Inequities and COVID-19 with Marcella Alsan

Mari Megias:

Good day everyone. I am Mari Megias in the office of alumni relations and resource development at Harvard Kennedy school. And I'm very pleased to welcome you to this Wiener Conference Call, the first one of the spring semester. So today we are joined by Dr. Marcella Alsan, who is professor of public policy at Harvard Kennedy School. She is the medical doctor and applied micro economist who studies health inequity. Her bachelor's degree is from Harvard college and she also earned her masters in public health from the Harvard Chan school of public health The MD from Loyola university and a PhD in economics from Harvard university. She trained at Brigham and Women's Hospital as a global health equity residency fellow and then combined her PhD with an infectious disease fellowship at Massachusetts General Hospital. Before returning to Harvard she was on the faculty of Stanford University. Given her expertise and experience we're so fortunate that she's chosen to share her thoughts today with the Kennedy School's alumni and friends. Dr. Alsan.

Marcella Alsan:

Thank you so much, Mari. And thank you very much for joining us today. I actually have for several years at Stanford taught a course called the economics of infectious disease and was able to teach it for the first time this past year at the Kennedy school. And so I thought I'd talk a little bit about what makes infectious disease? what are infectious diseases? What makes them special and unique? And why they are is sort of a role for government involvement when it comes to infectious diseases from a theoretical perspective. And then end with a little bit more on vaccines, since I know that a lot of people are interested in that topic in the current moment. So this was the Johns Hopkins map in February of 2020 it was focused on China and there were 43,000 cases at the time, and a thousand deaths. It was focused on China because really that is where the problem was. There wasn't really a problem anywhere else outside of East Asia and other parts of Asia. That we can fast forward to February 4th.

So roughly a year later, we have over a hundred million cases now. Over almost 2.3 million deaths and the map has panned out because we can see now that the entire globe has been touched by this virus. No country, no nation state really has escaped the tentacles of this virus. And this was an economist cover that really struck me in the summer. Just basically the entire earth had been closed down by this microscopic viral virus.

And a lot of my training, I started out in development economics as a healthcare worker in East Africa and other parts of Africa. And there is projections and now we're starting to actually see some data coming from household surveys, but these are projections from the World Bank. And after kind of a decade of progress following the great recession of 2008, there had been a decade of progress in reducing. This y-axis is the millions of people in extreme poverty around the world. The pre COVID projection had us continuing on that path and as the pandemic has continued on the April and then the June baseline in June downside projection have seen those gains eroded and more people in developing countries being put in to poverty.

Interestingly, Angus Deaton, who is a Nobel Laureate in economics at Princeton talks about the possibility across countries there actually being more convergence but within countries more divergence, because some developed countries economies might be actually really hard hit leading to stagnation for them as emerging economies might not be hit quite as hard but regardless of whether we see at the country level, some convergence within countries it does look like the poor will be very hard hit from these most recent household surveys that are coming out from developing countries. And in our own country, in the United States we see this disproportionate burden also affecting people. Marginalized communities, people of color, et cetera. So I include this.

This is by Anthony Fauci in 2012 the title is very appealing, The Perpetual Challenge of Infectious Disease. And again, I am trained in infectious disease as Mari said so, know your source. I have a very sort of oversized view of their importance, but if you look throughout history they've had a profound impact on human society. They have influenced as written here, Wars, determined fates of nations and empire, affected the progress of civilization. And they are compelling actors in the drama of human history. And why perpetual? I mean, just looking back since the 2000 we've seen lots of different viruses and other pathogens emerge or re emerge. so SARS, took a younger virus, Zika virus cholera has re-emerged on the Island of Haiti after that country's devastating earthquake. And then the UN peacekeeping troops actually defecated in freshwater and led to a massive cholera outbreak in that country. Ebola, as we were dealing with. Just recently MERS, and of course antedating this is the emergence of HIV AIDS. And actually in the background of all of this is antimicrobial resistance, or antibiotic resistance, which is also extremely terrifying in the sense that, you know we have basically built our modern medical enterprise on the use of antibiotics. And you might say, gee, but I don't go out and plow and get a knife cut in my leg and have horrible infectious and et cetera, et cetera. But you know think about childbirth. Think about any operation you have. Think about whether you get cancer. If any of these things happen, cancer is basically obliterating your immune system. That's what chemotherapy often does. So if you get an infection, you'll need an antibiotic. So if you go to surgery you're given a pre-op antibiotic to prevent infection. If you don't have any complications with childbirth sometimes you're put on an antibiotic if you have a ceasarean, so antibiotics are really the crux. They're the basic pillar that allow modern medicine to function.

And so if we have huge resistance building to antibiotics and new types of ways for bacteria to evade our current antibiotic system, and it's not a money making enterprise to have for antibiotics as it might be for other chronic diseases because the hallmark of a good antibiotic is it works really well for only a very short amount of time. And you don't use it that often or else you develop resistance. So you can see why we don't have a lot of RD going on in antibiotics and yet our pipeline of effective ones is really running dry. So that's not on this slide but it's also an ongoing challenge.

So what are the characteristics of infectious diseases that set them apart from other diseases that you might be familiar with? Well, as we've seen they have the potential for explosive human spreads. And they're caused by a single agent, so even though the sort of phenotype of it might vary based on your vulnerability, based on that particular actual pathogen and what it exploits. It's not always the elderly. It can be, for example, in Japan pregnant women were extremely vulnerable. HIV AIDS hit those who were in their prime of life because of its route of transmission, was sexually transmitted.

So basically you don't need to have, for example in cancer there's a two hit hypothesis, you need another one mutation and then another mutation, genetic predisposition and something else. This is just like one thing, or cardiovascular disease is sort of, a lot of different conflation of co-factors coming together. And it also has a few known routes of communicable transmission. This is why we have a whole surveillance unit in the CDC that gets deployed when there is an outbreak, because we can just figure it out through careful history who is sick? Who were the contacts? And what were the types of behaviors they had in common to help us determine is this something that's transmitted respiratory, is it human to human? Is it fecal-oral? Is it mother to child, et cetera, et cetera. And then once, you know, the transmission it's possibly preventable because if you know how it transmits then you can know how it could be prevented.

And I haven't asked you there because I think what we've seen again in the current moment and we certainly saw with HIV AIDS going back to the 1800 and looking at color on the United States, we saw it with the Irish in Boston, even now there's evidence from the bubonic plague that the poor in our society are less able oftentimes to protect themselves. They're less able to telecommute. They're more reliant on public transportation systems. They're more in positions where they're economically vulnerable and have to expose themselves. I remember Paul Farmer, who's a medical anthropologist at the medical school, and he would talk about HIV in Haiti and talking about the sort of non-voluntary nature of sex that was leading a lot of women in Haiti to contract HIV AIDS. So it's preventable with an asterix. It's almost a luxury good to be able to prevent infectious diseases sometimes.

And then this last bullet or the second to the last point I think is extremely important because, I feel like maybe we have become a little more attune to the notion that we have conquered infectious diseases. I mean, this was not just social scientists who've been seeing this. A lot of medical physicians and the medical community felt like infectious diseases were kind of a thing of the past. And we'd gone through the demographic transition. We'd gone through the epidemiologic transition. Infectious diseases are a problem from poor countries and poor people in poor countries. But the fact of the matter is that infectious diseases have, their genetics are just... They're actually astounding and I think are really... If I could come back and analyze that maybe just focus on that because they horizontally transfer genetic material and they're able to pick up genetic material from the mule. They exponentially proliferate, and so there's a lot of opportunity for mistakes in their editing process, and their genetic material to be passed on. And they can really quickly figure out which one is surviving, which one is not. Just through the process of evolutionary selection in the population.

So I hope that we have lost some of our hubris when it comes to thinking that we've conquered infectious diseases. And then there's close dependence on the complexity of human behavior, we've seen it, and a lot of times infections are introduced by trade, by the military, by oftentimes the first people to get sick will be those people that are more mobile. Often the elite we'll get will fall sick first, but it does have a pattern, a very market unfortunate pattern whereby it settles in and really grips and takes hold in the communities that are less privileged. Okay. So in my course that gives you all of these different factors. I'm just gonna talk a little bit about the theory of externalities. But in my class, externalities are a problem. Sorry, I should've said so. The fact that infectious disease are communicable is what makes them by definition have an externality. I'll talk a bit more about that, but in my course I also talk about the measurement of externalities. You can't actually simply... Think about a randomized trial. You generally have a control group and a treatment group and you just compare averages across the two groups, right? And you randomly assign them, so you dealt with bias. That is easy to do in the presence of externalities because there is by definition a spillover effect, but the treated group could be affecting the control group. So even the straight or RCT, Randomized Controlled Trials becomes challenging in the setting of externalities, then there are different frameworks we need to bring in mind. And more theory that we go through in the actual course.

So the First welfare theorem for many of you that our alumni probably remember this from your intro to micro courses, and it is the basis for kind of the prominence of the free market system. Is it the competitive equilibrium is pareto efficient and maximizes the social surplus. Maximizes the song of consumer surplus and producer surplus and is pareto efficient. Meaning no entity can be made better off without making another entity worse off. And however, there are some assumptions that go behind that. And of course, they're all kind of farcical particularly in the setting of infectious diseases. So no asymmetric information, everyone is a price taker, so there's no monopolies. And then of course this part that I've highlighted in red, no externalities. But again, as we just said and I'll formally define here, infectious diseases by their communicable nature have an externality associated with them. So an externality is present whenever some agents welfare, utility or profit is directly affected by the actions of another agent in the economy and this effect lies outside the price system. As I said if externalities are present that violates an assumption of the first welfare theorem and the competitive equilibrium no longer maximizes surplus. The private and social marginal benefit or costs differ. So think about on the producer side.

Well, I'll give you a couple of examples in this next. So there are actually, you can draw a two by two table of the different types of externalities that exists there on the consumption side and on the producers side, and they're positive and negative. So negative externalities we want to curtail, positive externalities we want to promote. And so consumption externalities might be consumption of an electric vehicle. The government won't promote that sort of thing. Negative externalities are exhaust fumes from maybe driving a diesel car. So we might want to figure out a way to discourage that, because that person that's driving that car might really enjoy that old vintage mobile, but not fully appreciate the fact that they are packing the health of the environment, and maybe particularly hurting people that have vulnerable lungs or something like that. There are also production externalities, basic research into new technologies might be underfunded, particularly those, like I just mentioned antibiotics that don't have extremely, you know, their market size is gonna be limited because the time period that you wanna use them is actually very, very short. And doctors who are trying to preserve them, so that they don't develop resistance. Aren't going to be prescribing them all that often. So the market size is maybe smaller, or maybe the market is poor. We might not see a lot of investment into technologies but overall investment into new technologies could suffer, because if you put all this money into finding some natural resource who's to say that your company will be able to drill or use that natural resource, or to patent a new system who's to say that that secret won't get out. And so we need to think about government approaches to encourage production. And then pollution from factory is the most common canonical sort of negative production externality. So infectious diseases, we could populate this whole thing with COVID-19 externalities. On the consumption side people might under consume the vaccine, they might not understand that not only is it helping them, but it might be protecting others around them that could actually have fiscal externalities. It can have benefits for the entire economy. People might go out and have gatherings and whatnot and that might actually have a negative externality in terms of disease spread. Investment in R&D with respect to COVID or showing a film, or having people come to your restaurant, or something like that. That could have a negative production externality as well.

So you can see that again, by dent of this communicable nature, people can take actions, firms can take actions that have effects on others in the economy, and they don't necessarily have to pay the cost or maybe not receive the benefit associated with those things. So basically that means that there is large scale scope for, I mean, this is classic 101 basic economics. No economists would argue that there's not a role for government in the presence of externalities. It's just economics 101. And then there are different solutions. Command and control regulations, or just the government coming in and kind of setting a standard. Could be in taxes or subsidies, or trying to tax any of the negative externalities. Subsidize those that are positive, encourage those things that are positive. Taxes are seen as sort of a double dividend, because not only can you correct the inefficiency and improve the size of the social surplus, but you can also raise money without distortions, but for all of these types of interventions, you need a lot of information to know what is the right size of the tax or the subsidy in order to actually align the marginal private cost with the marginal social cost, or marginal social benefit if it's a positive externality Now, just to show you that this is not, again I think Greg Mankiw, is seen as. I think he worked in Republican administrations. And so he's not kind of one of the most left economists out there by any stretch, but he wrote in the New York times, we should be paying people to get vaccinated. Again, this is the notion that we want to encourage this positive consumption externality. And so to do that the theorem suggests that this would be an appropriate way to proceed. And will be happy to debate this more in the Q&A, but at least from the theory, it definitely follows that you know you have something that you want people to do more of. They might under consume it, because their private benefit doesn't align with the social benefit. And this is a way to make those two things align, to correct the price system. Now of course on the production side there was a concern particularly in if I think it's still pretty cute but there was a concern that, first of all we should pull resources globally, through this mechanism called COVAX, because we might not actually have a winner. So we want to distribute the risk associated with investing just in a few games manufacturers, BARDA max operation works giving money to a few companies, but globally we could invest in a lot more companies where we could share the knowledge, share the innovation that is occurring.

Let's say Oxford actually got there first and Pfizer's didn't work. We could pull this knowledge together for the global good. So COVAX was to invest in nine candidate vaccines and to pool resources in order to do that in the innovation stage. It also plan to distribute $2 billion to participant countries based on population size. So it's still because of that sort of innovation problem. I mean, with the new variants I guess we could also discuss how we're going to innovate and response to that. But because I think all of the vaccine candidates or majority of them went after the spike protein that seemed to work no matter whether you used an mRNA technology or a viral vector technology. The first goal of COVAX which was to kind of spread risk across multiple different producers is not as pertinent anymore. But the second goal, which is to distribute vaccine to developing countries is still very pertinent. And the idea of claw backs kind of falls... A lot of people we'll talk about it in an advanced market commitments. Advanced market commitments are actually something that came before you know, 10 or 15 years, years ago now, Michael Kremer the recent, shared the Nobel with Esther Duflo And Abhijit Banerjee in 2019 for their work on using randomized control trials and development economics, but him and his wife Rachel Glennerster, who is now the head of DFID, they talked about advanced market commitments at least a decade ago when it came to Pneumovax. Pneumovax was a vaccine against strep pneumococcus which is a bacteria that really affects children. Can kill children, causes meningitis. Ear infections, make them deaf. Hard to learn. And Pneumovax was being used in the United States but there were different variants of the strain over different strains in Africa and other parts of the developing world. And no manufacturer work actually producing vaccine for those particular strains that were circulating in Africa. So the idea of that advanced market commitment was basically to say, look, governments or there'll be a private public partnership with maybe Gabby, Bill Gates, wealthy countries will come together and they'll commit if companies will invest in R&D they will commit to buying the product, after it passes some specifications. Now that's a different problem than the problem we have now. The problem we have now is really capacity. We have a lot of the innovation already done. So we're farther down at the pipeline. They're trying to kind of build something that is pretty far upstream in terms of the pipeline. One of the problems with technology is way up in the pipeline. Let's say you wanna come up with a brand new technology for a disease like Chavez disease. You wanna have a vaccine against a neglected tropical disease like Chagas disease. If it's so far upstream, it's hard to actually specify in the contract what the vaccine or what the technology has to do. So there are some contracting problems that people have noted with this idea of an advanced market commitment. But the idea is basically to subsidize these firms to engage in research that is directed towards poor people, problems of poor people. So it's a very noble idea, even if there are some concerns about how you contract that or whatever, but that sort of a different problem than we're at right now.

Right now we have a problem of just capacity. How do we actually make enough vaccine for all the people in the world who need it? And then of course, how do you distribute it? And how do you make sure that it's equitable? Okay. So COVAX ideally was going to be the centralized authority which would basically, if every country in the world was participating in COVAX and only running its agreements through COVAX imagine it. So sort of a centralized place, still working with whoever the players are, the manufacturers are in the current moment, but then COVAX would basically take all the orders kind of serve this middlemen and decide and dole out to each country, according to its population size how much vaccine it would get. That could be one approach to COVAX, but what's happened of course is that all of the rich countries have gone and done these purchase agreements with different companies. and they have, they call them this is a slide from Duke, Duke universities doing a great job, tracking all of these deals that are going on.

This slide is a little bit old, but you can see that even before a vaccine was developed a lot of countries were going in and making deals with these manufacturing, with these companies saying, we'll buy this, we'll buy that, et cetera, et cetera. And if you look across where are these vaccines being distributed as of January 30th, we can see that, this is red is low income and then pink is high-income, and you can see Oxford university AstraZeneca, that partnership has put the most. First of all, I think they can produce the most, their scale seems to be larger than other countries. And also they've committed to COVAX more than these other companies. And, you know, that's a sort of academic as well as public private partnership. But a lot of the supply has been going to the countries that can pay the price. So those are Pfizer and Medina are almost exclusively going to high income or disproportionately going to high-income countries. Now, I don't see on here the production of, so there's Sinovac. And I don't see on here the production of Sputnik Sputnik is Russia's vaccine that's enhanced it was recently shown to be very efficacious actually, even though they went out prior to having those results. So I think Sputnik has made some deals already with South American countries. So those are not represented here just as an aside.

So what can we do to increase the supply? And this is from, I mentioned in the pre-call that Pfizer and Stat news are two great resources again and also Duke for looking at the actual supply side of things. Technological challenges are daunting and it's hard to know what companies actually need. And of course the Biden administration has committed to use the defense production act for things that are kind of on the fringes, like needles or vials, or maybe PPE that people need. You know, fresh gloves and hand sanitizer, in order to actually be able to poke someone you need little alcohol rubs. So all of that is potentially going to now be produced using the Defense Production Act. But other things it's not really clear what the holdups might be. And this is from statnews, where there was actually, Andrey Zarur, a CEO of GreenLight Biosciences actually writing an op-ed in statnews saying I'd like to help my company and others can. In fact by breaking a number of production bottlenecks with our technologies, facilities, and staff, but for now we can only stand by because we don't know what the bottlenecks are. No one company can solve this alone. And then there's this question if the United States government actually tried to take over a firm that was, you know a Pfizer or a Moderna firm. That could lead to a lot of retaliation. It might be a global mess is the point here. So what power does the government have, and why hasn't the defense production act been used yet? This suggests that there might be consequences of basically a takeover. There's other problems as well. There's shortages in actually the manpower. I think people who have tried to get vaccinated might have had problems actually getting a hold of anyone, either if they're going through insure and they're getting someone on the line to talk to them, or if they're trying to book an appointment and they're put on hold, or if they're just refreshing their screen. And then a lot of the distribution right now is happening in mass production sites, which work well for people that have cars, or have licenses, and can drive, and actually have information as to where that is and how to get there. But for the frail, for people that don't have licenses for people that don't own vehicles or they work with public transportation it can be more challenging to try and get there, and try and get there safely. And so just this notion of maybe we don't have enough people and we don't have trained enough people unlike a lot of developing countries that rely on community health workers to distribute vaccines and to do well childcare and maternity checkups.

We don't really have that public health army at our disposal that could go and really reach those people that are vulnerable. Both to tell them about the vaccine and inform them and then also to distribute it. And then this is just talking about where are some of the products coming from. Forbes is talking about Switzerland produces one of the mRNA ingredients for the vaccine. Germany produces some of the lipids. Roche is producing some of the nucleotides. So basically a lot of this distributions having not just in different geographies within one country, they're actually, a lot of the supply chain is across different countries. So trying to coordinate all that might be a little bit daunting too. So basically the other, I resurrected this slide just to mention, this idea that some companies wanna help and they don't have the information. The idea that there are obviously working in a competitive market. We have protections for these companies that have put themselves out there and develop these technologies. And I should say the academic sector and Russia and China. So not just private entities have been successful in this domain, but it means that we're far outside of the assumptions. We have asymmetric information. We have priced. We have kind of non competitive markets not monopolies, because there are a few companies, and countries, and academic institutions that have been successful, but certainly we're far from a competitor market.

So this was a recent article, Should the Government Make Vaccines? And I thought it was interesting, because vaccine shortages have the United States on the brink of public health disaster. Federal Health Organizations are pushing for nationalized vaccine production, but industry says, no. But what year was this written? Well, this was actually written in 2002. And so again, this is a sort of I just wanted to kind of one of the main points I hope people take away is that, let us respect infectious diseases. These problems have been there before. They're going to come up again, maybe not in your lifetime or my lifetime but maybe in our children's, and we have to start. So these vaccine shortages, we were at the mercy, we didn't have enough DPT vaccine. And we were at the mercy of other countries to produce it for us and children were going out with diphtheria vaccine. And sometimes we run out of flu shots.

And then this really came to a head in 2001 with 9/11 and the threat of anthrax. And not having enough vaccine to vaccinate our military. And so it becomes a national security issue. And so Dr. Kenneth Shine, who ran the National Academies of Medicine and Physician, a product physician and is now a meredith and basically had tried very hard to establish a coordinating mechanism and actual vaccine production capacity in the United States, and was unsuccessful in being able to do so. The idea that dynamic inefficiencies from lack of innovation, lack of profit incentive would be harmed by having additional capacity at the ready for the United States was sort of dismissed. But I think right now we're also in a situation where we're talking about questions that are extremely heart-wrenching. We're talking about vaccinating, you know do we vaccinated teachers, or elderly and so on and so forth. And these trade-offs are really all coming because we have this problem of supply and maybe we'll get better, it seems like we're doing a little bit better, but again I'm thinking about what's the long run. How are we thinking about this in a longterm? And then the other idea that has been proposed is this idea is government manufacturing, but could in fact respect licensing agreements and whatnot. You could really just pay some royalties to a firm and start to just mass produce and coordinate in a way at scale. This is another idea that was actually extremely important for HIV AIDS.

So there is the TRIPS, the trade related aspects of intellectual property rather agreement that governs all intellectual property by the WTO and some countries have actually, This is MSF Doctors Without Borders have actually supported this notion that was brought forward by I believe South Africa and India to waive patents for vaccines at this time, so that they could be produced. A lot of vaccine production actually comes out of India so that they could produce large scale. So just have a waiver. What actually happened for HIV AIDS was compulsory licensing was issued by Brazil, and the United States actually started to block that Brazil and India compulsory licensing to be able to actually produce generic versions of the antiretroviral therapy. And there was a fight about that. It became a political issue. There were a lot of protests, ACT UP, got involved. And at the end of the day that compulsory license was not challenged and Brazil and other parts of developing world were able to access ARVs through this mechanism.

So this one I think has a little bit more concerned about maybe some of the intellectual property aspects. This part, I think could in fact, I mean, this could be within the conference of the WTO but it hasn't been viewed favorably by Europe and the United States. This has the idea that potentially with the right agreement in place it could respect IP as well but would also take some time to stand up. So thank you.

Mari Megias:

Yeah. Thank you very much. Very interesting. So now we're gonna open up the session for questions. So to ask a question, please use the virtual hand-raising feature of Zoom, and a staff member will notify you via the chat feature when it's your turn to speak. Note that you may experience a short lag time. So be sure to unmute yourself when you hear from us. And finally, we'd appreciate it if you could state your name and your Kennedy School affiliation before you ask your question.

So I'll just start things off by asking you a question that was submitted earlier by Siddharth Ramalingam NPA 2018. And that question is, very often the terms minorities and marginalized communities are used interchangeably, while there may be a significant overlap the two are often not the same. During COVID-19 has it been important or relevant to make a distinction between the two groups at all from a policy point of view?

Marcella Alsan:

Thank you for the question. I think in what I work on mostly in the United States, and I think it's important to think about who is historically disadvantaged and who might need particularly vulnerable because simply being less than the majority doesn't necessarily mean that you'll be equally vulnerable. So here are some data, again, there has been a data vacuum. Can you see my screen? Are people's, Mari too?

Mari Megias:

Yes we can see you.

Marcella Alsan:

So what we're seeing here, this is Pfizer data. So the United States has been extremely challenging to get data on the vaccine distribution. We really need to invest in public health infrastructure. Even if you're going to go with a decentralized distribution, let every town, and County, and State decide what they wanna do with the vaccine. We still need to figure out who is getting it. And that data has been slow. And the CDC recently put out something with demographics, but I can tell you that my team and I we went to every single website in California when we were checking, maybe they've changed it. They were only telling you how many had been distributed not who. And in terms of the demographic characteristics, we went to several States that were at least reporting age but the age groupings weren't the same across. I mean, not even harmonization. And I just don't think, I mean that lack of transparency is shocking. It's just not okay. I don't know how else to say it. I am being very normative here, but I just don't think it's. Even if the vaccine distribution you're gonna let people do whatever they want and interpret the ACIP guidance, the way that they want they should have to report to the public in the same way. But Pfizer has talked about filling the role of not having a transparent, reliable data source. And so they put out this which shows the gap between the share of vaccinated who are Black and healthcare workers who are Black, and state residents who are Black. And in some places you can see that this gap is profound. And the share of people that are getting the vaccine who are Black is a lot less than their proportion of the population. Even when you think about who is a healthcare worker? We know that Hispanic and Black Americans are also often overrepresented in service industries doing a lot of the face-to-face work. So I think it is important to think and mind who is actually gonna be particularly vulnerable. We have a lot of diversity in the United States and I'm sure other countries do too. And so the question, I still think the first order question in a dynamic sense is the supply, because we're talking about, you know, if we're thinking about not just COVID-19, but COVID-20 or COVID-25 or COVID-31, we have to think about how are we going to actually build capacity and distribute technology for our public health in the future. But it also has to be acceptable. And so what is the demand side look like? How are we going to provide information? There's still huge information gaps in some of my own research, about what Black and Hispanic individuals compared to white people know about this virus. Now that's just going to be the same when it comes to the vaccine. And so how do we understand what information gaps exist and how do we correct them? How do we garner and leverage social media to understand what are the rumors? How do we respond to those rumors in real time? I mean, these are really important demand side questions that we need to also consider. And not just in the United States, I know in India there were forced sterilizations that occurred during the emergency period, and people might be wary to take vaccines. This idea that they're trying to sterilize people. So whenever there's a breakdown of trust, demand is going to be an issue in groups that are most likely to mistrust have an empirical, usually historical basis for that mistrust, and I think those are the ones. They're also by the way, the ones that are generally more ill to begin with and more vulnerable to the biological aspects of the disease. But those are the ones that we might really need to think hard about outreach.

Mari Megias:

Great. Thank you very much. A reminder, if you'd like to ask a question please use the hand-raising feature in Zoom. So just wanna talk a little bit about the efficacy of the different vaccines. It just came out that France will only administer the AstraZeneca one to people under age 65, citing a lack of sufficient data about its effectiveness in older people. And can you talk a little bit about that and some of the vaccines that may not have been approved in the United States as well?

Marcella Alsan:

 Yeah, honestly I think we have a lot to learn still about these vaccines and it kind of comes back to surveillance. Sorry, obviously I'm an economist so I like data and I get frustrated when I don't have data, but even as well run and as miraculous as it has been to see us have not just one or two but many different vaccines, as I said including Sputnik that are potentially available that could fight this virus, there's a difference. There's a well-known difference in clinical trials between efficacy and effectiveness. So efficacy is what happens in the trial, effectiveness is what happens in the real world. Effectiveness can be, you know, there are so many different factors that will affect the effectiveness that can't possibly be learned in a trial. And there are so many different ways that people from different backgrounds might respond. There are different variants out there. So surveillance as to how things actually work on the ground is extremely important. I would say that if our we're looking to one system right now, I would say we should be looking to the countries that have nationalized health programs. There it's not gonna be perfect, but they are probably better poised to pick up, if they're doing surveillance on different mutants they will pick those up. So do I really think that the UK was the first place to have a mutation in SARS-COV-2? No. But it's quite possible that the UK was the first one to pick it up because it has a national health system. And although there are lots of people who say they could be doing their vaccine rollout better and they've got their own issues to deal with. One of the advantages of being able to see the data from everybody is to be able to pick up issues, problems. To let the public be aware and to see how things might change over time. So we need to continue to surveil these different innovations. And I think some of the key differences and the technologies are important, but I think the main reason they're important is not so much on the age effectiveness though of course, none of the first trials were done in children, and now Johnson & Johnson is doing children, and children are going to be important to know about. Some children have type one diabetes. Some children have other diseases, sickle cell, et cetera. And some children, they might also be, transmitting obviously as well. So getting that figured out getting those in the oldest range who are the most vulnerable figured out getting the size that we need to test is important to make sure that all of these different subgroups are receiving the same benefit or maybe a better benefit, or maybe slightly muted benefit. Those are important details to work out still. But the biggest difference in the technology right now I think is the mRNA versus the viral vector. Viral vector is an older technology, you insert the genetic code into a virus that has been deactivated. And then you put that into the person versus an mRNA which is just a little sliver of the code which is the blueprint that you give to ribosome to start kicking out the protein, the spike protein, and the mRNA requires a lot colder temperatures to store than the viral vector ones. Oxford AstraZeneca is one of them. So that just means so the production costs are also very different, and how much is being charged I should say is different. So 10 or $15 for Pfizer Moderna per dose. Versus AstraZeneca, which is $3. And so just think about how different those will scale. And then of course, how they deal with the variance. So I think there was some disappointing news about the South Africa variant. This are the AstraZeneca, but I think we're gonna be playing this game of the viruses is mutating, as soon as we can sequence that we can figure out what the right genetic code is either to put into this viral vector or to put as an mRNA in a lipid and insert that into people's bloodstream. But you have to know, again, surveillance. You have to know what variants are out there. You have to be sequencing these viruses. I said it as a plural on purpose because there are two different types. and you can't respond to it unless you know what exists.

Mari Megias:

Great. Thank you very much. We are coming up against the end of our time. So I'm just wondering, we do have a question from Kim Doc. And if you can speculate about whether, let me just read this. Where having a national manufacturing and development processes you identified could affect efficiencies in distribution? Which in this country is something of a hash right now.

Marcella Alsan:

Yeah, I think it's possible. It is beyond the scope of what was originally envisioned by Dr. Ken Shine. But I think the idea that if you think about the purview of a national authority, it would be able to once you know where things, I mean, what did the CDC director say when she first took over? She's like, we don't even know how much we have. So if you knew how much you have, it's sort of a first step in knowing where it's going. And so I do think that having a sense of how much do we have, could then lead us to understand where is it going? And then of course, who is getting it? These are really terribly important questions. And as I said, maybe not for COVID-19, but let's please understand that when it comes to our genetics versus their genetics and by their, I mean bacteria and viruses, this is basically workable. And whether it comes back we're still not out of this one, but this is not something that's going to be rid of humanity forevermore.

Mari Megias:

Thank you. We do have a question. If you could, please let us know your Kennedy School affiliation Ammar.

Ammar Waraich:

Hi, my name is Dr. Ammar Waraich, I'm actually an infectious diseases trainee, and master's in public policy from 2019. I'm actually in the UK right now working on the COVID boards. My question really was about the ethics of paying people to use vaccines. Do you think that it's like politically acceptable and ethically acceptable to pay people to use vaccines firstly? And secondly, do you think it's acceptable to pay more to people who are resistant, and to kind of set up almost a bidding process or a pricing process in paying people to use vaccines? Thank you.

Marcella Alsan:

Well, thank you doctor for your work. You're truly the hero. And we're so grateful to you. So personally, I think there are two issues. One is that, again thinking back to ARV, my experience working in HIV in Africa if you made foodstuffs, food packages there's moral hazard involved, right? So if you made foodstuffs contingent on your CD4 being low. So people would get food packages only if their CD4 count, which is as the doctor will measure up like the robustness of your immune system. And what do people do? People are so desperate, right? That they're gonna let their CD4 count drift down even to their own detriment. So if you say, okay let's say a government plan that, assuming all supply side issues are obviated and we figured everything out and we're pumping out billions of doses or whatnot. So moving on objecting from that, we're gonna pay $10 if you don't get it by June $20, $30, $50. And you can imagine that people are gonna hold out. And the people that are gonna hold out are gonna be the poorest. So there's moral hazard involved with something like that. But even still, there are some people that have severe allergic reactions to this drug. So paying people to get something that they might have a severe reaction to, that is also I think dubious. And I don't think it addresses, but let me say that there are clear structural barriers. And that's why I don't like to say trust is an issue among disadvantaged communities or exploited community it's all trust, because there are structural things, obstacles for people to getting vaccinated. There's transportation costs, there's childcare costs. You know, people have to take off time from work. So, do I think that there should be maybe transportation vouchers? We do that in the developing world sometime. Yes. Do I think that there should be, childcare provided if needed? Do I think that we should be coming to people, as opposed to trying to have very vulnerable people come to us. In the Turkish national immunization campaign of 1985 which I've studied. They made a plan that every person would be five to 10 minutes walking distance from a vaccine station. And they use churches, and they use Mosque, and they used trusted community spaces, and trusted community messengers, and it worked. And everything was riding on that campaign because it was the first large scale vaccination campaign that UNICEF did. So I think there are things that we could do to make this easier for people to access. But I like the doctor, I do share weariness with paying people to get vaccinated, because I think that doesn't really deal with the trust issue, the fundamental trust issue in the first place. And it could create the possibility that people who, for this vaccine might have, We know very little, there are very few side effects especially as far as we can tell, but let's say someone goes into anaphylactic shock and dies, and we paid them to do that. How comfortable does that make people feel? But transportation vouchers, overcoming structural barriers, understanding the real problems that people have, having trusted messengers. Having food distributed at a place where you talk about the vaccine and tell people about the vaccine, and educate them about the vaccine,. But no I would not condition receipt on money for those reasons.

Mari Megias:

Right. Well, thank you very much to everyone who called into listen to this Wiener Conference Call. And a special thank you to Dr. Marcella Alsan for her sharing her expertise with us today. Our next call will be held on March 3rd with Joseph Aldi who focuses on climate change policy, energy policy, and regulatory policy. Thank you very much. And everyone have a great rest of the day.

Marcella Alsan:

Thank you.