This article is part of an ongoing collaboration between the Colorado School of Public Health, the Denver Museum of Nature & Science, and the Institute for Science & Policy. Find all of our previous COVID-19 webinars and recaps here.

The distribution of highly effective COVID-19 vaccines is underway across the U.S., offering a light at the end of the pandemic tunnel. The rollout to date, however, has been hampered by supply chain woes and a lack of unified strategy, leading to miscommunication between the federal government and the states as well as frustration among those left waiting for doses. As President Biden takes office, the question of national leadership is once again in focus as the country waits to see if the new administration and its agencies will be able to accelerate the pace of vaccinations and quell the virus. 

The Institute’s Kristan Uhlenbrock recently chatted with Dr. Tom Frieden, President and CEO of Resolve to Save Lives and the former director of the Centers for Disease Control and Prevention, discussing role and responsibilities of the federal government in organizing large-scale public health responses, the importance of accountability and transparency, and the 2021 state of play. 

This transcript has been lightly edited for length and clarity. Watch the full recording here and view the slides from the presentation.

KRISTAN UHLENBROCK: It’s great to have you with us today, Dr. Frieden. How are you?

DR: TOM FRIEDEN:It's great to be with you, Kristan, and I wish I were out in Colorado to go hiking or skiing.

KU: Yes, we actually just had a little bit of snow for the past day or two, so I'm sure many of us are itching to get out in the in the mountains and enjoy our weekend ahead. Okay, so I'm going to turn this over to you for a presentation to kind of help set the stage and then we're going to get to some Q&A.  I do want to just give a quick nod to those of you who are on Twitter - I encourage you to follow Dr. Frieden on Twitter. He's pretty prolific and he's got this COVID at the weekly thread that he does every Friday with a lot of great data and perspectives. I really enjoy seeing what he has to say every week. 

TF: Thanks, Kristan, and thanks for mentioning the Friday evening threads. I actually started those exactly a year ago because there was so much happening so quickly and at the end of the week, it was possible to kind of do a roundup of where things were, so thanks for that mention.  

What I'd like to do is just take us through some slides about COVID and also the future more generally. What I keep hearing from different parts of the world from different people is, what's the one thing that's going to make COVID go away? Unfortunately, no one thing is going to make COVID go away.  

We're going to have to prevent spread with layered interventions and a good concept there is the “Swiss cheese” model interventions that keep people from getting infected. Each of those layers has some impact on reducing the risk, whether that's distancing masks, increasing ventilation, avoiding going out if you're sick. But each of them has holes, and if you see the little mouse there, that's the misinformation mouse. Every bit of misinformation increases the holes in the Swiss cheese.  

Vaccination is also enormously important. It's the single most important tool that we have. But even with a vaccine, it's crucially important that we box the virus in to stop cases from becoming clusters, and clusters from becoming outbreaks. In fact, I'll go over why it's even more important that we do that now. The three W's of reduced risk of COVID are: wear a mask, watch your distance, and wash your hands. To which we would add the two V's: ventilation and vaccination. 

Now, assessing risk, we talked earlier about hiking and skiing. The risk of infection - really, you can think of as the product of the prevalence in the community, the proportion of people not wearing masks, the level of ventilation with outdoors being best, the number of people you're exposed to, and the duration and intensity of exposure. So, if you're outdoors in a low prevalence community, there's almost no risk. If you're indoors for a long time, with lots of people shouting or singing in a high prevalence community without masks, that's the highest risk.  

And just a couple of hours ago, the New York Times released a map of the US by county that we worked with them on to indicate the level of risk in each county so that we can empower people to know what the “weather” is. In essence, how hard is it “raining” COVID in your community. Now, the boxing strategy we released remains relevant. In fact, I argue that it's even more important in the context of vaccines and variants. Because the more uncontrolled spread there is, the greater the risk that there will be variants that emerge that can evade either our natural immunity or vaccine induced immunity. So far that hasn't happened, but it's clearly possible.  

And for that reason, we need to dually increase vaccination and also improve our comprehensive protection protocol. The boxing strategy talks about testing strategically to rapidly identify people with infection, isolating all infected people, finding everyone who has been in contact with infected patients, and quarantining all contacts. This is the essence of effective measures and to be very frank, we haven't done a very good job at this for the past year. We're going to have to do a better job of it in 2021, even with a vaccine. 

Testing is particularly important for anyone with symptoms of COVID, for anyone asked or referred to get tested, for anyone who has been in close contact with someone who has COVID, for anyone in a congregate setting, for essential workers, for those exposed to people who are sick or around people not wearing face coverings or not keeping safe distance, or people who are homeless. 

It's crucial that we provide incentives to manage isolation and quarantine with really strong wraparound services. And here's the bottom line about isolation: you want to make it so appealing that people want to get into it, not out of it. And I'm not kidding. Every community needs to make isolation and quarantine so appealing that people are not going to avoid it. And what you see are best practices from around the country and around the world on how that works. A care package to every single person who’s isolated with masks, thermometers, support for food, laundry, pharmacy services, health education materials. My favorite from around the world was on-demand movies - unlimited Netflix - for the two weeks of isolation. Ebooks, learning channels, tablets, other things to help people access high speed internet hotspots, hand sanitizer alcohol based cleansers, a note from a government leader is an optimal response.  

Every single person who is sick or exposed would be identified early and given this kind of support. In addition: daily check in calls, instructions on how to keep clean, a hotline in case people get sick or need counseling, garbage removal, telehealth and if requested, removal to a safe and desirable place. Maybe a hotel with services, or financial support. The best practices around the world pay people so that they can afford to not go to work for those 10 or 14 days. 

Vaccines are safe, they're effective. They protect our family and community. But rollout is taking months. They hold the prospect of an eventual end of the pandemic. But this pandemic is going to end with a whimper, not a bang. It's not going to be over suddenly in one day. Vaccine rollout has been slow, complicated, confusing, and potentially controversial. The demand for vaccine is going to outstrip supply for many months and we have to address inequities in both health and economics of the vaccine program. If the vaccination program is operated on a first come, first served basis, it will make inequality worse. 

This is the most complicated vaccination program in US history, and there are important things we don't yet know. We don't know how long protection will last. Could be a year, could be a lifetime. Only multi-year studies will really help understand that. We don't know how rare serious adverse events will be: so far, extremely rare. We've seen allergic reactions in one of about every 100,000-300,000 people. Some of those have been severe with anaphylaxis, almost all of them or most of them have been in people with a history of allergy or anaphylaxis before. But then again, about 30% of Americans have some history of allergy. But that's a rare adverse event. We may see other adverse events and the key is to be open about that. Can we manufacture and distribute enough quickly enough? No, but we're hoping that will scale up and we won't have production problems. Will people trust the vaccine? There is a lot of hesitancy and polarization here. 

The Biden administration released their COVID-19 strategy and I have to say, that this was such a relief because for a year, we have lacked a plan. I've been writing about this since March. There has not been, until the Biden victory, containment or clear organization or a clear plan or clear communication about COVID. And that's a big part of why we are really pushing 500,000 deaths in COVID in this country. (I say 500,000 and you may say that it’s 400,000 in the papers, but there's an underreporting of deaths. If you look at excess mortality that's clear.) 

So there are seven components to Biden's strategy: restore trust; mount an effective vaccination campaign; stop spread through public health measures; expand emergency relief and use the Defense Production Act; safely reopen schools, businesses, and travel while protecting workers; protect those most at risk; advance equity, including across racial, ethnic, urban and rural lines; and restore us globally and build preparedness for future threats. It's important that we address the needs of COVID-19 and beyond. That includes improving infection prevention and control and healthcare settings, because on average, about 70,000 people die each year from infections that they get in health care settings.  

We need to expand broadband internet. This is as essential as mail delivery or roads or electricity. And what we're seeing is deserts, not just in rural areas, but also in central cities where a third of school kids where I live in New York City don't have rapid internet to be able to get on to do distance learning. We'd like them to be learning in person, but for education, broadband internet is essential.  

There’s also reorienting healthcare to primary care, and I'll talk more about this, including scaling up telemedicine team-based care and financial incentives for prevention to preserve and improve health. Sustained funding for global health security to tamp down COVID and protect America's health defenses and a stronger, city, state, and federal public health presence with sustained support. 

Primary care is the most needed, and most neglected part of our healthcare system. Public health improves the efficiency of our health system to keep the whole population healthier, and it's incredibly important that these two areas work together. I know that Denver Health is really a model of collaboration. It's one of the very few places in the country and in fact in the world, where you have a good collaboration between public health and primary care and the hospital system. Everyone can do better, but it's good to have seen the progress there. 

Over the past 40 years, the U.S. has gone from having a life expectancy near the average for upper income countries to one that is substantially below. We live now, on average, two or three years shorter lives with more time disabled than most other upper income countries, and it wasn't that way just a few decades ago. And we're paying more and more for health care. We are a negative outlier. And again, we were at the top of the pack a few decades ago, but now we're an absolute outlier in terms of how much we spend, and yet how young we die. 

We need to restructure our health system to maximize and strengthen public health systems, pay for outcomes by reorienting health care delivery to reward providers to prevent illness, and empowering individuals to make the healthier decision. We need to focus on simple quality measures, have continuous improvement through information and empower patients, clinicians, and managers. Have public reporting, but patient ownership of their data. Team based care becomes the standard. That means optimal use of nursing, pharmacy, community health workers, and others primary care needs to be the center of our healthcare system. 

There's an overemphasis on specialty care in this country. People who have a primary care provider do better. They live longer. It has to be patient centered with clinical encounters at times and places most convenient to patients and minimal or no out of pocket costs. These are simple concepts and the pandemic actually may allow us to move faster in achieving this. Protecting primary care practices is really important. Many are going bankrupt or facing large administrative burdens because of the irrationality of our current healthcare system. What we should do is change to a per patient model, not per visit or per procedure, and at the same time, do away with a lot of the administrative burden of insurance claims. We can structure payments so they're substantially dependent on improved outcomes and preventing illness and encourage integrated multidisciplinary teams that will allow doctors to manage bigger panels of patients and use their skills where they're needed most and facilitates the involvement of behavioral health, pain and addiction management services and better programs to address non communicable diseases.  

I want to talk about hypertension for a moment, because when you ask a simple question like how can you save the most lives through health care, the answer turns out to be: control hypertension better. And yet in the United States, we get this most important question right, less than half the time. Only 44% of Americans with high blood pressure have it under control despite spending more than $3 trillion a year on health care.  

Now, we work globally at Resolve to Save Lives, and we've identified five key practices that make a huge difference. One, have a protocol. Kaiser Permanente has a protocol, they've gotten their control rate up to 90%, including Kaiser Colorado. Second, have good quality drugs and equipment. This is a bigger challenge globally than in the U.S., but important here. Team based care, as discussed. Patient-centered services, removing barriers to care and continuous monitoring and improvement, which really was the secret of the Kaiser system. They had monthly tracking of how patients were doing, and then I will never forget the call center I saw with 17 pharmacists, providing care to 14,000 patients by telephone to ensure that they were optimally cared for in the context of COVID-19.  

We need to improve infection prevention and control, reduce the risk of treatment interruption, and innovate with 90 day and 180 day prescriptions. Medication delivery, telemedicine, stronger primary care, team based care, and treatment in the community instead of in hospitals. Globally, we need a stronger public health system, a public health renaissance at national, state and local levels with a resilient, interconnected system that addresses the full range of health threats. We need to dramatically improve public health informatics infrastructure so we have real time accurate information. We need predictable, sustained flexible federal funding, and we need to reduce the chasms between federal and state, and frankly, between state and many local public health agencies. We have to end the tobacco epidemic, reduce the heavy burden of harmful alcohol use, protect people from unhealthy food, promote physical activity, reduce air and water pollution, and protect our children from addiction to tobacco, alcohol, drugs, and from predatory marketing by junk food companies. 

We also have to improve the global health architecture with funding that will cost the world, approximately five to $10 billion a year for at least 10 years, with technical skills, with more and better trained staff able to transform the money into actual action, with operational organizations, with more capacity, better governance so that we don't have inappropriate political interference mechanisms. Strengthening the World Health Organization, but also identifying new ways and new capacities to improve preparedness globally. And we need to recognize that health challenges are not just about health. They're also about economy, education and social development. 

We can keep this country and the world much safer. Tony Fauci, a good friend, said, never again, we should never ever be unprepared for something as catastrophic is what we're going through now. And that means new solutions to prevent, detect and respond to emerging health threats. We can't afford another multi trillion dollar pandemic, but we can afford the health security to prevent it. So I will stop there and I look forward to this discussion. 

KU: Thank you, Dr. Frieden. That was a really good overview, there's so much there. You mentioned incentivizing people to isolate and some best practices from other parts of the world. What could we be doing here in the U.S. to really do that kind of targeted approach? 

TF: Now's the time to begin building, preparing, looking back on what worked and didn't work, building trust with communities. And in each community, identifying the strengths that can be leveraged to support people who are isolating or in quarantine. Working with businesses, for example, to make sure that there is no disincentive for people to be out if they're either ill or if they are exposed. What we've seen repeatedly is that a lot of the spread of COVID is from people coming to work while sick. We should step back and say: why are people doing that? No one wants to work while they're sick. They're doing that because they're having to make a terrible choice between making money so they can put food on the table for their family or potentially putting other people at risk. No one should have to make that choice.  

So fully paid sick leave is enormously important and it's part of the new package that's been proposed by the Biden administration. It’s extremely important. In fact, the evidence for that is quite clear, including from influenza, where paid sick leave can dramatically reduce the spread of influenza in workplaces and in the community.   

I serve on some formal and informal advisory boards for countries and global organizations, and it's been really interesting to see global best practice in Singapore, for example. Their performance standard is that within two hours of a positive test result, there will be a video interview with the patient eliciting contacts. Now, we're so far from being there and we've worked with states and communities around the country. The challenge now is that we are still so far above the level at which there could be effective contact tracing that it's almost impossible that this would occur. But we can get ready and we can do tracing in some communities in some areas, build capacity, and in some communities where people are living in very large households with multi generational groups which is somewhat more common in the Hispanic population, Latino/Latina Americans. We see more crowding, more risk, and more spread in those households. So, in Asia, they're really clear: you're sick, get out of the household. You're going to make other people sick, especially if you've got older people or people who are vulnerable in the household if you don't do that. You propagate another couple of generations of spread of the virus. 

KU: We talk quite a bit about trust in science and trust in institutions. What's your take on restoring trust, maintaining trust, and how the administration can go about that? 

TF: Yeah, well, let me say first that I'm really excited. Today, for the first time in a long, long time, there's going to be a briefing by scientists from the CDC on where we are with the pandemic. And that will begin three times weekly briefings. This has been so overdue. Ever since February 25, when Nancy Messonnier from CDC honestly said disruption to everyday life may be severe and plan for what you're going to do if you have to close things, she was basically shut down as was CDC. We haven't heard from the experts and because of that, I think there's been this growing chasm of understanding. It's crucial that we all get on the same page. 

Senator Daniel Patrick Moynihan used to say, you're entitled to your own opinion but not your own facts. And I feel like we've gotten away from that in this society. If there's one thing we need to do to restore trust, let’s agree on the facts. The principles of communication in an emergency are very clear: they're evidence based and they've been practiced for decades at CDC. Be first, be right, be credible, be empathetic, and give people practical, proven things to do to protect themselves, their families, and their communities. And we've seen just an enormous absence of that. We should move forward, but it's also important to understand what went wrong so we can avoid that going wrong again. And of all of the hazards of the prior administration, I think the most damaging was on communication, because we didn't get on the same page, we weren't looking at the same set of facts. And that's crucially important.  

So having the CDC and other parts of the federal government speak directly to the American people, brief them on what is happening, what we know that's enormously important. Virtually anything the federal government knows should be public domain in just about real time. That's how we can build and rebuild trust. The other thing I found as CDC director is when you hold a media briefing, there's some really smart journalists out there, and they ask tough questions. And some of those questions make you realize that the way you express something, maybe it was clear to you but it wasn't clear even to a very sophisticated audience of these reporters who cover the health beat. So you have to say it better, and sometimes they ask questions that make you go back and look at something differently, and not having that kind of two way communication, I think, is something that led to an increasing gap or chasm between the understanding of this virus by those who are working on it scientifically and the public.  I think the more we can close that chasm, the safer off will be. 

KU: What advice do you give to people who are trying to assess their own risk? How should we be approaching it? 

TF: Well first off, a shout out to the state of Colorado, which has one of the best dashboards in the country on providing that level of risk in each community. That's what we think the whole country should have with one standard. We worked with the New York Times to suggest that standard in a way that we think is as close to accurate as you're going to get from the existing information.  

The idea is that you would know - just as you know the risk of forest fires or air pollution or ozone or pollen counts - you would know, essentially, how hard it's raining COVID in your community. And then you could make a choice: I'm not going to go over to a friend's house today, I'm only going to walk outside. I'm going to wear a mask because I may be near other people or I'm going to stay in today, because it's raining COVID really hard, and I can stay in. I think that kind of information will help us get on the same page. Understand that there is really a risk of COVID, and it's extremely high currently. If you look at the risk in the US, the diagnosis rate of COVID from the CDC data is about 50 cases per 100,000 population per day. That's it. These are numbers, but to those of us in epidemiologists, that's about 10 times higher than the highest number we thought it might be possible to do good contact tracing with  

So, what we're going to see, I hope, is a steady decrease in cases which have begun to come down. But keep in mind, we are at astronomically high rates and we're diagnosing well under half of all of the new infections. We don't know what proportion we're diagnosing - could be a third, or a quarter. We'll see it is different in different parts of the country, depending on how much spread there is. But fundamentally, what we hope to see in the next few months is a steady decrease in the number of cases. Remember, we never got below 20,000 diagnosed cases a day in this country. And that's a high number. We need to get it down to a low number so that we can begin to do that boxing in strategy, finding people quickly, stopping cases and clusters from spreading. Even with - and especially with - vaccination, it will be necessary to do that work all of this year and hopefully beyond 

KU: How is our vaccine rollout going? I've seen pledges by the current administration on some increases there, but what's your big picture on how are we doing on our vaccine rollout strategy?  

TF: Well, it's been really bumpy. And again, it's important to understand what went on in the past so that we can avoid problems. A lot of credit for the prior administration for developing the vaccines in record time. Pfizer developed it without warp speed support and then sold to warp speed, Moderna had a wonderful collaboration with the National Institutes of Health to develop their vaccine, and the mRNA vaccines are really impressive. This is a new technology it's been used. It's been thought about before, but it's a new technology, and it works way better than any of us had hoped. It's a highly effective safe vaccine. And I think all of us should get it as soon as it is our turn. 

However, the approach of the prior administration was essentially to throw it to the states and say now it's your problem. And that's not going to work. What we need to do is to have a whole of society, whole of government response to understand that there's not going to be enough vaccine. And we've seen a series of problems with the rollout, or lack of information. So really until yesterday, states didn't know in advance how much vaccine they'd be getting a week or two from now, and so that led to a lot of frustration. About half of all the vaccine that's been distributed is sitting in freezers instead of having been injected into arms. This is a quite a bumpy rollout because of the lack of organization and the lack of collaboration.  

We've seen a page turned with the current administration: a collaboration, a joining of hands. Instead of a pointing of fingers, there’s a willingness to work with states to identify problems. They've got a lot of cleanup to do. Even understanding what's happening with supply hasn't been clear. A transition, usually, is handing off the baton. But in terms of plan for vaccination, nationally, there is really no baton to hand here. So the new administration is having to really create that pretty much from scratch. And that's going to take some time. 

For four months, we're going to have so little vaccine, and we're going to have to prioritize. I would mention several things that aren't doing as well as they need to. First is vaccination in nursing homes. We're seeing high, high rates of nursing home staff not getting vaccinated. We're seeing a lot of doses that were set aside for nursing homes and given to CVS and Walgreens not being given and sitting in freezers because it was basically assumed that everyone would take them. But there are some beds that are empty and people not taking them. That needs to get redistributed quickly, but there never needs to be a time when we don't vaccinate in nursing homes because that's the number one priority. About 30% of all of the deaths in the US have been in nursing homes. And so if we can get that population vaccinated, we can drive that down substantially really within the next two months. We should be able to see not just falling deaths, which we will see in the coming weeks, but a falling death rate. If we can kind of take off the table,= the most vulnerable population and protect that part of a society better with vaccine. But that means getting the vaccinations done better.  

So one is to improve how it's going in nursing homes. Good start, but a lot more to be done there, particularly with staff. Remember, nursing homes have a lot of turnover. People come in for a little while, then they go back out to the community. You need a way to continuously vaccinate the nursing home population, and you need transparency. I would like to see publicly available data on what proportion of residents are vaccinated in every nursing home in the country. And then you can have some pressure from the community, like,  hey my mom is in that nursing home, why are only 50% of your staff vaccinated? But also outreach to the staff of nursing homes to answer their questions, to address their concerns, to make it easy and convenient. We shouldn't be too surprised that there's the challenge. We've been trying to get flu vaccinations to nursing home staff for decades with not a lot of success or progress, not as much progress as we should have. 

The other thing that we need to do much better at is addressing equity, First come, first serve just perpetuates inequality. You have to reach out to communities that may not have as much access to health care, that may have suspicion about health care, and about vaccinations specifically. There will need to be vaccinations in communities, make it easy for people because convenience basically outweighs hesitancy in terms of vaccine for most people, whether that's in churches, or in shopping centers or other places. You need to be proactive and proactive with our messengers so that we can reach the populations most at risk. 

KU: What is our US leadership role in response to the ethics of prioritization and distributing a vaccine globally and the interconnectedness of how we live?  

TF: There are really two parts to that question, Kristan. One is, what do we do about vaccination, and this is a big problem. I think if we're just honest, every country is going to look out for themselves first, and that's not ethically defensible, but it's not politically avoidable. So what we've seen now is that the Biden administration is actually buying more vaccine then will be used or needed in the US, and some of that we would hope would potentially be repurposed for other countries once we've vaccinated the people most at risk here.  

The US has also committed to joining what's called COVAX. This is the global COVID vaccination facility that is just getting started. And we need to see what vaccines are available, and how to get them out. COVAX is underfunded. So having funds for COVAX is very important as part of the plan that's there. And this isn't just about being ethical, this isn't just about doing the right thing. It's also the smart thing. Because if there's uncontrolled spread all over the world, the risk is that there will be vaccine escape. Strains that essentially are selected by natural selection for the ability to reinfect people, strains that evade our natural immunity. So if we don't engage with the rest of the world, and help tamp down spread globally, we have the risk that we will be worse off. It's not just about doing the right thing. It's also in our self interest.  

And that's true more broadly as well because health risk anywhere in the world is a threat anywhere else in the world. And yet, we work in dozens of countries and with the World Health Organization which has identified, literally, more than 10,000 life threatening gaps in preparedness in detection systems rapid response systems, the ability of countries to surge in and stop a threat before it expands the ability to prevent threats from threat from spreading. This is a huge challenge, but also a unique opportunity because it's now or never to improve our global health readiness, and that means strengthening early warning systems all over the world, strengthening rapid response systems all over the world. So for example, it shouldn't be more than a week from the time a cluster that may be a new pathogen emerges until it's recognized, and not more than another week between the time it's recognized and an effective response starts. That kind of rapid response would make all of us much safer. 

KU: We have a lot of these variants emerging around the globe, and they're often associated with a country where they’re first observed. Is there any sort of potential discrimination or stigma associated with naming a variation in that way? 

TF: Absolutely. In fact, we've gotten away from naming pathogens by places and that started with what is now called Sin Nombre, which was discovered in a part of the US which I won't name here. It can lead to confusion and frankly, South Africa and the UK are looking harder than other places. We don't know that the virus variants started there, they just found it there.  

Lightning Round: 

Can people who are vaccinated still transmit the virus? 

We don't know. We think it's probably less likely that if you've been vaccinated you can spread it to others, but it's not certain. The vaccine might not have worked in your case, the variant might have escaped if that happens in the future. And even if the vaccine worked, it's not clear to what extent it prevents you from getting infected even if you don't get sick, and from shedding that virus infecting others, so even if you get it, wear a mask. 

Given studies showing a high proportion of asymptomatic transmission, what do we do to increase testing in the US? 

We need to make testing much more routine. So start with anyone who's got symptoms and anyone who's a contact for anyone who's got COVID, and then think about a web of testing. Anytime you find a cluster, you're going to test around that cluster. We're still figuring out the optimal role of antigen tests, but rapid testing for antigen and PCR is going to be really important for herd immunity.  

What's the national estimate you think we need to reach herd immunity? 

Well, herd immunity isn’t an on-off phenomenon and there have been a lot of false dichotomies in this COVID response. We're never fully closed and we're not going to be fully open for a long time. Airborne spread versus not, it's more of a range than a yes/no. So the fact is, the more people who are either naturally immune from infection or immune from a vaccination, the less the virus will spread.And at a certain level, it becomes much easier to control the virus. Now, sadly, we're already at about 25% of Americans having the infection. That's going to help us with immunity. That was not a way to control the disease because allowing herd immunity to control it through natural infection would have meant as many as a million deaths from COVID in the US.  

With vaccination, I think if we vaccinate the high risk groups in nursing homes, especially people over 65, in the coming month or two, then by March we should see a big reduction in the death rate. But the vaccine won't yet have reduced the spread of COVID. By early summer, June maybe, we should see a reduction in the spread of COVID from vaccination and I hope if everything goes well, we don't have a variant that escapes vaccination. Then by fall, we should be close to or at the new normal, maybe still wearing masks, but able to go to school in person, businesses are able to resume a lot of activities with some additional safety measures. But I'd like to see us get to 60, 70, 80% vaccination in the US.  

What's the efficacy of masks and double masking for the new variants? 

Well, we don't know that masks are part of the problem, but we do know a few things. First, for source control, if you've got COVID, even if you don't know it, any mask does a massive amount of good. A cloth mask, any masks. If you want to protect yourself, a surgical or procedure mask is better than a cloth mask in general, and a N95 or K95 is better than a surgical mask. So what we hope to see is much more supply of these better masks so that people can use them.  

What antibody tests are available and how accurate are they? 

It's a blood test, it's cheap it's quick, but most of them are not very accurate. So we really want to see more accurate antibody tests on the market and understand if there is a test that correlates with immunity because right now we don't have that.  

And finally, who should take the lead on improving the global health architecture? 

That's a great question. It can't just be the U.S. It can't just be rich countries. That's an old and outmoded form of global health. We need a global collaboration to make the world safer and that means leadership from the global south: Africa, Asia, Latin America, elsewhere from the Middle East, as well as commitment from the upper income countries, and it's going to mean increased resources from all of us from the upper income countries as well as from low and middle income countries to grow their public health workforce in a sustainable way and improved technical information sharing. Building the capacity of people around the world to better implement public health programs that can find, stop, and help stop and prevent health threats and improve health, not just against infectious diseases, but also against today's leading killers: cancer, heart disease, stroke, diabetes.  

There's so much more we can do. We can stop COVID. And when we do that, we shouldn't stop there. We should also stop so much of the preventable illness, injury, disability and death that we suffer through and don't need to if we work together well. So thank you very much.