries are doing better, although not perfectly. And most of the doses have gone to high-income countries.

MS. STEAD SELLERS: Well, let’s focus a little bit on the supply issues. Those that are falling, going on from some of the higher-income countries. But now we’re producing huge amounts of vaccine. You’re dependent on donations, to some extent. How are you changing strategies to source from manufacturers?

MR. BERKLEY: So the idea never was to require donations. The idea was to put together a portfolio of vaccines. Since we didn’t know which vaccines were going to work, our goal was to have the largest portfolio in the world, which we do. We now have 11 vaccines in the portfolio. The challenge we have, though, is that when by the time we raised money, by the time we put together the effort, many others got in front of us in the queue to buy vaccines.

So we were delayed in being able to purchase vaccines, and then we also went to some of our traditional producers like the Serum Institute of India--the largest vaccine manufacturer in the world. And they started producing very early. We had doses from them in January of last year. And the challenge was when the delta variant appeared in India and the situation got severe, India stopped exports, and that meant that, you know, we’re now 300 million doses short of where we should be. So we put out a call to countries and said, look, you have excess doses, because those countries didn’t know which vaccine was going to work, either. So, you know, many countries bought multiple different vaccines in large quantity, and we said can you make those available. And the world has responded.

At the--at the G-7 meeting, the leaders talked about a billion doses of donations. We have firm commitments now of 640 million, and we’ve delivered a hundred million of those doses. But I will say that this is not the solution. The long-term solution is to have reliable supply from manufacturers for all people in the world.

MS. STEAD SELLERS: So in April 2020, this remarkable organization COVAX was set up. It’s a coalition of governments, businesses, philanthropies, others that I’m sure you can tell me about. How does this work? How do all these various parts move together towards this targeted goal of vaccinating the world?

DR. BERKLEY: So, you know, there’s an interesting question here, which is do you set up a new organization in that setting. And you said organization. It’s not an organization. It’s a network. It’s a partnership.

MS. STEAD SELLERS: Right.

DR. BERKLEY: And that’s important, because that’s the efficient way to work. I think we know that now. Networks are, you can bring in who you need, you can move people out. So we had an advantage. Gavi is an alliance. We work with WHO, UNICEF, the World Bank, the Gates Foundation, pharmaceutical companies. And that’s been what’s gotten us over the last 20 years to having immunization be the most widely distributed health intervention. So when we knew that this was happening, we said let’s form a working group COVAX. Luckily, some of the groups in it were groups that we were working with before--WHO, UNICEF, for example. But for example, the Coalition for Epidemic Preparedness Innovations which was set up for this work was not a member of the alliance, but we brought them in. And of course, they’ve played an important role as well.

So we have an informal network. Of course, since we didn’t set up separate legal entities, it is each institution that has the responsibility for the resources that come to it because of, you know, they handle larger amounts of capital and to do the type of work we’re talking about, you need systems in place. So we use UNICEF systems, or CEPI systems, or Gavi systems.

MS. STEAD SELLERS: So there’s a mantra in public health that says vaccines doesn’t save lives, vaccinations do. Could you talk about that in terms of COVAX and Gavi and how you’re moving from these supply issues to getting vaccinations into people’s arms?

DR. BERKLEY: Yeah, so as I said, we are hundreds of millions of doses behind where we should be. And I mean, you know, I’m not going to apologize. That is a terrible thing. We know the reasons for it. The challenge is, how we do overcome that? And that’s where having a coalition of countries come together is important. When we originally formed COVAX, we didn’t just focus on the poorest countries. That’s traditionally where we worked. But we didn’t know what was going to happen, which vaccines were going to work. So we opened it up to everybody, and we ended up with 194 countries coming together to work with us.

And that was very important for the fundraising component. We’ve raised, over this course of the last year, over $10 billion to purchase doses. We now have firm orders for 4 billion doses. The challenge is to get those moving forward as quickly as possible. And again, in a diverse portfolio, some are moving now. Some will be coming in the future. Some have had delays and problems in it. We’ve seen that across the world. But the challenge right now is the disease, as your video showed, is now. So that’s where donations and moving up the queue are critical to trying to make sure that those doses are available.

Over the last months, we’ve accelerated three times the number of cases--number of doses to Africa, and we see in the fourth quarter a dramatic acceleration in numbers of doses being provided and getting into those arms.

MS. STEAD SELLERS: So this is happening just as some of the wealthier countries, including the U.S., Israel, France, are talking about boosters. Also, there’s probably waning immunity from some of the weaker vaccines, possibly Sinovac, that will mean other people will require boosters around the world. How do you balance that? Are there going to be--are the demands from countries like the U.S. going to impact the supplies you have for the rest of the world?

DR. BERKLEY: So, you know, it’s a complex challenge, because our--from a public health point of view, the right thing to do would have been to vaccinate every healthcare worker in the world so any country, anywhere is prepared to take care of the pandemic, and then to move to the people at most risk of dying, because that’s obviously the most severe outcome, long COVID, et cetera. So that would have been the way to do it. Of course, the world didn’t work that way, and countries made a choice to get their vaccination up. Of course, they’ve also now moved into lower-risk groups and to younger people, into children.

And the debate about boosters is complicated. So first of all, when medically necessary--like, for example, if you are immunosuppressed and you don’t have a good reaction to--or don’t have enough immune response to the vaccine, you need a booster, you should get it right away. No question. But what we know is these vaccines protect against severe disease and death. What we see waning is the antibody protection which may protect against symptomatic infection and the ability to transmit. So the question I think on everybody’s mind is, do we continue to use vaccines to block that while people at high risk still haven’t been vaccinated and healthcare workers haven’t been vaccinated, or do we now complete the primary goal of getting vaccines out to the highest-risk and then continue the global movement of vaccines? And by the way, that’s the best way to protect against the variants of concern, of continuing pandemics, because the world is never going to get back to normal until everybody everywhere has the protection they need, particularly for the high risk.

MS. STEAD SELLERS: And of course, this has happened during the surging delta variant, which took over so rapidly in this country. That plays into people’s sense of urgency for boosters but also, for some people, an awareness that variants can come very quickly. Are you look at variants of concern that could render the vaccines we now have ineffective?

DR. BERKLEY: Absolutely. And I will say that we’ve been saying from day one, even before we knew if vaccines work, that in an airborne spreading pandemic, you’re only safe if everyone is safe. Now I think people all nodded and said yes, yes, yes. But as instinct is, let me protect my family, my community, I think when the delta variant appeared in India and you saw the dramatic pictures of the horror that went on there, and they weren’t prepared for that, but that virus moved around the world and began to replace the virus in other places, I think people began to say, okay, now we understand that we really have to have a global response to a global pandemic, not domestic.

So there is a watch. There are variants of interest, and there are some scary variants that keep appearing but we don’t yet understand. There’s a C.1.2 that just appeared in South Africa that may have resistance, you know, genes to vaccines. There’s a new Mu variant of interest. The challenge is, up until now, all of the variants have provided--have been able to be protected against severe disease and death by the existing vaccines. But that may not continue and why there is an urgency to try to get a global response and not just a local response.

Now we’re--and we are prepared, by the way--sorry, Frances, one more point--we are prepared as a community now. I mean, now that we have all of these different vaccines, manufacturers are working and making vaccines against the variants. Right now, there is no need to roll those out. But we have new technologies such as mRNA vaccines that can be very quickly changed. And so the world could pivot quickly if we needed a new vaccine. But of course, we’d be back to the same problem of how to vaccinate 7 1/2 billion people across the world with that new product.

MS. STEAD SELLERS: So I want to get back to a sentence you’ve said. I’ve heard--you’ve tweeted it many times: Nobody is safe until everybody is safe. It seems to me that individually people are thinking of vaccines as sort of bulletproof vests, and nationally people are using--and you used the term vaccine nationalism--as if vaccines can protect their countries. How are you doing with messaging and getting across this notion that nobody’s safe until everybody’s safe?

DR. BERKLEY: Well, it’s very challenging, because part of the problem right now--and people always ask me in the developing world, do you have vaccine hesitancy. Actually, we tend to have more in developed countries because developed countries don’t--they’re not familiar with the diseases. They don’t see people dying. Whereas in developing countries, they do. I mean--I mean, you know, normal vaccine-preventable diseases. And so what we tend to see is that situation.

Now in this case, it’s been quite different, because it’s been very politicized, and there’s been a lot of misinformation that has occurred as a result of the politicization that has affected, you know, the science and the reporting of science. And that’s a big problem because, you know, it’s one world now in terms of social media. So if misinformation occurs, it spreads around the world literally at the speed of light. And so that problem is there. We tend to have good systems to get people to understand why vaccines are needed into developing countries, but we are having to deal with this, you know, infodemic of misinformation that exists, and that is really problematic.

MS. STEAD SELLERS: So the U.S., of course, is a country where the vaccine politics has been incredibly politicized. But President Biden has pledged several billion dollars towards this goal. What more do you need? Do you need cash? Do you need donations? Do you need influence over manufacturers? What more do you need from the U.S. and other well-developed countries, rich countries?

DR. BERKLEY: So first of all, you know, the U.S. came a little later than other countries on it, but they came in with the full force of the U.S. And, you know, it’s been incredible. There’s been a lot of finance, $4 billion committed. We’ve done an incredible deal with the U.S. and Pfizer where we use some of that money to buy doses, and the U.S. bought additional doses. President Biden originally agreed to provide us 80 million doses as part of a dose donation, and since then he’s increased that to 110 million. And we’ve rolled those vaccines out almost instantaneously as we started to receive them. So I just want to say that the U.S. has really been a fabulous partner in moving this forward. And of course, they understand this issue of, you know, we’re only safe unless we’re all safe. So I think that’s really important.

But what are we asking right now? First of all, we’re asking countries to make the doses available that are excess immediately and now. And the reason is because then we get them out to try to dampen down the delta wave and the infections that are there.

Secondly, we want--if countries don’t need doses right now but they’re afraid to give them up because maybe they need them as boosters, let us jump the place in the queue. Let us take over their spot. We’ll pay for the doses, and then they can buy theirs later if they think they really need them.

And third is to make sure we don’t get pressure on manufacturers to do bilateral deals in preference to COVAX. You know, we’re not a government. I don’t have the same influence of calling a company’s CEO into, let’s say, the White House and saying to them I want you to do something. And so what we’ve seen, we think--we don’t have good examples because it’s not transparent--is that, you know, sometimes people jump the queue because they use their influence to do that, and that is not a smart thing to do but not the right thing to do. So we’re asking to please help with that.

And lastly, help countries with delivery. This is the largest rollout of vaccines in history, and we need to make sure that, you know, all hands are on deck to help with that.

MS. STEAD SELLERS: Will you be calling on DoD to help with logistics?

DR. BERKLEY: I think that’s an individual country decision. You know, DoD has been great in the U.S. helping with logistics, and they’ve been involved with some of the procurement as well. They may not play well in all countries that we’re dealing with, and they may not want to. But I think the challenge here is how do we get the world organized behind making this happen. And you know, frankly, in one sense this disease is high mortality and fast spread. But you know, if you look at SARS, much higher mortality. Ebola, we deal with regularly. Marburg just had an outbreak. I mean, you know, we also need to be prepared to deal with this, because it’s evolutionarily certain that we will continue to have, you know, infectious disease outbreaks. And in fact, with population increasing and urbanization, we’re likely to see more and more of those over time--so, you know, in a sense how do we as a world come together and make sure we can end these diseases.

MS. STEAD SELLERS: So we've been talking about donations of vaccines, but of course the U.S. has relied largely on these remarkable mRNA vaccines, but Pfizer is a very finicky vaccine, right? You need to get it ultra-cold to people. It comes in fairly large packages, still; although, those were reduced. Could you talk about the challenges of taking a Pfizer as opposed to a Novavax or even a J&J and delivering it to countries which don't have refrigerators as this country does? Even here it was a problem--but don't have ready access to those sorts of facilities.

DR. BERKLEY: So, if you had asked me this five years ago, I would have said, you know, very challenging. In the last five years, not because of COVID, we've rebuilt a lot of the cold-chain systems around the world. We've put 65,000 new units in place. And so we have a pretty good idea of what's available where. Now, none of that was ultra-cold chain, and that's what Pfizer requires, a minus 70, minus 80 degree storage.

Now, the one exception is we had to do that for Ebola, and we did that, for example, in DRC and North Kivu in a warzone. It was a heroic effort but it was doable. And so, when we originally started we, you know, were looking to try to get vaccines that were easier to use, that were storable at normal refrigerated temperatures.

But of course, given the quality of the Pfizer vaccine and their ability to scale up, we came to the conclusion that using that more broadly in the developing world made sense. So we've spent, at risk, $25 million to buy ultra-cold chain. We have 300-plus new ultra-cold chain fridges that are moving forward. We've also figured out how to work with dry ice, and that process is moving forward. Of course, it is logistically much more difficult and that's why we would prefer, in a sense, to have a range of vaccines so that we can use, for example, the Johnson & Johnson, which is a 2-8 degree vaccine, normal refrigeration, and a single dose, in the most fragile countries where, you know, trying to do a follow-up dose and store the dose at minus 70 is a problem. So many, many logistical issues, and that is one of the big things that we've had to challenge. But again, with all hands on deck and working together, we've really made progress on that.

MS. STEAD SELLERS: So, with all hands on deck on this incredibly important mission, what has been the ripple effect in terms of other childhood regular immunizations, measles and polio and all the other things, as well as impact on education, jobs, and economic development, human development, in the countries we're talking about?

DR. BERKLEY: Well, economically, it's been disastrous and, as you know, I mean, one of the things that's interesting is wealthy countries moved into a work-at-home mode. And a lot of workers are information workers and they could do that. And if you're on a subsistence economy and you have to be physically present, country--you know, people couldn't do that. You don't have refrigeration; you can't keep food in your home; et cetera, et cetera. So it has been devastating in developing countries.

You know, the challenge for us as a world is to make sure that we are working with countries to rebuild all of their systems. On routine immunization, last March and April--not this one, the one before--we saw a dramatic drop across the world as lockdowns occur. People were afraid to go out. The good news is the systems are pretty good with immunization and we saw a bounce-back. And now we estimate we're about 5 percent below where we were, but that's a big deal, because it's a slow process of getting it up. And so one of our key goals is to try to make sure we sustain routine immunization, because health systems cannot withstand outbreaks of other infectious diseases during this moment; so that's an important priority.

In terms of the education systems, that has been different in different countries, but that's been dramatically affected. They don't have the ability to teach from home, and that's affected vaccinations, as well, because one of our most important vaccines is the HPV vaccine which is against cervical cancer, one of the largest killers of women in the developing world, particularly Africa, and we usually give that in a school setting to adolescent girls. And so that's had a dramatic effect on being able to get that out.

So we're not out of the woods, yet, in terms of health care systems in general, but you know, this is part of trying to build resilient health systems that reach everybody for also the ability to have surveillance and figure out when unusual outbreaks of disease occur. By the way, during this, I mean, I was terrified. We've had two outbreaks of Ebola. We've had outbreaks of Marburg and, you know, they were able to be contained. But you know, in a sense, you worry with everybody flat out like this that we might miss diseases like that and then you could have other pandemics that are, you know, moving forward.

MS. STEAD SELLERS: So this has put you into a spot where you're having to negotiate with national governments, renegotiate with national governments. Talk to us a little bit about that process: keeping them happy; renegotiating governments--sorry, contracts with individual governments at the same time as they're making demands for doses for their own people and you're looking at this broader, global picture.

DR. BERKLEY: Which specific renegotiation are you talking about? Are you talking about--

MS. STEAD SELLERS: I was thinking about [audio distortion]--

DR. BERKLEY: About what? I'm sorry.

MS. STEAD SELLERS: About Britain, there, I was talking about.

DR. BERKLEY: I didn't hear the...

MS. STEAD SELLERS: With Britain, I'm sorry, the United Kingdom.

DR. BERKLEY: Britain?

MS. STEAD SELLERS: Have you not had to renegotiate with--

DR. BERKLEY: No, we haven't had to renegotiate any contract with them. Britain has been generous as a financial supporter and also has provided donated doses for us. So no renegotiation with them.

I have to say that so far countries have been great in terms of pledging. As I said, it's so far now over $10 billion, which is what we asked for, and they are making good on those pledges. And so far, we've had every--you know, pledge that has been made is moving towards completion. So there hasn't been a problem in terms of moving forward.

Of course, the challenge we do have is, if now--and you asked this question earlier--all the countries decide that they want to do boosters and do it now and do it for entire populations, that will make a dent in both doses, but maybe also the dose sharing that's going on right now, and that would be a challenge in terms of further slowing down the rollout in the developing world.

MS. STEAD SELLERS: So I think I have time for just one last question. You've talked about the evolutionary inevitability of other diseases coming up. There will inevitably be another pandemic. What have you learned from your experience during this one that you apply to a new one? And what kind of new infrastructure would you like to see in place before the next virus tries to take over the world?

DR. BERKLEY: Well, first of all, we need a surveillance system that reaches everywhere--everywhere, last mile. I'm hoping that this is a wake-up call. I did a TED Talk years ago. My TED Talk wasn't that well-watched. Bill Gates, who gave the back-to-back TED Talk, was very well-watched and he talked about running military-like exercises, getting prepared for this as the largest killer. And I think that is the reality of where we are. We need to be prepared in a completely different way.

We built a bunch of new systems. We have no-fault compensation schemes for countries. We have new delivery systems, emergency use authorization, pandemic labeling. All of that needs to be kept alive so that we can be faster when we move forward. And frankly, we ought to build a larger set of production capabilities across the world so that if India gets, you know, knocked out of the system for a while we have other places that can take their place. So there are a lot of lessons learned.

But I think the hardest one for me is we came into this with our eyes wide open, knowing some of these human-nature issues; and yet, you know, it's been really delayed serving the lowest-income countries, which is not a self-serving idea for the high-income countries, because we're all connected in this. And so I think one of the challenges is how do we make sure that there are going to be enough doses so that tradeoff doesn't have to occur in the future, and that we have mechanisms of finance that are available and that can be contingently called forth so that we can hire people quickly and move quickly when there is another episode like this.

MS. STEAD SELLERS: Well, let's finish with that loud-and-clear message that nobody's safe until everybody's--until everybody's safe.

Thank you so much, Dr. Seth Berkley.

DR. BERKLEY: Thank you so much, Frances.

MS. STEAD SELLERS: That’s all we have time for. Thank you for joining me today at Washington Post Live. You can go to WashingtonPostLive.com to see our future programming. I’m Frances Stead Sellers.

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