'We're Only Safe if We're All Safe': The Global COVID Vaccination Effort

; Abraham Verghese, MD; Seth Berkley, MD


January 20, 2021

This transcript has been edited for clarity.

Abraham Verghese, MD: Hi, everyone. It's a pleasure to welcome you to another episode of Medicine and the Machine with my co-host, Eric Topol. We are delighted to have as our guest Dr Seth Berkley, CEO of Gavi, The Vaccine Alliance. I met Seth a couple of years ago, but I heard him speak at a TED conference well before that, and I've been blown away by the breadth of the impact he's made on the world. He's a physician and an infectious disease epidemiologist.

He joined Gavi as its CEO in 2011. During its existence, Gavi has vaccinated more than 820 million children in 73 of the world's poorest countries. In 2015, in the second replenishment to the Gavi fund, they raised $7.5 billion in donor commitments.

Back in 1996, Dr Berkley founded the International AIDS Vaccine Initiative, the first vaccine product development partnership in the public/private sector. Not surprisingly, Dr Berkley is also co-leading the vaccines pillar of the Access to COVID-19 Tools (ACT) Accelerator, working to distribute the COVID vaccine.

He has been involved in global health for many years, and has been on the cover of Newsweek magazine and recognized by TIME magazine as among one of the world's most influential people. He has written extensively and traveled extensively throughout the world. Seth, it's a pleasure to have you join us here today.

Seth Berkley, MD: Thanks so much. Great to see you.

Verghese: You've had such an incredible career. I know you attended medical school at Brown University and went on to Harvard for your residency training. Did you chart a course similar to the one I just described? Or was much of this happenstance? Tell us about the trajectory of your career.

Berkley: I started out being passionate, as you are, about medicine and taking care of patients. But I also wanted to make as much of an impact as I could. I was drawn to infectious diseases because people can get quite sick and die from them, but if you can turn them around, you can often return people to their normal states of being.

Once I started working on infectious diseases, I saw that the biggest burden was in developing countries. As I began to work on that, I became interested in the public health perspective because that was how I could have the maximum influence. Vaccines became a point of fascination for me because vaccines and sanitation are probably the tools that have done more than anything else to improve the health of people around the world. So I certainly didn't plan it this way, but there has been some logic to how it's progressed.

Verghese: Tell us a bit about Gavi's origins and what it has managed to accomplish in all these years.

Berkley: In the 1970s, less than 5% of children in the developing world were vaccinated at all with the small number of vaccines we had for common diseases. That was considered a tragedy. There was an effort to get vaccines out, and that raised that percentage to close to 80% of children vaccinated. That was considered a success, but afterwards, people stepped away from it. In the meantime, new and powerful vaccines were being developed with the best of science, but they weren't getting out to the places that needed them the most, to the developing world.

The premise for Gavi was to create a public/private partnership that would work to take these new technologies from high-cost, low-volume production to high-volume, low-cost production. On that, we've been quite successful. We've introduced 496 new vaccines in the poorest countries of the world, and with that have driven down the price. For example, the World Health Organization (WHO)-recommended vaccines now cost, if you had the equivalent in the US, about $1300. We procure them for $27. We continue to try to drive that cost down so that we can get maximum access to these products in developing countries.

Verghese: That is amazing. My co-host, Eric Topol, is a cardiologist, but somehow he knows more about vaccines than most infectious disease people I've known. We both want to ask you: What is the strategy for bringing the COVID vaccine, or its many iterations, to the global community?

Berkley: First, let's go back in time and explain the last effort, which was quite interesting. We had an Ebola outbreak in 2014, in an isolated area in a confluence between three different countries, in a place that didn't really have a health system. As a result, it was misdiagnosed for months on end. Eventually it spread widely into urban centers and infected more than 10,000 people. Previous outbreaks had infected a couple of hundred people. It was quite a serious outbreak. There were early attempts at creating Ebola vaccines because people thought it might become a bioterrorism agent. But the challenge was, how do you create a market for those vaccines?

At that point, we decided to put $300 million on the table. We said we would purchase vaccines if a manufacturer would create vaccines that would work. Long story short, eventually this led to the Merck product that is now in a stockpile and has been used multiple times since to deal with epidemics.

I use that example because the problem there was having no market for vaccines. With COVID, of course, we had no idea whether we could make a vaccine and how long it would take, but the science has been breathtaking. It became quite clear early on that the problem wasn't going to be a lack of a marketplace; the problem was going to be that everybody wanted it. And therefore, what would likely happen was that wealthy countries would buy up all the doses of vaccine and there would be none for the rest of the world.

That's not a good thing — not only from a humanitarian point of view, but more important, when you have a global pandemic, we're only safe if we're all safe. If the virus is still circulating uncontrollably in different parts of the world, you can't go back to normal. And of course, you could end up with problems with new strains appearing, as we've begun to see now.

This effort was about how to create a global distribution of vaccine, the exact opposite problem as with Ebola. So, we created the COVAX Facility, a mechanism for procuring and distributing the COVID vaccine equitably, throughout the world.

We divided the effort into two parts. In one, we went to the familiar places, the poorest countries, the countries where we normally work. But this time we expanded the number of countries from 73 to 92 and included a number of small island economies that would have problems, and a few slightly richer countries. Those were countries that would be our traditional customers.

But we also said that if self-financing countries were interested in joining COVAX, we could work together. We had no idea whether there'd be interest, but in the end, 98 self-financing countries joined. So, 190 countries came together within a short period of time to work on trying to make sure that there will be equitable access of vaccines.

Eric J. Topol, MD: Seth, I don't know of anyone who's more grounded in the planetary landscape of vaccines than you. In the COVAX effort, the United States said it would not participate, which I find very upsetting and objectionable. What have been your thoughts about that?

Berkley: The United States has been an extraordinary supporter of Gavi the entire time. Even the current administration was very generous and gave us an increase for this most recent replenishment. Abraham talked about the previous one, but more recently, we raised about $1.4 billion more than we asked for to expand the work that we're doing. But in the end, the United States decided it would create its own program and moved forward. Of course, we've been in contact with them because of the important science work they're doing. But we were happy to learn that, as part of the last supplemental bill, the US government provided $4 billion for COVAX.

The United States is the single largest supporter of the effort to provide vaccines for developing countries. It took the United States a bit longer perhaps than some of the others to engage, but now they are substantially engaged. And we look forward to continuing to work together.

Topol: I think part of the problem is the amount of vaccine nationalism, in which many countries are only worried about their own population and supply. Obviously, this is a world challenge; if we don't get the majority of the population of the planet vaccinated, we're not going to get containment. Can you comment about nationalism vs "worldism"?

Berkley: That is a very good point. Remember, this started as a point source outbreak. Within a few months, it was in 180 countries. So we're dealing with something that is that infectious and moves from country to country. But we've also learned that when a country was able to dampen down the case numbers and then relaxed containment measures, often it would be people traveling out and getting infected or infected people coming in who started another outbreak. The idea that you have one isolated community that is going to be protected and safe, and the rest of the world is not, is not the reality of the infectious disease world.

To your point, for humanitarian reasons, we should try to support countries around the world. But in this case, it's also in our own self-interest. If you want to resume travel, tourism, commerce, and the ability to engage with the world, and if you don't want new strains to develop, then you really want to make sure you dampen down the disease everywhere in the world. That's the biggest argument for having a global solution for what is clearly a global problem.

Finding the Right Plan for Each Country

Verghese: You mentioned COVAX. Can you get more granular as to exactly how you distribute the vaccine in these countries? How do you identify who gets vaccinated? We can't seem to do it state by state within the United States, so I marvel that you're going to do this in 190 countries. How do you do that? Do you have a one-size-fits-all approach?

Berkley: In essence, you put up guidelines that are uniformly clear. From our perspective, healthcare workers are the first priority because they're taking care of the sick.

If the healthcare workers get sick, they have to quarantine and create a lot of absenteeism. If they die, you lose talented workers and the health system gets overwhelmed quickly. So the first goal for COVAX is to let countries vaccinate their healthcare workers. Those numbers will vary. Some wealthy countries may have a higher percentage of the population in healthcare. Some poorer countries may have a lower percentage. We can be liberal with how we define healthcare workers, but that would be our recommended first priority.

Then we would go to the high-risk groups, and those will vary. Obviously, the elderly are high-risk, but also those with comorbidities. Other countries may have a much younger demography but have different refugee groups that are at high-risk. If you look at the United States, risk groups may be those working in nursing homes, people in prisons, or people in meatpacking plants. But in a developing country, risk groups may be people in an urban slum, or people in a refugee camp, or a displaced set of persons. So I believe that countries will have to adapt and adjust their strategies.

WHO has put out guidelines for what they think are the priorities for vaccinating in a stepwise fashion. Then individual countries will ultimately make the decisions internally. COVAX doesn't vaccinate anyone; we support countries to do the vaccinations. In this case, a country applies to COVAX and says, "We want doses and here's what we think we're going to do; here's our state of readiness; here's what our cold chain is like; and here's what the supply chain is like."

If that is all acceptable — it's looked at by an independent review committee — then we provide the vaccines. If it turns out that something isn't right or the review committee says, "We don't think you can do that," we don't reject them. Rather, we say, " How can we help you strengthen your cold chain, strengthen your supply chain, do more training, etc., so you can get these doses out as soon as possible?"

Comparing Efficacy Between Vaccines

Topol: You used the word "breathtaking." I couldn't agree more as to the rapid validation of extraordinarily high-efficacy vaccines, namely the two mRNA vaccines. That sets a very high bar for the subsequent vaccine reports, of course, some that we're still waiting for, some that have come along without much transparency, some with murky efficacy results that range from 62% to 90%. How do you sort this out in terms of efficacy? Do you think there's something special about this mRNA platform that's making it distinct?

Berkley: First of all, I'm a great fan of novel technologies. Certainly, if you look at the mRNA platforms, they've been very exciting for a while. I made a special trip to visit Moderna before COVID was even on the horizon, just to see the technology and the possibility of using it for quick responses to outbreaks. And when I say it's breathtaking, if you look at previous vaccines, 4 years was the quickest vaccine we had ever made. The average vaccine takes 10-15 years of development. Here, within 42 days, they went from sequence to the first vaccine in a vial, 63 days to the first injection in humans, and then about 330 days to a result from a serious-sized efficacy trial.

The compression of development has been extraordinary. The mRNA vaccines are exciting in terms of the way they work and how they stimulate the immune system. But there are many other technologies that perhaps take a little longer to get started. I suspect that we will see efficacy results that are similar to those levels from other technologies. We don't yet know the correlates of protection, but given the way these vaccines are constructed, I think we can expect to see them.

Of course, this won't be true until we actually see clear data. Then you have to ask whether there will be products that are more attractive for use in different settings. For example, the Johnson & Johnson vaccine is being tested as a single-dose immunization. That would make a real difference in terms of being able to use it in a campaign mode vs having a follow-up period.

Other vaccines also are easier to use from a temperature stability point of view. Others are incredibly inexpensive. So we'll have to balance efficacy as well as ease of use and the economics in terms of global distribution.

Finally, we don't know how long these vaccines will be effective. We don't know if this is going to be about having one large campaign to cover a large enough percentage of people, and that's it, or if we will have to go back and reboost people in some time frame, or even if we may have to vaccinate on a regular basis. And now that we're seeing the amount of variability that's occurring with the virus, will we need different vaccines? Will we have to adjust the vaccines for new variants that appear, as we do with flu? At the current time, it doesn't look like that. But these are all scientific questions. What's extraordinary is that we're rolling out vaccines around the world before we even know, for example, how long the shelf life is for the vaccine.

So today, we can't put on a "this vaccine expires at this date" label, because these vaccines haven't been out long enough to know how long they last. Instead, the labels are being stamped with "This vaccine was produced on this date." It's almost like saying, "And please check back regularly to learn how long it is stable in the bottle as we do those tests." A lot of interesting new things are being done this time.

Maximizing Vaccines and Opportunities

Verghese: What is COVAX doing in terms of which vaccines you pick? Are you just taking the ones you're able to get, or are you selecting particular ones for particular countries?

Berkley: The idea was to create a portfolio. That was particularly important at the beginning, because we had no idea whether any of these approaches were going to work. Luckily, it seems that different approaches are working. We've seen the mRNA vaccines work very well, and now the vectored platforms. Eric talked about some of the differences; today I think we have a pretty good understanding about why there are some differences. The one group we haven't seen yet are the adjuvanted protein-based vaccines. Those in the preclinical models and in the immune studies look promising.

Finally, we have a number of the inactivated products that recently have reported some results.

If it turns out that all different types of vaccines work, then we could take a mix of those based upon the quantity and the ability to produce. Remember, if you want large quantities of vaccine, even if you have one that you really like, you can't make that one everywhere; it's going to be very important to have multiple producers.

But the other thing we try to do, as we look at new candidates, is ask, "What's missing in the portfolio? What would make a difference?" For example, a single-dose vaccine would make a difference, or a vaccine that produced a much better result in the elderly, or a vaccine that would be much more stable, or stable at room temperature, or could be given orally. What you ask for each vaccine after a certain point is, "Does it add to the portfolio or not? Does it serve a certain problem?" And if it does, then we want to look into it.

Topol: People talk about the priority vaccination schedules, such as for healthcare workers and the elderly. But when phase 3 trials have been conducted, they go into hot zones, to places where there are lots of infections, so they can get a readout on efficacy quickly. Wouldn't it naturally follow to prioritize vaccines to go to the hot zones of those 190 COVAX countries, because that's where they're going to do the most immediate good, rather than giving them to the elderly and healthcare workers and so on?

Berkley: It's an interesting question, Eric. You have to look at it from the point of view of experience. If you go back to the 2009 swine flu pandemic, people said we should go into the places with the maximum number of cases. But often, those places had a case curve that was up near the peak of the curve and was starting to come down. The effects of the vaccines in those communities turn out to not be as helpful, whereas if those vaccines can get to places before the curve takes off, they can have maximum efficacy.

The question at the beginning was, will this virus cause outbreaks in only a few places or is it only going to occur through one set of outbreaks? But what we've seen are waves of outbreaks. The reason healthcare workers are important is that if a wave of cases comes to a country, a protected healthcare workforce can then deal with some of the highest-risk groups — the ones who would fill those hospitals and overwhelm the health systems. So you would at least do everything you can to protect that health system.

This is something we have to plan through modeling, to try to understand over time how this is going to work. If we see antibody levels and cell-mediated immunity coming down, then we're going to have to think about whether we will need booster doses, etc. But it's too early to have any of that information. Right now, we're out trying to vaccinate acutely to try to stop the pandemic, not necessarily to understand what the long-term strategy is going to be.

Global Patterns of Disease

Verghese: I suspect that you have a much better sense than most people as to how things are on the ground in many of these countries. I've been struck that the amount of devastation I expected to see with COVID in sub-Saharan Africa and many African countries doesn't appear to be what I had feared. I don't know if that's poor reporting or an actual observation that the disease is somehow less prevalent or causes less morbidity there. We had a guest on this show who speculated that, to some degree in small villages where people walk and don't travel extensively, there isn't that exponential spread. Do you have any thoughts on the prevalence in those countries?

Berkley: The honest answer is, we don't totally know because the amount of testing going on in most of those countries is well below that in most other parts of the world. That being said, in some countries we've seen severe outbreaks that have led to teaching hospitals having people piled up sick, pneumonia cases, people dying, morgues overwhelmed. But we haven't seen that in most countries.

My guess is that we're not missing a huge outbreak. Now, why might that be? Well, to one point, it may be harder to transmit. But also, people spend more time outdoors, the temperature is such that you don't have as much indoor gathering. You also have different age demographics, where half of the population is younger than 18 years of age. That may have an effect.

This is what's scary: South Africa had cases, but they weren't that severe. As you know, a new variant has now appeared there, and it seems to spread much faster, just like the variant that was seen in the United Kingdom. Right now, I'm told that their intensive care units and hospitals are becoming completely overwhelmed with these cases, and that is a real problem.

If you try to stay ahead of this and guess where it's going to go and what's going to happen, it won't always work. Initially people thought that maybe the tropics wouldn't see so many infections, but India has the second largest number of cases in the world. We've certainly seen other places that have had severe disease. So we need to say, as of today, that anywhere is potentially at risk. Of course, it may be worse in some places than others, and with the new changes occurring in infectiousness, this could change further.

Topol: I'd like to get into the variant a bit more. The B-117 variant, as you mentioned, was seen in the United Kingdom, and there is the Y501 South African variant. They both have this increase in infectiousness. Whether the magnitude is 30%, 50%, or 60% is not entirely clear, but they are quickly becoming dominant.

In Ireland, in just a few weeks, the prevalence of the UK variant went from 9% to 45% today. And now Ireland is number one in new cases per capita in the world. It's like a vertical line. So even though these two variants — or strains, if you will — are not likely to interfere with the vaccine efficacy in a substantial way, they're clearly going to be competing at the moment to become dominant strains around the world.

Can you comment about this new challenge? Just looking at the Ireland infection plot today, it's pretty scary, and we know the United Kingdom is in similar shape and other countries as well. As you're well aware, we have this variant in the United States; it's at a low frequency, but it's certainly going to be on the rise.

Berkley: The first thing to say about this is that we can't become complacent. Now, how to deal with this? Obviously, we need to continue to use the same nonpharmaceutical interventions — masks, physical distancing, handwashing, etc. — perhaps with even more strictness than we did before. But this has been a cycle of tightening, relaxing, tightening, relaxing, and if you relax with a more hypertransmissible strain, you will see increasing numbers of infections.

The worrying thing is how this plays out, for example, in school children, who may not get sick but may carry strains that are much easier to spread. The children may become foci of transmission through families and moving this through the community. These are some of the concerns that we have.

Of course, if we had adequate amounts of vaccines available everywhere, the first thing you'd want to do is vaccinate everyone you possibly could, because the quicker you bring down those who are susceptible, the faster you'll be able to stop the spread of disease.

At the moment, there isn't enough vaccine, so it's going to require people redoubling their efforts to try to practice prevention where they can, to test and trace, isolate, and all of those efforts. The reason why this is a lesson for us is that people thought we'd have a wave, and there was a whole set of discussions on herd immunity. What we're seeing here is that you do not want to leave this virus unattended and not addressed.

Anyone who says it's just like the flu... No, it isn't. We see that not only from the high death rates but also from the serious complications we're seeing afterwards. We don't fully understand those, but large percentages of people are having residual long-term side effects and morbidity, which is going to be very important in the years going forward.

One Dose or Two?

Verghese: You probably have the world's most experience with distributing vaccines in different populations. Talk about the United States. Although I know that this is not where you normally distribute your vaccines, what do you think about the strategy so far for distributing vaccine? What might you advise the Biden administration going forward?

The more we can move to having some type of aligned approach with everyone working together, the better we'll be.

Berkley: Developing countries have a lot more experience coming in and rolling out outbreak-based vaccines and campaigns. The secret to doing that includes just a few simple things. First is having a national plan, and having it as well planned out as you possibly can, with almost military precision.

Second is having acceptance of the vaccine, having people comfortable and aware that this is important, that this is something they should do. That requires community engagement — religious leaders, politicians, and others to be on message to help people do that. Third is very careful follow-up. If any adverse events or problems or miscommunications occur, you need to be there to dampen them down quickly.

We've done lots of these. In India, for example, we did measles-like campaigns for 300 million people. These are extraordinary campaigns, but they have to be well organized. In a very fragmented system where there's not a standard way of working, it becomes much more difficult. If you leave it up to each different state, each different district, each community has a different way of working, which can create confusion from messaging and even from where people go to be vaccinated, where you report problems if you have any, or how you deal with the rumors.

We're seeing different models in different places, but the more we can move to having some type of aligned approach with everyone working together, the better we'll be. This is what's happened in Israel. Yes, it's a small country in size, but they've operated with a whole-government approach and have moved quicker per capita than any other country in the world.

Topol: The fact that they've already vaccinated more than 70% of their people over age 70 is extraordinary. We've been focusing on shots. But one thing that's surprising to me is that there aren't mucosal immune vaccines for COVID.

As you well know, the vaccines available so far haven't been assessed for achieving sterilization or mucosal immunity. There are some encouraging data from Moderna and a bit from AstraZeneca's work, but we don't know. It may possibly be good, but it won't be 100%, so we'll have people who've been vaccinated who are asymptomatic carriers. Why isn't there more priority to get even an adjunct, if not a primary vaccine, that confers sterilizing immunity?

This could be so easily administered. Why don't we put the turbo charge on getting those out there? Where do we stand with inhalation vaccines?

Berkley: In this case, vaccine development was moved as quickly as possible with the technologies that were available. Luckily, some of the new technologies were particularly well suited to this. But a whole generation of vaccines, multiple generations, are coming. There are now more than 250 vaccines in the pipeline.

Among those are live attenuated vaccines, which may be very attractive in terms of long-term immunity and single dose, etc. But there are also a number of nasal vaccines and oral vaccines that are being tested. So I think we will see these move forward. Logistically, they are a bit more difficult to produce because there hasn't been as much experience with them compared with vaccines administered parenterally.

Obviously, if you're trying to use vaccines that are live-based vaccines, there are sensitive issues in terms of safety and proving attenuation and all of that. But I think we'll see those vaccines coming up. The question will be, do they provide better protection?

This has been a debate that's gone back and forth with the polio vaccine. The oral polio vaccine gives you mucosal immunity, and therefore, it's great for using in outbreaks. But it also can transmit to others — it is a live vaccine — whereas the inactivated vaccine protects the person but doesn't provide mucosal immunity and community protection.

We've used both of those vaccines in an outbreak setting, to both protect individuals and to try to deal with this ability to transmit infection. All of the COVID vaccines were studied for disease-sparing and preventing severe outcomes of disease. There hasn't been as much study yet on whether they block infectious transmission, in part because, given the situation, what people were concerned about as the initial priority was trying to protect against severe disease and death. But those studies will go on and are very important, because there may be differentiation between different approaches and which may be better for public health use.

Verghese: My last question is really about the controversial UK strategy of just using the first and second doses that they were saving, to vaccinate the whole population. What is your sense of that decision?

Berkley: It's a complicated answer, but I will give you an honest answer. If you go back to what Eric talked about at the beginning, the AstraZeneca data, a subset analysis showed a 90% prevention rate. The overall cohort had a 70% prevention rate and then 62% in the two full doses. The group that had 90% efficacy had three different changes associated with it. They received a half-dose to start, and that was an error in doing the titers for the vaccine. But there was also a delay in the time of giving the second dose, and that regimen was also given to those under 55 years of age. So initially, it was quite puzzling. Now that the data have been examined, it is quite clear that antibody responses to the vaccine go up dramatically as you extend the second dose schedule from 4 weeks to 8 weeks, 10 weeks, 12 weeks — you see a much, much higher antibody response when you boost at a later time period. But the trial in the United Kingdom was done with a 4-week interval, so the approval is for a 4-week interval.

From a policymaking point of view, it is pretty clear that that dose interval is probably what makes a difference in the AstraZeneca data. We know from Johnson & Johnson's Ebola vaccine, where they did a very careful dosing study — it's a different adenovector —they were able to show that a longer dose interval gives much higher protection. So this has scientific credibility, and with other doses as well.

Thus, what the United Kingdom is saying is that although study data are only there for the 4-week interval for regulatory approval, the overall data suggest that a longer interval is better. From a policy point of view, a longer interval allows you to distribute the time and give more doses. In a sense, it's logical.

Of course, you want to make sure that they actually do the study to validate that this is correct. That will have implications not just for the United Kingdom but for the whole world because, given the shortage of vaccines, we would also love to be able to vaccinate and have a longer time interval — do what we call a "1 + 1": give a dose and then, at a later point, give a booster. But if the regulatory approvals are for short time intervals and we don't have any scientific data to extend them, it will be problematic to recommend a longer interval to other countries. Because, of course, it may be that you don't have as good protection in the interval between the two doses.

From a public health point of view, that may be okay because if you have double the number of people vaccinated, you may get a population immunity that's better. But from an individual perspective, they may be at more risk. There is lots of complexity to this. We really need the data to be able to answer these questions.

Topol: Seth, you are an incredible resource. You have the anchoring of all these other vaccines over decades and the whole worldview. What is your prognosis for getting out of this mess? Are we going to do it? When are we going to do it? Obviously, it's not confined to any country. It's a planetary story. What do you think?

Berkley: I'm an optimist. I think that by the end of 2021, we will have a vaccine in every country. We will have at least the critical groups vaccinated, and that will move us more toward normal. But we will not have enough vaccine to get herd or full population immunity.

Once we have that type of effect across the world, I suspect that will change the epidemiology. We don't know totally what that's going to look like. Of course, when we travel, when we have exposure, we'll probably still need to use nonpharmacologic interventions. But it may put us in a much better place.

What I can't predict is whether we are going to have new virus strains that are worse. Are we going to have other problems? One silver lining for all of this, and it's really important, is that this is a wake-up call.

It is evolutionarily certain that we will have more outbreaks. The population is going up. We're putting stress on the environment. We're cutting down forests. We're living closer to wild animals. Climate change is going to shift massive amounts of population.

So, what I'm hoping is that this is a wake-up call for the world to focus on being prepared for outbreaks. That's about having resilient health systems and having surveillance. It's about trying to study, in peace time, transmission among animals, and making sure you have vaccine-manufacturing facilities ready to go.

All of that really could help us so that the next time it happens, we're better prepared than we were this time. We do that in many other areas; we put a lot of effort into preventing things. The challenge for us is that people tend to think infectious diseases are all taken care of, they're all done. But we know that's not true. This is something we really have to work on going forward.

Verghese: Seth, that's a wonderful, optimistic note to end on. We can't thank you enough for being with us. I think our listeners have learned a lot. And thanks to my co-host, Eric Topol, my partner in crime here, for asking such incisive questions.

Berkley: Thanks for having me. I look forward to continuing the conversation as we learn more about the disease, more about the vaccines, and how we do what Eric says: move back toward normality.

Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.

Seth Berkley, MD, is a physician and epidemiologist. He has dedicated his career to improving the lives of people around the world by mitigating the effects of infectious diseases. Through his work and recreation, he has traveled extensively, including by foot, camel, and sailboat.

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