Hello and welcome to our conversation about
global challenges,
the COVID-19 pandemic and the world order.
My name is Nicole Bibbins Sedaca
and I'm the deputy director of the Master of
Science in Foreign Service program
at the Walsh School of Foreign Service
at Georgetown University
and I serve as a professor in the program.
The MSFS program is hosting a series for
our graduate students in the Walsh School
of Foreign Service
to foster rigorous thinking and
discussion about how the current global
pandemic will impact the world order.
We will host a series of high-level
interviews and conversations
with senior officials and thought
leaders and our own SFS
expert faculty. We'll explore issues from
democracy to global financial markets,
the great power competition to refugees,
fragile states to the environment and
energy.
The world is unquestionably being
reshaped and our students and our
community will continue to be at the
center of the conversation
and efforts to understand and shape the
future of the international landscape.
To open our conversation let me turn it
over to the
dean of the Walsh School Foreign Service
Dr. Joel Hellman.
Well obviously we're living in a time of unprecedented challenges but
we all know that the global system was
under tremendous change and strain
prior to the pandemic. We had seen the
rise of
nationalism and populism; we've seen the
rising strength of liberal powers; we've
seen rising distrust in government;
we've seen economic difficulties,
demographic pressures,
environmental challenges leading to mass
movements of people
around the world; we've seen inequalities
that have shaped and reshaped
domestic politics and the international order
and of course we've seen America play a
remarkably different role in the world.
But COVID, of course, has exacerbated all
of those fractures
and indeed it's created physical,
cultural, ideological and even emotional barriers
to the way nations engage with each
other as a result of the COVID crisis.
And therefore we really need to think
through
how COVID has reshaped, exacerbated
and changed the challenges that we were facing.
Now when COVID ends, and of course it will end,
we can't go back to the status quo ante.
There have been enough significant challenges
to the global order that we need to
really fundamentally think
-- rethink -- the core issues, the core
foundational principles
of the global order and how to ensure
that we can work together to solve
global problems. And
of course that's why this school was
created in the first place 100 years ago
in the aftermath of World War I
to really deal with the fundamental
drivers of conflict and global conflict
and to think about a new way of
organizing the global order
to sort of create the foundation for
peace.
A hundred years later we find ourselves
facing a new set of challenges, but one
no less significant than the ones where
we faced when we were first established.
And here at SFS we want to ensure that our students
are deeply engaged in this rethinking
and that's the purpose of the seminar.
The purpose of this is to bring together some of our best faculty and some of the most
interesting practitioners who engage in
this rethinking
and reimagining of the global order, to
talk
with our graduate students, to think
together with our graduate students
about how the global order needs to
change. They'll be looking at how COVID
has impacted some of the key trends in
global politics and they'll be thinking innovatively and
creatively about
new ways of organizing nations, new ways
of engaging across
nations, new ways of social movements and
other ways
in which countries and peoples come
together to solve global problems.
It's an exciting challenge and I think
that one that really does represent
everything that SFS is all about.
So I welcome you to be
an active participant in this series of
discussions and webinars. I welcome you to
really think through the challenges
that these talks are going to put before
you and I hope together
we will come to some interesting and
creative
solutions to some of the challenges that
we're facing today because that's
what SFS is all about. So I wish this
seminar series all the success. I hope it
shapes and frames
your thinking over the next several
months and I hope that it makes this
semester
one that I think will be truly impactful.
Thank you.
This week in our conversations about
global challenges, the pandemic and the
world order,
we look at the science and public health
facts
behind the pandemic itself.
We have two interviews: the first with Dr. Anthony Fauci,
an American physician and immunologist
and the director of the National
Institute of Allergy and Infectious Diseases
at the National Institutes of Health.
He is leading the American efforts
to address the pandemic in the United States.
Our second interview is with Dr. Agnes Soucat,
the Director of Health Systems
Governance
and Financing at the World Health
Organization,
a renowned public health specialist who
has focused
on public health education and
governance throughout the world
and specifically in Africa. Our
conversation today
focuses on understanding the pandemic
itself,
understanding the science and public
health information
that we have available as to the impact
of
the pandemic and how it impacts so many
other parts
of life in the United States around the
world
and what the longer term implications
will be of this pandemic.
Good afternoon everyone and thank you
for joining today's virtual event
hosted by the Global Health Initiative,
the O'Neill Institute for National and
Global Health Law,
that Kalmanovitz Initiative for Labor
and the Working Poor
and the Institute of Politics and Public
Service
at the McCourt School of Public Policy
which is known to many of you
as GU Politics.
My name is Alanoud Asuleiman. I'm a Health Law LLM student here at Georgetown Law.
I am focusing my studies on access to health care.
I'm also working with the O'Neill Institute on various projects, recently, the collaborative project on
COVID-19 laws and policies and before joining
Georgetown I received my Bachelor's
Degree in Law from King Saud University in Saudi Arabia.
I am pleased to introduce our guest today Dr. Anthony Fauci.
Dr Fauci is one of the U.S. most visible
leaders in public health.
Dr. Fauci also currently serves as
the director of the National Institute
of Allergy
and Infectious Diseases at the National
Institutes of
Health and he is also a member of the
White House coronavirus task force.
We are thrilled to have Dr. Fauci with us
today to discuss
the COVID-19 pandemic and
the unique risks and responsibilities
young people have in mitigating their
spread of COVID-19.
Please join the conversation on social media
using the hashtag
#FauciatGU and for our students please
remember to submit your questions
for Dr. Fauci using the Q&A feature at
the bottom of your
screen and please remember to include
your schooling year.
This event will be moderated by Mr. John
Monahan,
a senior advisor to President DeGioia
who has helped organize
Georgetown's Global Health Initiative
over the past three years.
Prior to this role Mr. Monahan served as
senior global health positions at the
Department of Health
and Human Services and the State
Department during Obama administration.
Our second moderator is Mr. Mo Eleithee,
the GU Politics Executive Director
and I will turn it over to them now to
kick us off
and thank you very much.
Great.
Thank you, Alanoud, that was a terrific
I appreciate it.
And Tony I want to just
start off by thanking you for joining us
on the webinar today.
Over the years you've always been so
generous to
in sharing your time and experience with
our students that we're just delighted
that you're able to join us today
and I should also add that we that
all of us deeply appreciate your
enduring commitment to public service
and your commitment to public health and
science both over your many years at
NIH and through this pandemic so thank you for being with us.
So let's just jump in I think
to help set the stage it would be
terrific if you could provide us with an
overview of where we stand now with the
COVID-19 pandemic both globally,
regional hot spots, how the
U.S. compares
and within our own country,
what states have rising cases what
populations are most at risk and have
been most impacted.
And then if you could -- because I know you
take
history very seriously, how you approach
these issues -- if you could
put this in some context compared to
say the pandemic influences of 1918 or
more recently in 2009
and the other coronavirus outbreaks
we've seen like SARS and MERS, if you
could just
help put this experience we're going
through right now in that sort of
context as well. So thank you, Tony.
Okay, thank you, John, you've asked a lot of
questions.
I want to do it very succinctly. So
obviously we are in the middle of a
global pandemic
and a number, I mean it's over 200
plus countries have been involved, it is
really in many respects ravaged
many many parts of the world. We have a
serious situation here in the United States,  it's a
mixed bag in the United States, you know.
We have
areas that have been hit really badly
like the New York Metropolitan area
are doing quite well now in getting the
outbreak under control and
trying in a stepwise prudent fashion to
open
and seem to be doing it successfully. The
numbers
are quite sobering. You know, we've have
over 135,000
deaths in this
pandemic for the United States. We have
over three million
cases. If you look globally there's
close to six hundred thousand deaths and
about 13 or 14
million infections. So this is a pandemic
of historic proportions. I think we we
can't deny that fact. It's something that I
think when history looks back on it'll
be comparable
to what we saw in in 1918.
The situation that is the current
challenge that we're facing right now
is the resurgences of infections in the
south and southwestern part of the
country,
but particularly in areas like
California, Florida,
Arizona and Texas. They're seeing record
numbers of cases,
mostly, interestingly, among young
individuals strongly
suggesting the link between
attempting to open and in many respects
as we saw pictures of and photos and
films of
is that and I will get back to this in a
moment about responsibility
where individuals mostly young people
were seen at bars congregated in crowded
places,
many of them without masks which really
adds fuel to the fire. So our challenge
today and tomorrow
and next week is to try and contain
these outbreaks and get us back
on the track of being able to not only
contain, but also to open
safely. So bottom line it's a
global serious situation, it's a serious
situation in the United States,
the United States being a very large
country and very heterogeneous
both geographically, demographically and
other ways.
It's a mixed bag. Some areas of the
country are doing really quite well
and others are being challenged as the
states that I just mentioned.
You said to compare it and I'll do it
briefly. Right now if you look at the
magnitude
of the 1918 pandemic where anywhere from 50 to
75 to 100 million people globally died,
I mean that was the, you know, the mother
of all pandemics and
truly historic, I hope we don't even
approach that
with this, but it does have the makings
of the possibility of being, you know,
approaching
that in seriousness. Though I hope that
the kinds of
interventions that we're going to be and
are implementing would not allow that
to happen. But it does have strong
similarities
with that in that it was the emergence
of a brand new infection. That was
influenza. This is coronavirus.
That, you know, essentially thrust itself
on the human population
and had two characteristics that are the
thing that make it
as I say the perfect storm. And that is a
virus that jumps species, but that
almost immediately has an
extraordinarily capable and efficient
way
of spreading from human to human
simultaneously with having a
considerable degree of morbidity and
mortality.
And that's what we're facing now. And you
asked me to compare it
with other outbreaks and I think I can
give you examples
of each of those and I'll do it very
quickly, that had one
or the other of those characteristics,
but not both
and that's what I refer to when I say
the perfect storm.
So let's take the threat of
the bird flu that you and I had a lot of
experience when you were in the
Department
and that is the H5N1 and the H7N9. It jumped from a chicken to a human. It
had pre-pandemic potential,
but what it didn't do, it didn't spread
from human to human.
So if you were unlucky enough to get
infected you had a 35,
37, 40 percent mortality but it was a
dead end. Mostly with humans it didn't go
from human to human.
Then you had the situation with the 2009
H1N1, which was very efficiently
transmitted
from human to human, but pathogenically
it was a weak virus. I mean the deaths
that year
were less than with a seasonal flu so
you had the two ends of the spectrum. One
transmitted well, didn't kill.
One killed but didn't transmit well and
what we have now
is a virus that is very capable of
spreading from human to human and even
though it has a wide range
of impact from 20 to 40 percent
of the people who have no symptoms to
individuals who get moderately sick,
very sick, serious enough to go to the
hospital,
serious enough for intensive care
ventilation and even death. So
it's a very unusual virus in that the
range
of severity is so great and wide,
which actually leads to confusion on the
part of people as to whether
this is really serious as some people
say it is.
Well it's not serious for some people,
but it's deadly serious
for others. So I'll stop there and that's
kind of the overview.
No, that's exactly, that's incredibly
helpful, Tony. And really my follow-up is:
because I think that the virus has this
disparate impact as you've described,
there's some issues that the public
debate now that would be really helpful
if you could help
clear up. I mean one would be there is
this
discussion about whether a rise in total
U.S cases is a result of testing alone
as opposed to the disease progressing
and two is
should we take comfort the death rates
are declining, which they are,
even as infection rates increase?
And then this recent discussion about
the ability of the
the virus to spread through aerosolized
form versus the droplets. And,
if you could, those issues have
been coming up regularly,
if you'd be able to help us
understand what the science shows us.
Yeah, okay, so first hang on I just I want
to write down your questions.
Okay so sorry I was distracted with that.
The first question is: is this just
an increase because of testing versus an
increase -- well there's no doubt
that it's both. I mean obviously the more
you test, the more you're going to pick
up. So increase in testing
is going to give you increases, but there
is no doubt that there are more
infections
and we know that because the percentage
of cases,
of the the cases that are tested that
are positive is increasing.
Therefore unequivocally you're seeing
truly more new cases. In addition we're seeing
now more hospitalizations, which lag behind
infections. And we're starting and we'll
see, though not
as much as we've seen, very likely more
deaths.
So clearly there are more infections. The
second question is
I think you hit it which is:
really should we take comfort that death
rates are declining?
Okay, so we've got to be careful because
remember the big spike in the death rates that we
saw was the
terrible situation that they went
through in New York City Metropolitan
area,
in situations in Chicago, in New Orleans
and Detroit
and that death rate happily is going
way, way down. What will happen is that
we will likely see some more deaths as
people get hospitalized,
but I doubt, John, that it's going to go
up to the extent
that we've seen before mostly for a
couple of reasons.
One is that if you look at the age range
of the individuals who are getting
infected now as opposed to
earlier on a few months ago, it's about a
decade to a decade and a half
younger. So even if young people, which
some do
get sick enough to get hospitalized,
it is highly unlikely that the death
rate among them
are going to be at the level of the
death rate of what we saw
in the real core of the explosion that
we saw in the Northeastern part of the country.
And then the last -- really the other
question has been the debate is the
extent to which the virus is transmitted
through aerosol.
Yeah, that is still debatable, John.
In fact, two minutes before I came in I
just read a summary
analysis of it and there's almost,
certainly, that there is a degree of
aerosol occurrence.
The degree of transmission
aerosol wise is very unclear.
Most people think it is not the dominant
modality of transmission, but the
definitive proof has not been put --
I don't think it's dominant. I think it
actually
occurs. And for those listening to know
the difference
is that droplet type of transmission
rarely goes beyond six feet. So if you
cough, sneeze or even talk
a droplet would tend to drop to the
ground, which is the reason for the six feet
limit that we talk about, about
staying away.
When you have aerosol, it's in a droplet
that's less than five micrometers, which
means it has the capability
of floating around so you would expect
that it does have the capability not
only temporally you're floating around
but getting behind the mask, around the
mask or in the mask.
So that's what they talk about with
aerosol.
I mean that's very helpful.
I'm going to turn this over to Mo now
for the next question.
Hey, Dr. Fauci. Thanks again for joining us
today. Let's turn to the response a
little bit now. You know, as we've already talked
about, the disease has hit the United
States harder than many other
nations around the world. And as you
talked about it's not entirely
just because of testing.
And so starting big picture first, you
know,
how much of that do you think has to do
with --
some of the nations that have dealt with
this, maybe a little bit more effectively,
have had more of a coordinated
national response whereas we have opted
for more of a
state-based or local or regional
response here in the United States.
Is that part of the disparity? Can we
even have a coordinated national
response in the United States?
You know, Mo, it's
it's always easy to
look back and say if we had done this
would it have been different. I mean
that's always where, you know, and that
will happen
when this is over and people will I'm
sure analyze it every
which way. Some of the things that I
believe
have an impact on the differences,
and I don't think we can fully explain
it, is that in Europe, for example,
and in some of the Asian countries when
they shut down,
essentially locked down, they locked down
to the tune of about 90,
90 plus percent. They really locked down.
We have a very large and a very
heterogeneous country
with different risks in different places
geographically
and demographically. And in reality even
though we locked down
considerably, we only locked down, the
estimate
is somewhere around 50, 55 percent or so.
 So when we had the outbreak and in
Europe they went up, they peaked and then they
came right down
to baseline. They really did go down
from thousands of infections to handfuls or
so of infections. Whereas in the United
States if you look at our curve,
for better or worse, we went up,
we peaked, we came down and we never
really came all the way down to baseline.
We stayed around 20,000
a day of new cases
until the most recent surge when we went
to 30 and 40 and 50 and then 60.
So the issue is we never got down to the
baseline so that when you started to
open up, you had relatively few amounts of
infections to deal with.
Whereas when we opened up now, you're
seeing the surge.
The reason for that a complicated, Mo, and
there are many.
The issue of how one does a response,
you know, we live in a country that from
its founding
had a federalist bent to it where there
were states that had the independent
right and
and capability of doing things their own
way. In many respects
that works to our advantage in other
situations.
Possibly that really was a little bit of
a disadvantage here,
very difficult to make a definitive
comment about the contribution
that that paid for the difference
between what we see here and what we see in Europe.
Okay, I'm going to toss it over to John.
We all have so many more questions.
We're going to try to get through John
and mine as quickly as possible before
we go to the students and this is just a
reminder to the students
you can still continue to submit your
questions using the Q&A tab at the
bottom of your Zoom screen.
Great, Tony, speaking of the schools and
students, you know, many schools around
the country
are announcing their guidance for
the fall -- we have at Georgetown --
but just yesterday the LA County
and the
San Diego County Public Schools
announced that they would be
online for the entire fall.
The president, many others have been
talking about
reopening schools, full reopening as
quickly as possible.
The CDC's issued guidance
describing steps that schools can take
to open safely.
I guess what I'd love for you to do
is step back and just help us
think about how should how should
schools approach the upcoming academic
year
and if you could clarify what we know
now about the risks of children
teenagers and young adults across that
whole age cycle from
K through 12 through Higher Ed and
the risk that they present to
among themselves but also with teachers
staffs and their families.
What's the right way to think about this
as schools go forward?
Okay so let's, John, for clarity, let's
just talk about
you know elementary, middle, high school
and not
university because there are major
differences there
and we could get into universities later
but I think people
are much more focused on school. So I
start off with a general principle and then work
your way
towards the operational aspects and the
exceptions. So as a general
principle, we should try as best as
possible
to keep the children in school for the
reasons
that the unintended downstream
ripple effect consequences of
keeping the kids out of school and the
impact on working families
and on other aspects of society can be
profound
not to mention the negative effect on
the children. So as
a principle we should try as the default
to get the kids to stay in school.
However
that's going to vary from where you are
in the country and what the dynamics
of the outbreak are in your particular
region.
So that's the reason why, although the
fundamental principle
is there, the one other guiding principle
that is
overriding is the safety and the welfare
of the children and the safety and the
welfare
of the teachers. So you've got to take
that into consideration. So
if you're in the part of a country where
the dynamics of the outbreak
are really minimal if at all then
there's no problem at all in getting
back. If you're in a situation where
you're in outbreak mode
then you leave it up to the local
individuals as you've said in certain
California schools,
certain Florida schools of making a
decision
based on the judgment of making sure
that safety of the children and safety
of the teachers
are paramount. So you guide the principle,
let's try and get them open to the
extent that we can,
but let's take a look at the dynamics of
the infection
in the area that you're in.
Thanks, Tony. Thank you. Mo?
This maybe is a little bit more, less
about the response
from the government, more about the
response from citizens.
Look, yeah, I'm glad you're here and I'm
glad you're speaking out
and I'm glad that you are giving
students a chance to talk with you
because a lot of people are confused
right now about the state of the
pandemic and what they should be doing.
My wife and I every night sit down and
try to figure out what we're allowed to
do with our kids based on, we're
comparing different news stories
we've read or different pieces of
guidance that we've picked up.
And I think a lot of the confusion can
probably be attributed to
three main issues. One: the evolving
nature
of the pandemic has resulted in more
information
and new information and involving
guidance.
Two: a growing body of deliberate
misinformation and disinformation that's
being spread,
much of it online. And three:
the polarization and growing
politicization
of the discussion of the pandemic. Right?
I mean just
even this past weekend, the White House
pointing to some of your previous
comments,
in order to question some of the
guidance. So my question is
this: given all of that, misinformation,
disinformation, evolving guidance,
increased politics in the
conversation, how do people synthesize
all this information in order to make
the right decisions?
How do they know who to trust?
Well that's a good question and
it's difficult, you know,
to give you a definitive answer
except that for the most part I believe,
for the most part, you can trust
respected medical authorities.
You know, I believe I'm one of them so I
think you can trust me.
But I would stick with respected
medical authorities
who have a track record of telling
the truth, who have a track record of
giving information
and policy and recommendations based on
scientific evidence and good data.
So if I were to give advice to
you and your family and your friends of
your family,
I would say that's the safest bet to do,
to listen to the recommendations from
that category of people. But it's
entirely understandable
how the public can get mixed messages
and then get a bit confused
about what they should do.
Let me ask one quick follow-up before tossing
it back to John. You just
mentioned data and, you know, there was a
story that broke
literally moments before we convened
here today
about bypassing, that data collection
will now
bypass the CDC and go straight to HHS
and I'm wondering if you had any
thoughts on that sort of late breaking
news.
No, Mo, one of the bad ideas about
commenting on late breaking news that
you didn't read --
that's a surefire way to shoot yourself
in the foot. I think I'll pass on that one.
Fair enough, fair enough, all right. We're
gonna go to John
and then after that right to student
questions
which will be probably better than
any of John or my questions.
Absolutely and I think my last
question, as we start to queue up the
students, Tony, really is, and I know we asked a lot of
questions, but it really does
so far get to the complexity of this
experience the country is going through.
But, you know, most of the people on this
webinar are students and they're our
young adults
and I guess as we start to bring people
on, I'd love to ask you to say, given what we know now,
given everything we've talked about:
what is your message to young
people young adults, teenagers, you know, as more states
open up? Some are pausing, but really
focusing on so what are the risks
and the responsibilities of young people
as we think as we as we approach the
pandemic
where we are right now given what we
know. Well, thank you, for that question,
John. I was hoping someone would
asked it because I think it's key,
it's really key to what is going on
right now
with the resurgences that we're seeing
in some of the southern states.
And I say this with
some trepidation because I don't want to
seem preachy about it, but
since right now if you look at what's
going on in the country
that the infections are among young
people
very likely contributed at least in part
to what you're seeing
on TV of young people gathering at bars,
crowded places, congregating many without
masks,
there is an understandable
situation where a young person could say,
you know, "statistically
the chances of my getting into trouble
by getting infected are
much smaller than an elderly person and
a person
with an underlying condition. And since, I,
as a young person,
I'm really quite healthy it doesn't
matter to me.
I'd rather be there sipping my margarita
at a bar in a crowd." Well to me that's
understandable. I'm not blaming that,
that's innocent. However,
what they need to understand is that
given
the nature of this outbreak, even if you
get
infected and have no symptoms at all
and never get sick, you are inadvertently
propagating
the pandemic. You are part of the problem
and not the solution because by
propagating the pandemic --
I mean it may not matter to you
because you probably are not going to
get any symptoms --  but the chances are
you're going to infect someone
who then will infect someone who then
will be a vulnerable person
who could get sick, who could get
hospitalized, who could even die.
So not only are you propagating the
outbreak,
but you're actually putting other people
in danger. So I would hope you could
appeal
to the young people to not only take the
individual
personal responsibility, but think about
your societal responsibility and that's
what I mean when I say
we're all in this together. Everybody has
a
place and a role in getting this
outbreak
under control and your not caring
whether you get infected or not
is not a good way to get the outbreak
under control.
To get it under control means you don't
let yourself get infected
and you don't spread to anybody else. And
again I say that with some trepidation
because
I'm not blaming anyone and I think
people do this
innocently. They don't mean to be part of
the problem,
but inadvertently they are a part of the
problem.
And that's the message we've got to get
across.
This hour has been unbelievably
informative
and I would say inspiring.
Since the time I first met you,
more years ago that I care to remember,
you've really been an inspiration to all
of us about what public service
health and science mean. And I'm
confident that our students really
benefited from your message today; so
thank you for
all you have done and all you will be
doing to help our country. And thanks again for your time. We
really appreciate it.
Well, thank you, John. Thank you for having
me. It's always a
a very enlightening and
enjoyable experience dealing with you
and with the students of Georgetown; so
thanks for having me.
Take care, Tony, and thank you.
I'm delighted to be joined today by Dr. Agnes
Soucat who is the Director for Health
Systems and Governance and Financing at
the World Health Organization.
And it is just a tremendous pleasure to
have such an expert with us
today. She has served in a number of
positions working on health and education and a
wide array of other issues. She served at
the World Bank, at the
Global Leader Service Delivery and lead
economist,
she served prior to that at the African
Development Bank where she worked on
health, education and social protection
for countries throughout the continent.
She comes with a long, long history of
tremendous experience
and academic work. She earned her master's, her
PhD, rather, in health economics and it's
just wonderful to have her here
as we kick off this conversation this
semester about
how the pandemic that we're all
experiencing
has impacted the global landscape. And
it's right that we start
with those experts who are scientists,
researchers, public health specialists
who
know the science and the health data
behind
the pandemic that we're facing to really
engage
with their expertise as we lay the
groundwork for conversations about many
other areas
including security and governance and
refugees and a number of other issues.
So, welcome, thank you for being here, Dr
Soucat, and it's just wonderful. Thank you
for taking your time to be with us today.
Thank you, thank you. Very nice to be with you.
You bet. So as we start, maybe we can
go back to the time before the pandemic,
if we can remember the time before the
pandemic,
and really if you could help us
understand what were the primary
challenges the world
faced prior to COVID-19? What I'm trying
to do is get a picture of
how prepared was the world, what was the
world already dealing with from a health
perspective
before this pandemic came into the scene?
That's a very very good question, thank
you for that.
Actually the World Health
Organization and
some partners published a report
in September 2019
that was presented at the U.N. General
Assembly, the high-level meeting on UHC,
and that was the basis for the political
declaration on universal health coverage.
And that report pretty much summarizes
the challenges that the world is facing.
I mean in a way over the past decades the world
had never enjoyed such good health. So we were
really seeing. After the 20th century sort of created
a great divide and a great escape
between the developed world and the
developing world in which
the developed world enjoyed good health,
slow child mortality, low maternal
mortality,
decrease in infectious disease,
there was really the hope at the
onset of the 21st century that we would
have a great convergence.
And the Lancet Commission on Investing in Health in 2013, which
I was part of, really called for reaching
that convergence, saying it is possible
for low-income and
low-middle-income countries to join the
curve
that high-income and upper-middle-income
countries had already
created of long, healthy lives.
Right? Is everybody living over over 65?
Child mortality becoming really
close to anecdotal.
And that we could really see that
between last year
2019 or between the first year of
the SDGS 2015
and the horizon of SDGS of the
Sustainable Development Boards in 2030
that we could actually accelerate
progress
and reach that ambition of universal
health coverage by bridging the divide
between the rich world and the poor
world.
And reaching the the divide within
countries of inequality
because we realize that, increasingly,
those who had not
access to health services and enjoy
and were
suffering from poor health outcomes
were the poor in the middle income
countries. Not only people living in poor
countries, but really an intra-country
divide.
Does the importance of universal health
coverage because universal health
coverage is a social
contract that calls for solidarity
and particularly subsidy between
rich and poor, I mean from rich to poor,
and subsidies from healthy to
sick. So there was a lot of hope.
In this report, we actually said that
we were on a very good trajectory. Although we
could already see
that the progress was slowing down. And
we could see that the progress
in access to health services, but also
in health indicators
was slowing down between
2010 and 2015 the rate of progress was lower than between 2000 and 2010.
So we could already see that the
trajectory was
not as good as we could have hoped
and that we may, that we had to invest
in efforts to accelerate progress and
that's why we called for
every country to invest one percent
of GDP
additional to what they were doing until
now
into premier healthcare
as a way to to reach the universal
health coverage
and the health SDGS. So that's why we
were very optimistic. Good trajectory.
A very good understanding of where the
challenges were.
The challenges were equity. The
challenges were
the political economy of countries that
had to
develop their own model
that delivered universal health coverage.
So their model of
financing, their model of service
delivery. And a call there for really
investing in those preventive
promotive services 
in those common goods and those
close to people
services and try to correct
what had started to become a race
towards technology
and high cost technology, high cost
hospital technology
that cost a lot to countries but doesn't
necessarily buy
a lot of health outcomes. So we were in
that really
reasonably optimistic mood
and thinking that by addressing those
fundamental issues of
of of equity and and social contract
and we could continue
enjoying progress globally and we
could
really get to this convergence in
which the poor would join
the level of health of the rich.
That's an excellent overview of where we are and I do want
to come back to that question of equity
in just a bit,
but let's fast forward to the beginning
of the pandemic if you could speak a
little bit to what the the source of the
pandemic was but then
also how you would assess the response
and the initial phase of the pandemic.
We've seen successes and challenges in
the response
within countries and then differentiated
between countries
what would you attribute, what
factors would you attribute
that successful or less than
successful
response that we see whether it's the
health infrastructure or communication
or linkage between the health
organizations
if you could just give us a picture
of those, how the pandemic started
and how you would assess the
response.
So it's again very very important
question in
and that again we actually
published
a special series in health systems
and reform on financing common goods
at the end of 2019 
a little bit after the high-level
meeting on universal health coverage,
and together with the kind of reasonably
optimistic message that we delivered at
the U.N. general assembly,
that report was actually bringing a
whole
element of caution about this optimism
by saying
that we had as global health
experts or generally as a global
community, we had some black we have some
black spots
and that they were looming
threats that were bringing
some major risk
to the achievement of this convergence
and beyond. That is not only
it would threaten the objective of
universal health coverage and
better health for all could actually
get us to revert 
back on our progress.
And this is where we we really
identified
that basically the world
being increasingly globalized and
what we see as globalization is
globalization of markets
with China joining market economy with
Russia joining Russia and the ex-USSR
countries joining the group of
countries who
 pursue market-based policies
with open trade and
and a lot of trade agreements being
developed over the past decades,
basically what globalization is 
globalization of markets. Right? Is the
world is interconnected? The world has become one,
but at the same time while markets have
been
increasingly globalized and this
pandemic shows it very well. Because I
would say, when you say, what are the the sources of
this pandemic well one of them is
globalization. Is the fact that
people and goods move around in the
world in a way that they've never been
before. The world is is more interconnected than ever
and that's certainly at the root,
right, at the root of this is the fact
that there is no place on earth today that
is isolated in a way that it is not
concerned by a
pandemic. And 100 years ago that was not
the case. There were regions that were
isolated and would not have been reached
by
something like that because they had
very little contact with the outside.
So that is really a
first element. The second one is
the fact that we are many.
Right? This is, we are now more than
seven billion people
and we are heading towards being nine
billion and
yes that's many people and it's more
than the planet has ever
hosted and we know that
that epidemics flourish in crowds,
right, particularly
particularly respiratory respiratory
disease.
And this crowd, this
human crowd is also pushing we know the
boundaries of nature.
And epidemics always come from the
from the animal world. And
we managing that interaction between
nature and
humans is more important than ever
because we are so many.
Right? So that's really the second thing.
And this is what we were saying in this
in this special series on common
goods for health that
these looming threats were coming
from the fact that the world has changed
tremendously
and there are threats that come from
the fact that we have now a global society.
That this global society follows market forces.
That it is exhausting natural resources. So there's all,
the entire link with the 
environmental health agenda
including climate change, but not
limited to it, right. It's also
biodiversity, ocean acidification.
I mean there are many
different areas that are
incredible threats to
humans to our species.
So it's really the sort of threat of
the Anthropocene, right, is the second reason. Aand I
would say the third one
is  while markets
are become global, while we have,
we are exerting tremendous
amount of pressure on nature and
and creating our own risks,
we also have not developed
what countries had developed at nation
state level, which is collective action through a
government and a state.
So while markets have globalized,
governments have not.
And the closest we have to a global
government, which is the U.N.,
was established just after World War II
and is no longer really
fitting the world as we know it. Even, you
know, if you think about the security
council,
is has has a group of countries, which
does not really represent the forces of
today or the demographics of today.
And the U.N. is questioned because
there is a questioning of the international
order and their geopolitical factors there
about different locus of power globally.
But at the end, the
the consequence of all of that
is that we don't really have a global
government in the sense we don't have a
global treasury,
we don't have a pot of money that is
actually there to address
the global public goods, the global
common goods. I mean global public goods
is just those pure goods
that cannot be 
excluded that nobody can be excluded
from and cannot be divided.
But the common goods are those goods in
which you have large market failures
such as vaccine, for example,
and all the research and development. So
we see that those
those common goods are created
in a bit of a haphazard way.
And there is no so.
Whatever has worked over the
past two centuries in terms of building
modern states and it's been
pretty amazing like what modern states
have managed to
to do including in terms of public
health and hygiene
and social protection and social
contracts that benefit
the entire population with decreasing
inequities, we don't have that at
global level.
Ao we sort of missing an instrument
to respond to global problems.
And pandemics are a global problem, but
our mechanism for global action
are not fit for purpose. We see it
generally that the U.N. would need to be
strengthened or reformed depending on
whose views it is.
I would say, personally, I, of course, I
have views, but generally, I say, whatever the views, it's
just, there is a logic that we need a
global government because we have global
problems.
And if we don't have that, it's going
to be very, very difficult to address
those global problems whether they are
pandemics
or other environmental threats.
That's excellent. That was an excellent
pot-de-force of
so many different issues and really
draws in
how none of these issues whether it's
health or the environment
or governance or security can sit alone
in a very globalized and interconnected
world.
Can you paint a picture for us of what
that relationship looks like between
actors at the global level, so the World
Health Organization or other parts of
the U.N. and national and local governments as
scientists are working in a lot of different
corners of the world, governments are
working
to manage each of their respective
jurisdiction.
Organizations like the World Health
Organization have a global mandate.
What does that relationship look like?
What does it look like officially and
what do we commit to? But also what does
it look like in practice as we as we seek to
think about some of these questions that
you put on the table of
how do we respond as a global community
to global problems in a world
that is structured as nation states. So
what is that relationship between the
WHO  and nation states and
national and local governments and the
scientific community look like?
Yeah, I mean it's a very interesting
question. At the face of it, the way
the WHO is structured,
it's not easy to find a better way, right.
It's structured as one country one
vote. It's structured as the U.N.
All the countries have a voice.
And so what is the relationship between
states in WHO? I mean the states own the WHO.
The WHO has all its members.
And what is often referred as the WHO is
the WHO secretariat,
which is a group of experts with who is
serving these countries.
So in this respect, they are probably, the
relationship
is a relationship of ownership and
accountability.
And you could say and of course as
you know that I am a government
expert that the fundamental flaw is the world
order because the very way the whole show
is structured is a way in which they need to be
collective action of 190 something states,
right, so these states need to work
together.
And that's the difficulty, right. It's the difficulty.
That's the difficulty, generally. The
difficulty of collective action on
global common goods is the fact that we need
more than seven billion people
agreeing. That's not easy we already know
that. You know having an agreement in a family
about where to go on vacation
is not that easy. So,
yeah. Pandemics know that very well.
So getting a consensus of billions of
people
on what we need to do globally is what
we are facing as a
species about how we address
the issue of environmental degradation
and on all the other common
issues, common problems that we have in
WHO. We sort of, the way that which we set up, we
just simplify a bit this problem
in saying, "Okay, each country has its own
conversation with its people.
They get some kind of consensus there
that they convey by,
you know, choosing their government and
their government brings a voice to the
WHO."
So we've reduced the problem of
collective action from a few billion
to about 200  stakeholders. The question now with the
doubling of the relation with the states
is how these states build alliances.
And also, of course, there are weaknesses of the one country
one vote approach in the way that it is
not,
it is not weighted by population.
So a very small island state has
theoretically the same power
as a country that has more than a
billion people, which is very different from the
structure of governance of
development banks, for example. You know I
worked for the World Bank for many years in which
the Board, the structure is linked to the
share.
So it's about funding.
It's about economic power. So the
decision is taken
in a way faster in the sense that
you have less actors and it's
very much related to the financing capacity.
So, WHO, it's a bit more
complicated.
It is the U.N. framework as it was
designed of one country one vote.
We know that the countries, some of them
have been,
the borders have been designed
after colonization on the basis that
sometimes this question. So all of these
are other questions, right. They're not
directly linked to WHO, but they
influence
the way WHO works. So
at the end is WHO requires collaboration
and it requires
alliances. So when there are big
geopolitical tensions like they are today. Like
automatically
a multilateral organization
feels the convulsions of these tensions, right. So this
is where the WHO is trying
to really continue to do a
a good job at the secretariat and
actually, you know,
synthesizing the science, bringing the
the guidance and the normative work,
but at the same time our governance is a
political governance
and there are disagreements between
countries and member states and
we need to work out those differences
and develop collective action.
So there are many suggestions on how
to improve the way the UN works,
including the WHO,
but I would say that my view is
whatever we decide as a model we need a
WHO because WHO
is the ministry of health of the world
and the world has become globalized in such a way that we
need a ministry of health of the world.
Right? We need an agency
that provides the guidance on policy on
regulation,
on science, and that is a kind of a
neutral space and neutrality is ensured
by the fact that all countries are represented.
I'm just taking the principles there without any particular view on how we should go about it.
No I think you've brought up a number of really
crucial points and let me dig down in
two of those
particularly. What I'm hearing you
mentioned, you know, when there is tension
and I can imagine with 190 some
countries and seven billion people there
are agreements, the locus of action though
remains with the state. I'm assuming which then
puts WHO
in a challenging position when it's
tremendous researchers or scientists and
policy
shapers believe
a certain action should be taken and yet
states are the locus of action. I assume
that
largely then falls to the state
as the most
direct actor then
in implementing that.
Yes because this is the way the world has
organized itself
post World War II, right. And this is the
way the world has organized itself. This is
the way the the world has organized the
U.N.
is by putting the
the states at the center of the
decision-making and as being sovereign.
I mean there are a lot
proposals out there and
both out there and in drawers about how
to reform
the system, but so far that equation remains at the heart of any proposal,
right. That it is about
sovereign states and
for them to find ways to work together. I think what COVID 19 shows it's
an amazing epidemic in a way
that acts as such a revealer
of weaknesses of societies, of weaknesses
of our international system, of
weaknesses of health systems at country
level.
Exposing inequities in societies,
exposing vulnerabilities like high level
of non-communicable disease.
It's been said before, right, that high
levels of non-communable disease were
vulnerability, but now it's obvious.
Yes, whoever was making the case for
preventing non-communicable disease
as a way to avoid the economic
shock. I mean now you have the
evidence, right.
There's so much evidence that is coming
out of
issues and that were identified before but for which
maybe there was still some doubt
about how they were playing and and this
pandemic highlights those underlying
issues. It's fascinating to see that some
countries who have
incredible technical capacity, incredibly
strong institutions
considered before the pandemic as the best
universities, the best researchers,
the best public health institutions and
at the end
because there are societal weaknesses and societal,
how to say, yes, vulnerabilities
and social contracts that are not fully
established.
You see that it's fascinating how the
response is much less
effective that one may have thought
right.
And in many ways this pandemic
has basically
given life to or shines light on the
existing problems and have really
exacerbated all of the existing fissures
that we've seen
within societies and within the global
system.
Isn't it fascinating, I mean,
it's like every country you see actually.
The pandemic exposes a different problem.
Correct and obviously we have
the health issue to deal with, but there
are so many other
issues which are obviously light and
that's in
large part why we're having a
conversation over the course of a
semester to say
what are those those weaknesses or those
challenges in the system that have to be
addressed so that we can ensure that
we're prepared not just for the next
pandemic, but we're prepared for whatever
shock the system will, the international
system, will have in the future
as well. Maybe if you could speak a bit
to
where you have seen successful
responses
to the pandemic and to what do you attribute that
success. We've seen a number of countries
significantly get the problem under
control
and are beginning to open up their
economies and are beginning to return
let's say somewhat normal or maybe a new
normal.
But they no longer have a significant
spread. They no longer have a significant
death rate
and their economies are returning. To
what do you contribute the difference in
success or maybe just point to the
countries that
we have seen significant success.
Well, I'll start with a preamble and then
I'll try to give a few a few hints to
get to your question. But the
preamble is, I'm not sure the right way
to look at things is always to look for
success.
Because I think it's actually probably
one thing that has been a big
weakness of global health,
of the global health conversations over
the past 20 years
is sort of this sort of quest for
ever success.
And sometimes the construction of success,
right, in the construction of the
story of success. When it comes to something like
health and building a stable society, success is
not that easy to define.
Right. And every time, for example, when it
comes to universal health coverage,
every time. And it has happened again and
again because you always have
somebody who comes at some point
politicians or policy makers
or, "which country is a success? I want to
learn from."
Or can we identify the factors of
success. So we
dug into it and then it is so
complicated because success happened
some years and not other years. Very
difficult to find
what is it that actually drove that
success or not.
Also not so easy to define success
and because
if one thing that this pandemic has
shown
is the weakness of our global system
to assess the quality and veracity of
statistics.
So it's been really and we see it
now the conversation is in the general
public. It's
happening about questioning what states produce as
statistics.
The fact that it's even discussed in the
U.S. is absolutely fascinating with the
discussion that happened in
in Florida and in some other states. But
we should never forget that
the word statistics has the same latin
root as the word state.
So the control of the storyline, the
control of
numbers is at the heart of what states
do.
And it's only when there is full freedom
of information
and democratic and transparent control
that you can more or less say that
whatever is
available in terms of of statistics and
data
reflects a reality.
And even then we are hostage to the
weaknesses of science. The weakness of
data system
in this particular pandemic is we don't
we don't test that much, so
I mean until recently. So all of this to
say that I think at this point
August 2020 is very difficult to say
whether there is success or not.
It's too early to tell. It's too early to
tell. Some countries have done well at
the beginning and then
less well after.
Some countries the jury's still out
there.
The data story is not clear at all
and for one thing the central problem is
the replacement mortality.
As long as we don't have
the full mortality profile at the end of
2020 and knowing whether COVID accelerated
some because it affects more people
who are vulnerable
like elderly or people with underlying
conditions,
there is some element of replacement
mortality that might be there.
And so as long as we
we have not the full story,
it will be probably very difficult to
tell.
So even the sort of basic
information, right, is whether
the number of cases,
mortality.
I think it's too early to tell.
And then the next point which would be
success in the sense that
some policies made a difference. It's
very, very early to tell because then
it's really difficult to disentangle
the policy impact from
the population structure, the underlying determinants such
as NCDs the
inequalities and access to
services. So all of this
vis-a-vis the response, the policy
response.
How you weighed all of this. I would
say that right now it's very, very early.
Now, clearly, I would say
if successes are difficult to identify
the fact that some countries really
are not doing very well is pretty
striking. The fact that some
high-income countries
who we thought would be, I mean 
with the international health regulation
they had a very high score,
the fact that they are not doing
particularly well is really a concern,
I would say, right, yeah, it's really a
concern. I would see it more that way.
That you would have expected that
high-income countries with a lot of scientists, a lot of
institutions with a very good access to
health care would have done better.
Now I think there are some
countries, it looks like
East Asian countries, you know, South
Korea, Vietnam, might do better. But
we also don't know about
biological factors, such as cross
immunity.
So we don't know whether people would
have some kind of immunity that would come
from previous exposure
to similar type of virus. This is unknown,
right, so again it's very difficult to
say.
But, I would tend to
think, yes, there are some countries that
are doing better.
I'm not saying that it's not the case,
but we have to be very, very,
very careful in not hyping them at this
point. That's what I'm saying.
And being really rigorous
in the analysis.
That's very, very helpful. Let me come
back to an earlier point you made about
the difference of the impact of the
pandemic on different populations. And
you said:
we see a difference both between higher
income and lower income countries but
also within societies
of differences between different
populations whether that's based on
wealth
or other disparities or maybe belonging
to one ethnic group or a different or
gender or
other issues. Can you just speak to this
issue of how we've seen a disparity
of the impact of the pandemic and
the
provision of health services, the
disparity that's existed there as well.
Well, clearly, I mean this
pandemic has just been such a
an acid test and a revealer right of
previous, you know, clay feet of some systems or
achilles heels or.
But one thing that is really striking
is the fact that utilization of
essential services
dropped almost everywhere.
So following the pandemic, we've seen,
most of the countries have seen a
decline in immunization services,
a decline in utilization of HIV
and TB services, a
decline in services of material and
child health.
So the fact that
that's also talks a little bit to the
previous question, you know, how do you
measure success.
If yes you responded well to COVID
but next to that the number of deaths
from other causes has risen,
which is what happened during the
ebola crisis, for example, the ebola
epidemic.
Because people stopped going to the
health centers, so in fact child and maternal mortality
increased probably.
So that's really,
the pandemic has revealed many things
about the way we deliver services so
in countries like the U.S. it showed that
some people don't have access to
services
or have insurance coverage that
don't protect them and they need to pay
extraordinary amounts.
Or also
what we see is that
basically there is a disconnect
between the need that is increasing
during a pandemic and the fact that
people who lose their job because of the
economic crisis,
lose their coverage. So, for
us, for me, as a health financing expert,
the pandemic has been again an
incredible natural experiment that we
should not
fund health services losing
wage-based contributions because the
moment you lose your job
then you lose access to services. So that
we need to shift
towards some contributions that are not
linked to your working status. So
something that is linked to some kind of
taxation or some kind of contribution
that is delinked
from your job status. So I
think, for example, is these three
messages ,these three
lessons learned in the U.S.
The fact that people are not covered,
the fact that coverage
doesn't protect them from crazy prices
that they have to pay,
although they are
affected by a pandemic,
and the third one is the fact that
health insurance is linked to labor.
But in other countries,
for example in Europe,
what we discovered in northern Italy or
even France
is that years of focus on efficiency
in which we try to
control the density of health workers,
trying to limit the number of health
workers and trying to limit
the bed capacity, there was
some logic to it but we went
too far.
Right, that we went too far and the
systems have been so defunded
that the moment the pandemic came they
were not enough beds,
not enough house workers, not enough
respirators.
And when it happens to a country like
France or Italy that is incredible
because they were able to address that
in a couple of months.
So it should not have happened, right, so
it's really about
re-thinking the health system it's like
that.
We probably went much too far
in thinking about health system as
dealing with the disease of yesterday
and not thinking at all that we need to
have a system that is ready to handle
crisis
and ready to handle the problems of
tomorrow.
And that we need to have
a mechanism to address surges
in demand.
Excellent. So much to draw from there. We are almost at
time and I want to just ask one
final question. Although there are so many
more that I have --
looking forward to a time when
hopefully we have this pandemic
behind us or relatively under control --
what are the issues that you are
seeing as the primary issues you just
articulated a number of key concerns
related to national health care but as
you're thinking
broadly from 30,000 feet,
what are the changes that we need to be
thinking about? Whether that's on
the level of our international
infrastructure, our global governance or
whether that is on a national level
or whether that's on integration issues
of health with other issues.
Where do you think the
international community needs to focus
its efforts
to ensure that we're better prepared 
to address this
and other issues going forward?
Well, on this I'm actually 
really clear
and we've been very clear in WHO, in our
partnership, the UHC 2030 partnership,
with all the other partners working on
health system.
The the first thing we need to do,
what we call the step zero of universal
health coverage, is to invest in common
goods.
This was our black spot after
20 years of global health effort. We
focused on one disease at a time,
you know, malaria, HIV, TB, 
polio. Now we were talking about NCDs,
but in the meantime we were forgetting
to invest
in the fundamentals. In the fundamental, essential,
public health functions. We're forgetting
to involve, to invest in public health
institutes, in environmental health
programs,
in prevention, in animal health,
in
environmental
health. We invest in laboratories,
installation system,
in policy coordination.
So and it's going back to that special
series I was mentioning of health
systems.
You have five categories of common goods
and we need to make sure that every
country
invest in that as the first thing they
invest in health. Because this cannot be
delivered by the market
because these are public goods or these
are goods that suffer from market
failures. So only collective action can
deliver on that.
Only governments can deliver on that so
we are really working very closely
with the World Bank and others to
really
discuss with treasuries, with
ministries of finance, so that
budgets include enough
funding for these common goods.
So that's for the national level. For the
nation state level. And then for the
the global level then ,we need
some mechanism. We need some mechanism to fund these
common goods because we don't have
a global treasury. So we need to find
ways.
And it doesn't matter where it sits, but
we need
a steady stream of revenue.
We need somewhere, a way to manage these funds and
we need some guidance
how to use these plans and we need to
make global investments. We need
R&D in future vaccine. We need global
surveillance and of different types
of threats.
So we need,
we need stocks, strategic stockpiles.
There are series of global common goods
and all of this is identified. It's not a
technical problem.
We know what we need to do, but somehow
because it requires collective action,
because nobody is going to pay user fees
for that,
right, because there is no market for
these goods because they are collective
so there is a free rider problem.
So that's that's really what should
be our message. And really
I think it should be hammered over
the next few weeks and months.
It should really be hammered that
we need to invest in this commitment
before anything else. Because this is
really,
this is the foundation of health
systems in the universal health coverage.
There is a lot of work that remains 
and I'm
deeply thankful for the great work that
you are doing
and others at the World Health
Organization.
And all of your words will certainly be impactful on our students who will be
carrying forward many of the challenges
that you've said and thinking about
how do we address those questions of
of
addressing the common good and ensuring
that we're all investing in that.
Dr. Soucat, I want to thank you for
taking the time today it was
extraordinarily
enlightening and certainly edifying for
our students and our community as a
whole.
I wish you well with your good work and
I certainly hope that we're in touch
in the future going forward as you
continue to do your good work
on global health. Thanks for taking the
time today.
Thank you very much and thanks to
Georgetown University. I'm a big fan
excellent. Thank you very much.
Thanks, bye bye.
Two fascinating conversations with
leading experts
dealing daily with the pandemic and its
impact
around the world. As we begin to wrestle
with
the information that they shared and
their analysis of the situation, we have
a number of questions we ask ourselves.
How did we get here? How did individual
countries, but the global system
get to the point of having a pandemic
that has shut down
a significant part of the international
system whether it is our interconnected
economic system, travel, trade?
What are the problems that existed
before the pandemic arrived that have
now been exacerbated
by the pandemic? And what are the new
problems which have been created
and will have long lasting effect
because of the
pandemic's impact on the world? And then,
finally, going forward
what have we learned and what are we
learning from the
pandemic, the responses and the impact
of the pandemic throughout the world so
that we are prepared
in the future for another pandemic
and prepare to deal with the
long-lasting impact that the
pandemic undoubtedly will have on
individual countries, individual lives
and the global system?
