Health

Yanzhong Huang, senior fellow for global health at CFR, and Rebecca Katz, professor and director of the Center for Global Health Science and Security at Georgetown University, lead the conversation on global health security and diplomacy. FASKIANOS: Welcome to the final session of the Winter/Spring 2024 CFR Academic Series. I am Irina Faskianos, vice president of the National Program and Outreach here at CFR. Thank you for being with us. Today’s discussion is on the record, and the video and transcript will be available on our website, CFR.org/Academic, if you would like to share these materials with your colleagues or classmates. As always, CFR takes no institutional positions on matters of policy. We are delighted to have Yanzhong Huang and Rebecca Katz with us to discuss global health security and diplomacy. We circulated their bios in advance, but I will give you some highlights now. Yanzhong Huang is a senior fellow for global health at CFR. He is also a professor and director of global health studies at Seton Hall University’s School of Diplomacy and International Relationships—sorry, Relations. Dr. Huang has written extensively on China and global health, and is the founding editor of Global Health Governance: The Scholarly Journal for the New Health Security Paradigm. And he is author of—his most recent book is Toxic Politics: China’s Environmental Health Crisis and Its Challenge to the Chinese State (2020). Rebecca Katz is a professor and director of the Center for Global Health Science and Security at Georgetown University. She previously served as faculty in the Milken Institute School of Public Health at the George Washington University. Dr. Katz’s work primarily focuses on the domestic and global implementation of the International Health Regulations, as well as global governance of public health emergencies. And her seventh book is coming out next week, I believe on Monday, and it is entitled Outbreak Atlas (2024). So you should all look for that. Dr. Huang and Dr. Katz coauthored a Council Special Report entitled Negotiating Global Health Security: Priorities for U.S. and Global Governance of Disease, so we did circulate that in advance. And I think we will begin with Dr. Katz to talk a little bit about global health security and diplomacy, and some of the findings from your report. So over to you. KATZ: Thank you so much, and really appreciate the opportunity to speak with everybody today about global health security and diplomacy. I could note—a quick disclaimer that like many people in Washington I wear multiple hats, including one that works for the United States government, but I am speaking today only in my academic capacity and not representing anybody else. So we are—we’re living in interesting times in the global health security and diplomacy space, and just the work of global governance of disease. As we speak, negotiators are working through what is hopefully a final agreement on amendments to the International Health Regulations. And in about a week, yet another version of possible text of a proposed pandemic agreement will be circulated to member states in advance of the resumed—the INB, Intergovernmental Negotiating Body, negotiations that are now scheduled, I believe, starting the 29th of April, where they may possibly finalize substantive negotiations in advance of the World Health Assembly. It is not a surprise, though, that the negotiations themselves have stalled, and they’ve stalled primarily over issues around access and benefit sharing, and the relationship between developed and less-developed countries. There are significant remaining redlines, including related to the way that pathogens are shared or the information around pathogens is shared. It’s related to the production of medical countermeasures, access to medical countermeasures. There continues to be an evolving power dynamic at this time of call it strained geopolitical tensions. And there are some real questions about the future of multilateralism and just the global governance of the disease space in general. So while this is all sorting out, the world is also working on questions like how do we fund pandemic preparedness and response. So there are questions around the World Bank’s Pandemic Fund, and the breadth and scope. There’s the role of what is the evolving role of the more horizontal entities like the Global Fund. There is limited response funding in general and overall kinds of shrinking budgets. In the academic space, there is a really interesting space set evolving looking at predictive analysis, and some of the technologies and scholarship that’s coming out to think about how do we predict and adapt, both from surveillance and thinking about the evolution of outbreaks. There is the rise of wastewater surveillance. And as the disease threats continue to evolve, we’re also looking at these threats as part of the climate crisis, and a community that’s very keen in looking at the role of artificial intelligence and changing biothreat landscapes. So there is—there’s a lot of movement. There’s a lot of things that are going on. But at the same time, there is diminished interest of governments as competing priorities reenter the fray, and increasing challenges thinking about response capacity in an age of mis- and disinformation and eroding trust in science. So, all this is to say that the space is challenging. It’s dynamic. There is a tremendous amount of work still to be done. Which is one of the reasons that we need to be thinking about how do we use all the roles and approaches that are available to us, including enhanced efforts to focus on the role of diplomacy. I am delighted to see the launch of a Foreign Ministry Channel for Health last month, and we’re now seeing ministries of foreign affairs around the world organize—better organize to address these health challenges. So not all the challenges are easily solvable, but heartened to see this coordinated effort. We’re trying to more fully realize diplomacy for health. There are—there is a lot—there’s a lot of swirl, but why don’t I stop there and turn to my colleague Yanzhong. HUANG: Thank you, Rebecca. Thank you, Irina, and for the Council for invite me to speak at this important event. Thank you for participating. And Rebecca just talked about this progress for the ongoing negotiation over the Pandemic Accord; the need to better organize to address the challenges we are facing. When we’re speaking of the challenges, you know, we—you might have—if you read just the CFR Negotiating Global Health Security—I’m seeking to advertise that one more time—(laughs)—you know, we basically talk about all those different global health security challenges, which are real. We already in the United States experienced a major global health crisis, that officially is not over yet, but—(inaudible). All of the important threat—serious threat we are facing, you know—mind you that COVID caused more than 7 million deaths, right, more than 700 million infections. That 700 million is a clear underestimate, right, because to my knowledge, right, in China alone they have more than 1 billion people infected, right? And now WHO is talking about Disease X, you know, the name given by WHO scientists to an unknown pathogen which they believe could emerge in future, maybe. So it could be, you know, anything, right, with pandemic potential. Like, it could be Zika. It could be Nipah. You know, or it could be another coronavirus, you know, that could cause a serious international epidemic or pandemic. You know, and unfortunately, Rebecca just mentioned climate change is the major contributor to this increasing risk, right? Warmer temperatures can affect the transmission dynamics of pathogens. But the climate change alone could also cause direct loss of life and morbidity, right? The projection is that by the end of this century the millions of heat-related death could be comparable in scope to the total burden of all the infectious diseases. And we also face the threat of antimicrobial resistance, or AMR, which is one of the top global public health threats. The estimate is that bacterial AMR is directly responsible for 1.27 million global deaths and contributes to 4.95 million deaths in 2019. So you combine those two and it’s, like, pretty much close to the COVID death in three years, right? And then there’s the problem of food insecurity. You know, we are facing a global food crisis. This is the largest one in modern history. We talk about nearly 350 million people around the world experiencing, you know, the most extreme form of hunger right now, right? And then—and finally, last but not least, the threats of violence and revolution, you know, that presents new risks to global health security. You know, last time the Council had an event, you know, we saw the former national security advisors participating, speaking, and weighing the—they were asked: Is there an issue that’s on your mind that’s not in the news all the time? I remember former Secretary Condoleezza Rice, you know, said that I worry that we are not paying attention to things like synthetic biology, which could have a huge impact on things like pandemics. So, all the threats call for good health governance, right, global/national level, you know, giving it, right, this—the implication. But I want to emphasize that geopolitics actually are complicating, not undermining, this prospect, right? When you talk about, certainly, right, the armed conflicts, right, worldwide, you know, they can lead to widespread displacement of populations, wide destruction of health-care infrastructure, disruption of supply chains of essential meds and medical equipment, and also increase the risk of the infectious disease outbreaks, right? And certainly, civilian population will bear the brunt of all—most of those impacts, right, that we saw, right, in Ukraine, Syria, now in the Gaza Strip. Sometimes this—that is of particular importance to global health security, the issue of lab safety, right? You know, laboratories taken over by warring parties or in areas under direct attack risk releasing the dangerous pathogens that could start an epidemic, not a pandemic, right? We all—you might recall in April last year, the WHO said, there was a high risk of biological hazard in Sudan’s capital, Khartoum after one of the warring parties seized a lab, holding measles and cholera pathogens and other hazardous materials. Rebecca talked about misinformation and disinformation. You know, the—in a way, the wars and conflicts also encourage, right, disinformation/misinformation, right? For example, the wars in Ukraine, right, they essentially reduced Russia’s incentives to participate constructively in global health governance, right? Russia, in order to justify its invasion, launched a disinformation campaign claiming the United States was secretly aiding Ukraine developing biological weapons. You know, that conspiracy theory sort of echoed, you know, by the U.S. Five Eyes and in China, right? The wars, of course, also exacerbate the other global health issues like food security, right? We know the war in Ukraine, combined with the COVID pandemic actually disrupted the supply chain, fueled inflation, and aggravated the food insecurity problem. But, I think it’s equally important when we look at the issue of how geopolitics or geopolitical tensions actually curbs the prospect of international cooperation addressing all the threats we just talked about, right? Because geopolitical tension, rivalries between nations, can hinder international cooperation and funding for global health initiatives like disease surveillance, sample sharing, vaccination campaigns, research and development of new treatments and preventive measures. Just to use my familiar area—(laughs)—the U.S.-China geopolitical competition, as an example, most certainly U.S.-China geopolitical competition is not new, right? But it is only recently that China became so-called America’s most consequential geopolitical challenge, right? You know, that sort of leads to zero-sum thinking even by the international cooperation over issues like the probe of the COVID-19 pandemic’s origins, sample sharing, supply-chain resilience. And in fact, during the beginning stage of the pandemic we saw China basically threaten to use this leading—the status of being a leader in pharmaceutical—active pharmaceutical ingredients manufacturing to sort of—like as a weapon, right? When the Xinhua News Agency said that—because the U.S. instituted travel bans on China, basically, China at that time was unhappy and said, you know, here we decided to ban our export of APIs to the U.S., so we are going to be plunged in the what they call the sea of COVID, right? So this is an example of how even the medicine could be weaponized during—as a result of geopolitical tensions. And then if you also look at how this U.S.-China geopolitical rivalry could be combined with the lack of personnel—personal exchange, right, sort of deepened by these mutual misunderstandings and misperception, you know. So, you know, now we’re seeing that even after almost the end of the pandemic, right, that the two nations still have no serious discussions over public health issues, even though we think, like, China is actually one of the biggest risk factors. But there is just not much enthusiasm in supporting, like, a serious dialogue with China on cooperating on disease surveillance, sample sharing—not to mention, like, co-development of vaccines or therapeutics. And finally, I want to add that these geopolitical factors could influence the availability and affordability of health-care services and medical supplies, particularly in developing countries or regions affected by conflict or economic sanction. That sort of leads to disparities between North and South in access to essential health care and drugs. Again, the U.S.-China geopolitical competition during the COVID, when China launched this—the so-called vaccine diplomacy or mask diplomacy, the U.S., you know, sort of viewed that as a threat; they—it launched its own mask—vaccine diplomacy. You know, this competition sort of mitigated this so-called vaccine apartheid between the developed world and developing countries; but it also meant that, you know, the vaccine diplomacy would prioritize those countries that’s viewed as strategically important, right? That, in turn, exacerbated the global disparities in access to the vaccines—(all the ?) COVID vaccines—(inaudible). So, to address these challenges, I think we need to have a global health détente with geopolitical rivals. We need to embed the health diplomacy in a multilateral instead of a bilateral framework, right, and support WHO Global Health and Peace Initiative—the GHPI—to better address the underlying diverse critical health needs in fragile, conflict-ridden settings. So, with that, I can stop there. (Laughs.) Thank you. FASKIANOS: Thank you both. Appreciate it. Let’s go to all of you for your questions and comments. (Gives queuing instructions.) OK, so with that, let’s go to the first question. I’m going to go to Mojúbàolú Olufúnké Okome to ask her question. Q: Thank you very much. I’m Mojúbàolú Olufúnké Okome. And I teach political science at Brooklyn College. I’m also Nigerian. And the pandemic showed a lot of the fault lines in terms of the global governance arrangements for health issues, because there were—I mean, the vaccine—the disparity in access was profound for Africans. And, you know, the lucky thing is that not as many people as could have died, died. But I’m just wondering, because we’ve had the HIV/AIDS epidemic, we had Ebola, what is the learning from that? And how come we had all these challenges with the pandemic that we went through, the COVID-19? The other thing about it—that I want to talk about is food. And then there is—I don’t think the problem is insufficiency of food in this world, but distribution equitably. So, what would it take? I mean, and there are all these really heartbreaking photos and, you know, documentaries and reports. What is it going to take to solve this problem and make things equitable so that lives are not being lost unnecessarily, and then health challenges that come from malnutrition are not generationally affecting human populations? Thank you. FASKIANOS: Who wants to go first? KATZ: I will, very briefly and inadequately, try to address the question around vaccine equity. And then—and then I will—I will punt on food security. Since that’s more of Yanzhong’s expertise. I think the point you bring up is critical. And the issues of vaccine nationalism, of vaccine inequity are what is driving current discussion, debate, the feelings around global governance of disease and the effectiveness of it at all? It is—it is the issue that prompted the beginning of a negotiation for a new—(inaudible). And it is—but the solutions are why nations are actually stalled right now. I think your question around what have we learned, well, I think what we have learned is that there’s—whenever anybody talks about future of global governance of disease, you could probably count the number of times somebody says the word “equity.” Yet, operationalizing that is extraordinarily complicated. And unfortunately, we haven’t seen it yet. And I think that you can see that with, you know, the mpox outbreaks and the number of cases that were—you said, you’re from Nigeria—the number of cases that were in Nigeria, the number of cases that have been in the DRC. And the, I think it’s fair to say, insufficient amount of medical countermeasures that have reached populations in sub-Saharan Africa, just for mpox. So, I think there is—there is certainly widespread understanding, realization that we need to fix this—we need to fix this. Because we can’t—we can’t actually talk about we’re all in this together, disease spreads, knows no borders, we all need to work together, and then have situations like you did during COVID where populations just didn’t get access to lifesaving vaccine. So but now getting to the point of trying to figure out how we solve that is exactly what is—what is causing the discord in Geneva right now. And I’m not sure there’s an easy answer for you on how it’s going to be solved. HUANG: Well, I have—(laughs)—well, I really agree with Rebecca, right? There’s no easy answer, right, to all these questions that the professor just raised, you know, that—like the vaccine aspect, right? We know many of the low-income countries, right, that the vaccine—the vaccination rate was even low—very low even by the end of the COVID pandemic. But you know, there’s, like, multiple factors that contributed to that. Certainly, vaccine nationalism is one reason. But you know, even weighing we have all these vaccines available, right, they—the COVAX did a very good job of trying to reach this segment of the population, but then there’s the other issues, right? The shipment, right? How do we make sure they ship and distribute these vaccines in a timely manner? That’s become another issue. And so, I think, well, at this moment the solution that—for the—I think the transport technology for the vaccine technology, that is important. Now, I believe that the Pandemic Accord will talk about—is talking about that in the negotiation. But in the meantime, I think we should also invest to make sure those countries, especially with the manufacturing capacity, will repeatedly sort of have that—some investing there, like their capacity to manufacture the vaccine, right, to sort of—to scale the access. You know, that could be one of the solutions. Then, speaking of the lessons we learned from the pandemic, certainly what we have, right, the—(laughs)—I think it’s fair to say we know the problems, right? The experts—the global health experts, public health experts—they know where the problems are. It’s just that, you know, many of the issues—(inaudible)—only, you know, that it can easily slow them down. For example, we know that the WHO—(inaudible)—by strengthening its capability, enforced by the International Health Regulations. But in the—(laughs)—international system, where anarchy is the rule of the game, you know, that, yeah, I think much of this improvement will be still, you know, state-centric, that—and driven by national interest, just like we saw during the pandemic. Essentially, the IHR was talking about avoiding the disruptions in trade, disruptions to people’s movement, essentially tend to be ignored, right, by the nations there. But there’s another issue, is the lack of coordination. When states tried to use to institute all the travel, you know, the trade barriers, you know, they—there was no, like, coordination, no cooperation. You know, that sort of created this little tragedy of common situation, that then everybody actually was hurt. Finally, the issue of the food insecurity. Well, this is, again, not something new, but that clearly the pandemic, right, exacerbated the problem, in part because of the—this disruption of the supply chain. But in the meantime, there’s some other issues that, you know, could exacerbate that problem. Yeah, like in particular countries like North Korea, for example, we know that in this country—what is arguably the world’s most isolated state, right—they say—the people say—suggested a situation where it’s the worst, right, it has been since the 1990s, you know. But you know, people—the North Korean government certainly could blame the international sanctions. But in the meantime, the government mismanagement, right, is also to blame. In actually still—better still in the pandemic 2020 that cut off, right, the virus supplies, and that is also to blame. You could also talk about the—(inaudible)—killed more by starvation. Is this part of the humanitarian warfare, and especially, you know, in the war setting, where the humanitarian aid is twisted into the conflict by the—(inaudible)—and warlords that seeks to control the food supply as a means of increasing their military and political power, right? So, you know, that—the deliberate use of starvation, this the term we use, kind of war by starvation, right, that’s also was exacerbating in those that conflict zones. FASKIANOS: Thank you. I’m going to go next to the Fordham IPED. Q: Hello. I’m Genevieve Connell with Fordham Program for International Political Economy and Development. Thank you for being with us today. And my question is: During the COVID-19 pandemic we saw dissent where many people blamed China for the pandemic, which has catalyzed racial violence against people of Chinese or Asian descent in many cases. What implications do such social upheavals and demonization of a specific group have on global diplomacy and our ability to collaborate in future health response efforts? HUANG: Well, I’ll try to be—(laughs)—to be the first, whether Rebecca could weigh in. Well, this is, again, not something new, right? During the SARS epidemic, you know, that you also saw that the Chinese were sort of, like, blamed, you know, for sort of causing epidemic. You always, you know, target the certain group of people to blame. You know, you could—(inaudible)—like, historical, that could be traced—there’s a pattern there, right, that during the Bubonic Plague, for example, European Jews were blamed, right, the—for causing the pandemic, you know, that sort of to enforce to them to migrate towards Eastern Europe. You know, that certainly sort of the—poisons the atmosphere for tackling the crises, especially, like, when there’s intertwining geopolitical tensions between China and the United States. You know, that—remember that—and also, you have internal politics by the way, the Trump administration trying to find a scapegoat, right, for its mismanagement of the crisis, you know, that China become an easy one. So he sort of, like, started to talk about, you know, this is sort of a China virus, or kung flu, right, the thing that only—that sort of intoxicated the atmosphere of cooperation with China, making it even less willing to cooperate with the United States, especially on issues like the origin probe. So now, you know, we’ve seen how that—we were probably—given this sort of lack of cooperation, China, you know, really probably we are never going to find where that virus actually come from. But in the meantime, you know, also this created—sort of contributed to, like, a more divisive society in countries like the U.S. given this anti-Asian sentiment. Rebecca? KATZ: You know, I don’t have too much more to add, except that I just—it’s an interesting question. And I actually would put it back to you a bit too. That I think it’s important to separate out the challenge—I bucket the challenges slightly differently. So the challenges of the types of stigma and bias that might arise for subpopulations within our own country. And we’ve, as Yanzhong just mentioned, we’ve seen that over and over and over again. And so you think about the types of ways that that can be addressed, and people can be protected, and how we can think about, you know, it’s not really a vulnerable population, but populations at risk of inappropriate stigma. So I think there’s that question. And then there’s—I bucket into a separate issue of how the government response and dealing with other countries, and the geopolitical tensions that might arise, and how that affects the response into a different category. And that’s—and Yanzhong already kind of addressed some of those—some of those challenges along the way. But none of it—none of it is easy. And it’s often not done sufficiently. FASKIANOS: Thank you. I’m going to take the next question from a written question from José David Valbuena. He’s an undergraduate student at Buffalo State University. And the question is, what are the potential risks and limitations of implementing economic structuralism to improve global health security? HUANG: Define economic structuralism. KATZ: Yeah, I was going to say, I’m not sure how to answer that because I’m not sure what your—what you want us to get at? FASKIANOS: All right. So, José, I think if you’re in a place where you can—you can join in live, or unmute yourself, why don’t you do that? And if not, then we’ll move to the next question. KATZ: Here he comes. HUANG: To use that—something like the Marxism sort of argument, the economy, right, just determines the—(laughs)—almost the upper infrastructure, or whatever. If that if that is the case, right, there, you know, they—I think, you know, a single focus on economic development certainly does not help, right, in improving public health, even though a well-developed economy, you could find the policy high correlation, right, between the, like, high level of economic development improved, right, the health-care standards and, like, the average life expectancy increased. But in the meantime, the single focus on economic development could hurt the public health and global health, you know? One of the examples is urbanization, the industrialization, like, the—could, right, the—sort of make us more likely to be exposed to those dangerous pathogens that increase the likelihood of a dangerous pathogen of jumping species to human beings, you know, then start a—potentially, right, that if it obtained that capacity for efficient human-to-human transmission, right, the potential for a pandemic. KATZ: I think I just saw a note that he’s going to reframe the question, but maybe talk about economics, just one point I would love to be able to add to maybe help frame some of the—some of that discussion with a little bit of data. When we talk about what do we need for health security—and we can talk about the threats, and Yanzhong was talking about, you know, the challenges of urbanization and globalization—(inaudible)—land, and the competing challenges of looking at economic development and—but I do want to note—so one of the things that our research team has been doing for about a decade is trying to figure out what it costs each country to be able to develop their capacity to be able to prevent, detect, and respond effectively to public health emergencies, based off of their international legal obligations and then also looking at each region in context. And it—just so everybody has a number in the back of their head, the number that we currently have is approximately $300 billion that would cost at the global scale for every nation to be able to build sufficient—and sustain—sufficient capacity for health security. That’s in addition to approximately $60 to $80 billion that’s required at a global scale for things like research and development, and supply chain, and manufacturing. So just to note, we have approximately $380 billion problem. And we are definitely not spending that right now. And if we think about it as a problem, the pandemic itself cost—well, we’re not exactly sure what it cost—but somewhere around $15 trillion dollars. So $300 billion dollars sounds like a lot, but it’s actually very little if you’re looking at your return on investment for being able to address a future pandemic. But it’s a lot in the world of public health, where there’s very little money, and there’s shrinking budgets, and there’s shrinking opportunity for nations to be able to actually invest themselves, as well as international financing. So I’m using—I’m using the question as an opportunity to just throw that out there, so folks understand. HUANG: Yeah. I forgot to throw out, again, with the pandemic example, right, that the countries that are most developed, doesn’t necessarily mean that is the most—or, the best prepared for a pandemic, right? Before the pandemic, there was Global Health Security Index, that showed the U.S. was one of the best prepared. But as it turn out, it was the worst—one of the worst hit by the pandemic. FASKIANOS: Thank you. I’m going to take the next question, raised hand from Braeden Lowe, who also wrote his question. But why don’t you ask it? And if you could identify yourself, that would be great. Q: Yes. Can you hear me? FASKIANOS: Yes. Q: Perfect. My name is Braeden Lowe. I’m a graduate student at Middlebury Institute of International Studies at Monterey, studying international trade. My question is, how effective have multilateral development banks been in the development of health infrastructure in countries that need them? And could there be a greater role for them in the future, such as maybe development banks that are focused primarily on the development of medical infrastructure, and facilities, and the development of medical technologies? Thank you. HUANG: Rebecca. KATZ: Yeah. I mean, Braeden, it’s an excellent question. And I think that the history of the development banks has been mixed over—pre-pandemic and in the current situation. Let me start with—well, so, yes. The banks have been involved in developing health security capacity and including medical countermeasures—less on the medical countermeasures, more on mostly national capacity and regional capacity. And some have been more involved than others. The Asian Development Bank was really engaged for a long time. ASEAN was really the driving factor for coordination in that region. The Inter-American Development Bank has been engaged. IMF had programs. So there have been programs. And prior to the pandemic, the World Bank had something called the PEFF, the Pandemic Emergency Financing Facility, that they stood up both for preparedness as well as a response window. That came under a decent amount of criticism because the triggers for using that mechanism were so stringent that it basically became not helpful. And while the Bank and IMF and the regional development banks did assist throughout the pandemic, you could have a pretty lively debate on how effective they were, how fast they got into the game, where they could have done more. I think the general lesson is everybody could have done more. But where we are right now is that the G20 High-Level Independent Panel—well, the G20 appointed a high-level independent panel that was—that came up with some proposals for how to better position the world for being able to support national-level development of pandemic preparedness and response. And the recommendation was to use the World Bank as the mechanism for that. So about a year and a half ago, the World Bank—the World Bank board approved the creation of the Pandemic Fund. As I mentioned before, we have about a $300 billion problem. The first round of funds that was given out over the summer was for $337 million dollars. So we got a—$337 million dollars went out on a $300 billion problem. And there were—and that went to thirty-seven different countries where there were proposals, however, from—there were 600 proposals that were submitted. And these thirty-seven went out. So the next round is out right now. And the plan is for the Pandemic Fund to provide approximately $500 million dollars in this round. But, again, so it kind of—it depends on if you’re a glass half empty, glass half full kind of person, and whether you think that the banks are super engaged in doing all that they can, or if they’re really—if there’s a lot more that they could do. And that’s not even getting into all the other mechanisms that that they have contemplated and thought about in terms of being able to use to help countries, particularly being able to mobilize resources quickly. FASKIANOS: Great. Thank you. I’m going to take two—combine two written questions. The first is from Nicole Rudolph, who is an assistant professor at Adelphi University. Who is leading initiatives to integrate health security with climate resilience efforts? And then there’s a question from Izabella Smith. I don’t know her affiliation. How do you deal with the mass politicization of health safety, specifically before and after COVID-19? KATZ: Easy ones, right? (Laughs.) FASKIANOS: Yeah, very easy. (Laughs.) KATZ: Well, Yanzhong, why don’t I—why don’t I do a really quick answer, and then and then turn to you, particularly on the health and climate space. Except for, Nicole, I would say that I’m glad you’re working on this. We’ve always considered one health and climate as first principles of health security and health security threats. So they are, in our head, completely intertwined, and really need to be addressed that way. I think to Izabella’s, man, how you deal with the politics? It’s—we are in a really, really complicated environment right now. I’m a public health professional. Before the pandemic, most people did not know we existed. (Laughs.) And maybe that was OK. It was difficult because there was no money, but we were kind of quietly left to do our job. And we were most successful when people didn’t know we existed. What happened during the pandemic, particularly in the United States but also around the world, we saw the—a lot of these issues have always been political. They had never been partisan before. They became very partisan. And there was a tremendous amount of backlash against public health officials. There are—there are academic efforts underway to help and capture the—just the type of backlash that existed. The fact that there are academics who are measuring—there is categories for how many public health officials were threatened with gun violence and didn’t get support from their local law enforcement. And the fact that that number is so large, that there is a category for counting it, gives you a sense of the type of backlash that’s been experienced. I think what we’re seeing right now—I can talk to the United States—but a massive movement to roll back public health authority legislation and regulations. There are state legislatures across the country that are stripping their governors of emergency powers and putting that authority into the state legislative branches, which is basically going to make it almost impossible to take rapid action in the—in the next event. And, you know, there will be a next event. So it is—it is really difficult. We are seeing the—based on the vaccine—the increase in vaccine hesitancy, and in part due to the rise in mis- and disinformation. And now we’re seeing measles outbreaks across the country. And, you know, situations where the current public health officials are not taking scientifically based action to stop those outbreaks. So we’re—it’s rough out there. Let me just put it that way. As well—at the same time that people are quitting in droves because people did not sign up for this. So just that. HUANG: Yeah— FASKIANOS: So before—Yanzhong, before you—before you weigh in, and I’ll give you an opportunity. Rebecca, this is a group of professors and students. And so what would you advise—what’s the call to action for this group to—you know, to help, you know, push back on or help sort of make—to ensure that guardrails remain? KATZ: I don’t have any—I don’t have a great one-liner on that, right? Except there is, how do we—how do we rebuild trust in science, in public officials, in governance? There is a need to raise public literacy. And so I start there. There are a lot of folks who are working on how do we counter mis- and disinformation. I think those are two very different things. There is—you know, there’s a need to—you know, it’s everything from being able to do the policy surveillance of what’s happening in the world, to being able to—all the way towards advocacy and trying to help, you know, get programs and policies sufficiently implemented. But I think also just having kind of a strong evidence-informed voice. I wish I had a great, better answer that said, if you just pushed this button or did this thing, it would all be better. But I don’t. And I think—I think this is why a lot of people in the community are really struggling with how do we—how did we get here, and how do we fix it? FASKIANOS: Great. Yanzhong. HUANG: Well, I—just follow what Rebecca said, I think trust is, like, the key, right? You know, our colleague Tom Bollyky, his research has just already, like, demonstrated how important trust is in fighting the—dealing with a public health crisis, like COVID-19. You know, and to the question, actually, the challenge is how to build the trust, right? You can talk about maybe better transparency, better accountability. But you know, I think in a country like the U.S. which is so divided now, I think in order to rebuild that trust it’s very important for the—these different groups, like even—like, I’m talking about, you know, the two groups, they need to be able to have a dialogue, basically, need to speak with each other. There needs to be able to build consensus. But maybe I’m asking for the impossible. But the—so when we talk about politicization, I want to also add that it’s not just happened at the national level; it certainly has been—this past pandemic has shown that this also occurs at the international level. In fact, you know, I think, you know, we never have, you know, a public health event that has been so politicized as the COVID-19. You know, just to give you an example, the SARS, right, when we talk about the origins of SARS, you know, people never thought of, like, politicizing the origin probe. But it’s become a big issue during the COVID pandemic, in part because this is, like, the first time we’re seeing, like, ideology being encouraged by the pandemic response. This entire response to the pandemic is sort of framed as a competition between authoritarianism and liberal democracy, right. And also, geopolitics, like, again, right, the tensions between U.S.-China sort of also was driving, right, the global pandemic response. So I think, you know, in order to sort of—we need to start to depoliticize—(laughs)—this process of depoliticization. We need to reduce the geopolitical tensions. But in the meantime, we need to start the—sort of have—investing in those trust—or, confidence-building measures like having, like, a track-1.5 dialogue between the two countries. FASKIANOS: Thank you. I’m going to go next to JY Zhou, please. Q: Hello. FASKIANOS: Yes. Thank you. Q: Hi. Awesome. Well, my name is Chris Nomes. I’m an intelligence analysis student at James Madison University. And my question is about threats to global health. Specifically, do we—do we face any risks, like, from our adversaries or from lone groups that want to purposely tear down global health? Are there any risks? And how do we counter those risks, if they exist? HUANG: That is Rebecca’s expertise. (Laughs.) KATZ: I got it. Maybe I got it. I mean, I think—listen, you know, when you start the question you asked about threats to global health. And immediately I start making lists of, like, oh my gosh, right, how are we going to talk about the signal—the, what, 90,000 signals that WHO received this month and the, you know, 300 that they’re investigating, and then the thirty, like, field investigations are happening in a given month, and all the—all the emerging infectious disease challenges, including, you know, H5N1 in cows in the U.S., to mpox, to, you know, again the long list of infectious disease challenges that nature throws at us every day. But your question then pivoted to talk more about the threats of deliberate biological events. And that is definitely a thing. I mean, so let’s just say that. That is a thing. That is an area of work. I will say that for about fifteen years I supported the U.S. delegation for the Biological Weapons Convention. So there are—there are people who get together often and work through trying to assess what that threat is and how it’s best addressed. There are—there are mechanisms for trying to investigate allegations of deliberate biological weapons use, and the use of the UN Secretary-General’s Mechanism. And there are now a lot of folks who are deeply concerned about how AI is changing the threat space. And so, you know, in this forum, I think the answer we can give you is, yes. It is a threat. It is a thing. And there is a world of people who work on this, including within the intelligence communities around the world, to better address that threat and then feed that into response and planning efforts. I will say, though, that in the—in the event—the challenge is if there is an actual event, the response may not be very different from a naturally occurring event, at least not initially. And putting attribution assessments aside, and any kind of political response you might have. But that that’s the other thing that is trying to be sorted out, is that, you know, if you are in the midst of a response to what looks like a naturally occurring event and suddenly there is information there or an entity claims responsibility for having released an agent, how does that change? What stakeholders now need to be involved? And also, who—how is that managed at the national, regional, and international system? So, basically, you opened a can of—a huge can of worms for me. But I think the answer is, yes, it is a—it is a thing. And it is a thing that there are—there is a community of people who think very deeply about it. HUANG: Yeah. I’ll just—you know, I think what the problem we’re dealing with, like, deliberate-caused outbreaks, right, the challenge here is that this is not like a war against, you know, terror, because we are facing—we don’t know, actually, even who actually started the attack, right, whether it’s from individuals or states, because in part of this—(inaudible)—of the biological weapons or the use of, you know, the dangerous pathogens, you’re not going to find out whether, like, something unusual is happening. And here, right, a large number of people flooded the ER rooms complaining about the same kind of acute symptoms. So the logic of, like—of deterring such an attack would be different from logic of deterring, like, a nuclear attack, right? Because we have to rely on the building of the health infrastructure, greater trained health professionals, you know, the so-called deterrence by denial, in order to sort of decentivize the potential perpetrators from giving up such an attack. FASKIANOS: (Off mic.) HUANG: Irina, you are on mute. FASKIANOS: I am muted. And how long have I been doing this? (Laughs.) We’ve had a lot of questions and written and raised hands that we could not get to. So I apologize to all of you. Rebecca, I want to give you thirty seconds to talk about your book, Outbreak Atlas. KATZ: Oh, yay! (Laughs.) Sure! I was telling folks before we started the webinar, in academia we write a lot of words, and often we write words and they’re, you know, meant for four people in the world to read. But we put a book together that is designed for hopefully addressing some of the public literacy issues that we brought up earlier. For years we had been supporting public health emergency operation centers around the world in helping provide information about kind of all the activities that happen in an outbreak response. And what we’ve done is we’ve taken that and we’ve written it for a public audience. So, it is illustrated. It has 120 different case studies. Anything you ever wanted to know about what happens in an outbreak, or every epidemiologic term that you heard your grandmother talk about that you’re, like, wait a second, is that right? So we’ve written it all out. If anybody’s interested, Outbreak Atlas. And it comes out on Monday on Amazon, and all those other places. So I’m really excited. FASKIANOS: Great. Fantastic. And, Yanzhong, is there anything you want to highlight that we’re doing at CFR in the global health space? HUANG: Well, thank you, Irina. Thank you for your patience of staying through that one-hour conversation. So, yeah, we are facing a lot of threats. We are—you know, we are aware of many of these challenges we are facing. We know the loopholes in the global health governance areas. It’s just that, I think the—(laughs)—the challenge is how to fix them; you know, don’t expect those negotiations in Geneva can you solve all the problems. The problems are going to rise up all the time in many decades to come. But if you want to learn more about this area, in addition to reading Rebecca’s Outbreak Atlas, read our—this is more CFR’s Negotiating Global Health Security. Thank you. FASKIANOS: Thank you. Thank you both. So you can also follow them on X, formerly known as Twitter, at @YanzhongHuang and at @RebeccaKatz5. This is the last webinar for this semester. Good luck with your finals, and everything that comes with this lovely month of April and May. And for some of you who are graduating, you can learn about CFR paid internships for students and fellowship for professors at CFR.org/careers. We’re open right now. We’re accepting applications for summer internships. And they can be virtual. So that’s always a plus. And they are paid. Please follow us at @CFR_Academic, visit CFR.org, ForeignAffairs.com—and I’m going to really highlight; I do it every call—but our ThinkGlobalHealth.org site, which provides a forum to examine why global health matters and to engage in efforts to improve health worldwide. So, if you’re interested in these issues, you can—you should go there. We hope to be a resource for you all. Again, good luck with your finals. Enjoy the summer. And we look forward to reconvening in fall 2024. So thank you, again, to Dr. Katz and Dr. Huang. (END)

In January, the U.S. Supreme Court debated whether to overturn Chevron v. Natural Resources Defense Council—one of the most cited U.S. cases of all time, which established the principle that the courts should defer to federal agencies when they interpret the law in the course of carrying out their duties. During the COVID-19 pandemic, the deference owed to federal agencies’ exercise of public health authorities was already heavily litigated. How much overruling Chevron would alter U.S. health policymaking is a matter of debate, with some claiming the change would be modest while others argue that FDA decision-making and Medicare administration would be rendered unworkable. Mr. Nicholas Bagley, the Thomas G. Long Professor of Law at Michigan Law and an expert on administrative law and health law, and Thomas J. Bollyky discuss what replacing the Chevron doctrine might mean for U.S. health.

FRIEDEN: Thank you so much for joining us. I'm delighted today that we have Dr. Francesco Branca with us for a conversation about nutritional issues very broadly. Francesco is Director of the Department of Nutrition and Food Safety at the World Health Organization in Geneva. And I can say that I've worked with Francesco for many years and found him to be always insightful, always constructive, and someone we can learn from and work with. So, I'm going to start with asking Francesco to make a set of general remarks, then I'll be discussing some of them with Francesco, then we'll open it up for conversation with all of the participants. Francesco over to you. BRANCA: Well, thank you very much, Tom. And if I can say, I've been privileged to interact with you and with the organization Resolve to Save Lives that you chair. This has helped a lot in making headway in food and nutrition. And you realize—after my brief introduction—why I feel so. So, thank you for the partnership and thank you for inviting me to this very interesting conversation. I look forward to the interaction with the audience. I actually would like to start by giving my perspective on why food and nutrition are global challenges for health and development. And I think, you know, there are at least three reasons for that.  And the first reason is the health reason. Really, all together, one third of the deaths and about half of the disability burden is accounted for by factors related to diet and nutrition. Unhealthy diets is accounting for eight million deaths every year, obesity: five million deaths, maternal and child malnutrition: three million deaths, and unsafe food for a hundred-thousand deaths every year. But this is probably an underestimate because food systems affect health through other pathways to production practices, for example, to the use of antimicrobials in in animal production, to the use of fertilizers and pesticides that have an impact on Earth through the environment to the health of food workers. So, it's really a much more comprehensive assessment that we should make on the of the impact of food system nutrition, and health.  Then the second is the impact on the environment: twenty-five percent of greenhouse gas emissions, two thirds of freshwater use, over one third of Earth's landmass, the impact on biodiversity—as I said, the use of nitrogen and phosphorus fertilizers. So, it's a multiple set of impacts. And any economic impact of food system—and I just would like to say, and I'll put the link in the chat that just on Monday, yesterday, the report of the Food System Economic Commission has been released. And that report really gives an incredible description of the impacts, economic impact of food systems. And you know, the conclusion of the report is that the costs of the current food system are far larger than their contribution to the global prosperity. You know, the unaccounted cost of the burdens they place on people on the planet are currently estimated that fifteen trillion U.S. dollars a year, which is equivalent to twelve percent of GDP in 2020, which, by the way, is exactly the same figures as the expected turnover in the sector in 2030. So, you know, almost the same amount, you know, in terms of wealth and the same amount in terms of negative externalities. So only the health costs are eleven trillion US dollars.  By the way, obesity on its own is four trillion dollars, three percent of GDP, plus the three million environmental costs. And then we know that actually food systems are related to poverty. In Europe, we're now seeing the rebellion of the farmers who see their income threatened by the global crisis and you know, the price it's paid on their food which is inadequate. So, you know, the small farmers are challenged, but then also the system is such that a healthy diet is unavailable and affordable to three billion people in the world. The trends are not encouraged, because, you know, unfortunately food insecurity and undernutrition is covering. The improvement with adding nutrition targets, particularly stunting, is been relatively good. But the balance between the decrease in undernutrition and any increase in obesity is not leaving us in a better situation in the future.  What's been the policy response here? I was, together with colleagues in FAO, organizing the second international conference on nutrition back in 2012. And in that conference, we basically had the support of the global community on a series of targets, global nutrition targets, and noncommunicable disease targets that basically frame the narrative on food and nutrition in a much more comprehensive way. So it's not about as it used to be only about food insecurity. It's about a healthy diet. And it's about the prevention of noncommunicable diseases.  And in that conference, there was a final document that was calling for a comprehensive multisectoral response on health systems, food system, trade, social protection. Sixty-two specific recommendations all evidence based, so there was a very clear picture as this as this has been implemented. Frankly, the answer is not really, not really. Even recently, when big initiative which has been launched by the Secretary General of the United Nation, UN Food System Summit, last year, we just had a two year follow up the stocktaking. It was a large mobilization, but very limited policy commitments all entirely voluntary, the UN Secretary General call to action of this last stocktaking is very much open ended. It says you need to think about the food system. It's important for sustainable development, you need to engage all sectors and stakeholders, you need to invest in innovation and technology. You need to engage with business. But yeah, very general call to action.  COP28 was quite interesting. It's—the concept of sustainable healthy diets has been mentioned in the health declaration and the food declaration spoke about the impact of climate change on food production, but it really did not commit to any food system transformation. Now, the Food System Economic Commission estimates that two hundred to five hundred billion U.S. dollars a year are needed to transform, radically, the food system, but the benefits would be five trillion U.S. dollars a year. Going specifically on the specific issues: obesity.  Obesity, I mean, basically, the trend has been going up. You know, very few countries have been able to make a change. We've seen some change in some European countries in some sub areas, maybe regional changes, even actually, the United States has been some communities that have shown some change, but largely the change has not been there. The policy response has been inadequate. And the World Health Assembly asked WHO to do something about it. We developed what we called an acceleration plan, basically saying yes, obesity is complex. But can you do at least five things which we know are cost effective? Can you establish taxation of sugar sweetened beverages can you have warning labels to inform consumers that they should, you know, prefer certain products to others? Can you stop marketing for—to children? Can you have healthy public food procurements, physical activity in schools, and integrated health services in primary healthcare that understand the issue of obesity? So, these are fairly basic things. And thirty-one front-runner countries have responded to that. But you know, fifteen countries have committed to establish as a sugar taxation but you know, in a sense it’s a drop in an ocean yet.  Early nutrition, early nutrition. We know that early nutrition is good for the prevention of undernutrition and the prevention of obesity. And we've done well in improving breastfeeding rates, ten percentage points in the last ten years. But you know, code-of-marketing breast milk substitutes, only thirty-seven countries are implementing it entirely. Maternity protection law is not implemented. Baby-friendly hospitals, you know, how many hospitals are really done in a way that, really, breastfeeding is supported by adequate—adequately training health care workers.  For the environment, you know, the kind of policies that would make the food environment more conducive to healthy diet support is still, you know, a lower number of countries and also the well-known ways to deliver those problems are not implemented. For example, sugar taxation, no taxation of sugar sweetened beverages, yes, many countries do it, I think we have about eighty countries doing it. But you know, how many really have, you know, the taxation at the level which we know is going to produce an impact? Front-of-the-pack label, in Latin America, we have this warning symbols, which have shown to be effective in shaping consumer choices, but you know, others, other countries and other regions in the world, Europe, Australia, U.S.—scoring systems, which do not have the same impact.  And then finally, finally, you know, what we've been really working with, with Tom and his colleagues—the reformulation of process food—that's an area, but actually some remarkable impact has been demonstrated. Trans-fat, we now have forty-six percent of the world population is covered by policies that, you know, eliminate this compound, you know, which is industrially produced, industrial trans-fat, you know, for all the population. In the Americas—it’s actually this is even better. America is about to be declared trans-fat-free: eighty-five percent of the population seems to be covered. And you know, this change going in, you know, in only a few years—from six percent to forty-six percent coverage—has saved a hundred and eighty-five thousand lives. So, it's remarkable what you can do.  But also, you know, for example, very limited success. There are clear benchmarks, we know what, how much sodium should be in processed food, many countries, actually, in many countries, the intake of sodium mainly comes from processed foods. So, changing the content of salt in processed food would produce enormous benefits. Industry has not been willing to commit to changes. And again, the regulations there, the regulatory environment is not really making the change.  So just to conclude, basically, the challenges are enormous. The reasons to make the change are there, the solutions are there, but the policy commitment is not there. Can you speculate? Is it because of commercial interest? It’s because of you know, you know, capacity issue, and you know, capacity to develop? It's a complex system and food systems are complex. It's a capacity to really develop the right measures? Now we can discuss it, but the fact of the matter is that the action taken has not been sufficient. That's why we are in this situation. Thank you. Back to you, Tom. FRIEDEN: Thank you so much, Francesco. That was a whirlwind tour through the world of, of nutrition policy and where we are as a country, as a world, as a community. What I'm going to do is, I'm going to ask a few questions, and then in about fifteen minutes, we'll open it up for questions from any participant. Let's start with the good news. There are areas of progress that—you mentioned trans-fat for one—you mentioned, the Latin America front-of-pack warnings for another, in other contexts. And you mentioned also baby-friendly hospitals and a steady increase in breastfeeding. So, what can we learn from those successes? What can we learn from that progress? What are success factors that may be able to be applied to make further progress there, and also to extend that progress to some of the areas that are making less progress? BRANCA: So, I would say, first of all, you know, a good description of the issue, of the challenge with data. I think data are really important to understand, you know, what is what is the burden—health burden. We need to understand what is happening in the food system. So, for example, what is the content of these different compounds in food, so you know, good knowledge of the space.  Second is science. Contribution of science that has designed programs in a way that we could demonstrate effectiveness. I think that's important to convince that a certain measure, you know, may have a cost and we're able to assess the ratio of cost effectiveness. And that is important to persuade policymakers.  Third, a clarity about how to implement these things. So, you know, the trans-fat elimination, we need to understand exactly the different elements in the process, we need to see where the measures are needed. And we need to see—understand who the stakeholders are. So, for example, in the, for the trans-fat, it was really critical to have, this—what we call the replace package. So, a series of, you know, policy briefs in which we say, okay, this is how you do the monitoring, this is how you engage with the stakeholders, this is how you communicate. So, clarity about the measures.  And then really, probably one of the most important is generating the consensus. Generating the consensus, which requires civil society, media engagement, even for difficult agendas. Just to give an example, meet some of the warning, but you know, even before that, the taxation of sugar sweetened beverages in Mexico. That could only be done because of the deep involvement of civil society, you know, the organization called El Poder del Consumidor, or the Institute of Public Health in Mexico. And these people risked their lives, I mean, they were personally challenged. So, you need a very energetic civil society, of course, supported by UN organization. So, you know, creating basically a social movement around those measures. I think these are the success stories. For breastfeeding, definitely the—this is also the case, but you know, having a broad movement, including the people who are involved, including, you know, the mothers, including the health workers, so that has created the consensus that led to the adoption of defective—of defective laws. FRIEDEN: Great, very helpful. So, what I heard was technical, proven policies, pocketbook argument, money, clarity on how to implement, a social movement with partnership between civil society and government. And you also mentioned the importance of individuals willing to step up. I think in Chile, which had the first front-of-pack warning, it was perhaps one legislator who pushed for it year after year. Can you say anything more about how that kind of partnership between government and civil society can be most effective—where it's worked well and where there have been problems? You've mentioned in the past the breastfeeding movement, where there's possibility with synergy that wouldn't be there otherwise. BRANCA: I mean, I think in Chile is a good example. And personal leadership is important to me, definitely I mean in Chile, the fact that we had basically a member of parliament, the head of the Health Commission, who worked you know, in a sense in a bipartisan way that was that was really important. I mean, other good examples in the breastfeeding space has been when you know, ministers, female ministers themselves had gone through the understanding of the issue and you know, that was helping in the political commitment. It didn't work well when they were interferences—largely I would say. And then when these interferences were not overcome by adequate responses.  We still have countries who are reluctant to take on some of these measures because they have been threatened by some commercial entities who have said okay, we will withdraw our foreign investment—foreign direct investment in countries and trade agreements have been often the cause for the rapid evolution of the food system towards unhealthy food environments. And even if policies could be effective, there are interferences that try to undermine them and try to challenge the evidence base and okay, you know, if you establish a taxation of sugar sweetened beverages, there will be a reduction in the workforce. Or you know, there will be—if you put front-of-the-pack labels it will actually affect your trade and you might be challenged by the World Trade Organization.  Specific countries trying to establish restrictions on to the import of certain products, high in fat, challenge the index again, you know, on the trade basis. Even the current guidance that WHO has produced on digital marketing breastmilk substitute is challenged on the ground that, you know this violates certain trade laws in certain countries. So, I would say that, you know, the competing vested interests, that is the main cause.  But we can respond to that. I mean, we have developed a series of policy briefs, for example, on sugar taxation saying, okay, are these arguments, you know, solid? In reality, you know, there's no evidence that the establishment of taxation of sugar sweetened beverages has had any effect on employment rates. Trade laws, are they really broken? No. And you know, there are ways for of course, countries to establish import restriction, if these restrictions are also imposed on their own products, and they do not, you know, create—basically violate the competition rules of the World Trade Organization, so that it can be done so. So, there are misconceptions that are—that can be—that can be explained and deconstructed. FRIEDEN: Well, you've anticipated and answered my next question, which is, what are the main barriers to progress? And what can we do about them? How about—you talked about the science being clear as one of the success factors when it comes to obesity or sodium or some of the other nutritional factors, is there too much scientific doubt? Has that been something that has made it more difficult to act or is that just something that commercial interests exploit to delay progress? BRANCA: So, I mean, I admit that we've been able to consolidate the science relatively recently. So, when I started my job about fifteen years ago, we had some suggestions that you could go in certain directions, but then what happened? Some countries, because you know, you need, of course, it's important to have some pilot studies. We learned a lot from taxation of sugar sweetened beverages, because in U.S. cities, there were some experiments like that. Even in colleges—only in colleges, we could use that. But then what happened is that some countries basically had the courage to establish national policies. At that point, we had, you know, the information to be able to bring together the science. So, the science has been consolidating recently. So, you know, only last year, we've been able to update the, what we call the best buys for non-communicable diseases. And now we have a package of food measures for food and nutrition, which we didn't have before. And we can now prove they are cost effective. So, the science has been evolving, you know.  Also, our capacity to monitor policies has evolved. You know, in WHO we keep a database called the Global Database on the Implementation of Nutrition Action, which is, you know, several thousand document there. So, we have a good understanding of what is the policy space. So, all that understanding is contributing to make the case. So, the science is still challenged, of course, still challenged because we are not able to have the same level of certainty in analyzing policies, then when we do a randomized control trial. I mean, WHO has decided to develop guidance on policies. And so, we have last year we released guidance on marketing food to children, giving clear recommendation about regulating. You know, in the past, when member states had to agree on WHO whose policies, they were saying, well, you know, we recommend to do something, but it can be voluntary. Now, with our scientific analysis, you say, no, sorry, voluntary, we have the evidence, it's not effective. You're not going to be able to achieve that. So, you need to have regulation. So, that’s with the marketing policies.  We're about to release also a guidance, guideline on taxation of sugar sweetened beverages, another one on labeling, another one on public procurement of food. But in some cases, you know, the way we analyze the science as well actually the evidence is moderate quality, because you know, the nature of the evidence because you know, when you analyze, you know, these policy cases, you know, you cannot have a control, for example. And the kind of data we have, you know, could be somehow considered to be partially biased. But elsewhere, I think we're getting better, and also evaluating the policies. And whenever, you know, countries set up policies, we ask them to make a good, you know, to set up a good evaluation system, because that will benefit everybody else. FRIEDEN: One of the hot topics is ultra-processed food. You have in Latin America, a big focus on trying to reduce consumption of ultra processed food, you have some debate about what the definition is. What's your take on this topic? BRANCA: So, I must say that we have been discussing this, and at the moment, WHO doesn't use the term ultra-processed food. We prefer to say highly-processed, because, you know, we consider this as an important element, but we don't want to be at the moment seen as fully sponsoring the concept of ultra-processed food which is based on a specific classification, which is the NOVA classification. It's a very interesting concept and we believe it's important because it doesn't only bring together the—and actually make it much more scientific than what we used to call junk food now, makes it much more objective—doesn't only refer to the nutrition composition of these foods. You know, high-fat and sugar, so that is what they used to say in the past. Yes, that's, that's some characteristics of these foods. But there's another component and that’s the component of the, of the disruption of the of the original food matrix. You know, having an impact on absorption of nutrients, and creating something which, you know, has been demonstrated by many studies, very important, which is addiction.  Addiction, so addictive behaviors, would, in a sense, make this kind of food similar to what has happened with tobacco. So, in a sense that, then that leads out the argument, it's actually these foods have been chosen freely by individuals. No. They have been pushed on people who then have become addicted to them, and then, you know, it’s beyond their control. So that requires some form of control limitation. So that's an interesting, you know—plus the other component of the food which make them appealing, you know, which also contributing to their addictive power, you know, the use of certain additives, the use of certain—that, you know, for example, make them more appealing from the appearance point of view, the packaging may be improving the convenience. But, you know, how do we define all these elements in a more rigorous way? And above all, you know, how can we act on them.  So, the definition is absolutely critical to be able to define response measures. So, it is our intention to do more work on this, and to build on the excellent work which is now being done by many scientists all over the world. Now, starting from Latin America, but really covering, you know, many parts of the world. You know, I've just seen a report that we have done in the Asian region, you know, describing how they had the highly processed food, really have, you know, taken up and they are rapidly spreading in that part of the work, which already has an incredible problem of non-communicable diseases. FRIEDEN: If I'm understanding you correctly, what you're saying is: perhaps we should be thinking not so much about ultra-processed or highly-processed, but highly addictive food, which may then require a different approach. BRANCA: Possibly, but, you know, we need again—there are ways to do that, and there's this very good science about how to measure effectiveness, but, you know, I think the challenge there is the—is the definition and currently in the definition of ultra-processed foods, there are gray areas. You know, the interpretation in different parts of the world may be different. So, if we are able to do that, yes, I think you know, if we're able to come with a series of, you know, characteristics of the foods which have finally, a negative health impacts and define them then we can define a response strategy much more, much more effective. FRIEDEN: Great. Now, we can just turn to the CFR colleagues to outline how people can ask questions. OPERATOR: Absolutely. [Gives queuing instructions.] Thank you, Tom. FRIEDEN: Thank you very much. Let's delve a little bit more deeply into the issue of addictiveness. Is this the new frontier for how we should think about what should be regulated? Is it all about sugar sweetened fat? Is it all about increasing tolerance and increasing consumption? Is this an area where there's possible policy progress? BRANCA: I mean, definitely, sugar is a nutrient we should try to tackle much more effectively. The exposure to sugar unnecessarily starts from early in life, starts from you know, foods that are designed for children. And then it stays on and then we have ample opportunities to consume much more than what WHO recommends, which is maximum ten percent of energy from sugars, which, you know, if you translate it in a drink is probably less than one can of soda per day, you know. And then you don't eat anything, any sugar, any anything else than that. So, sugar is definitely important. And sugar, the way it's actually consumed through highly processed food can be responsible for an effect—a neurological neurobiological effects, there are demonstrated mechanism that then can lead to that reward mechanisms, for people look for that, and that's actually the starts of the addiction phase. So probably, that would be one of the nutrients to focus on. We say that, you know, we need to have healthy diets and we need to consume whole grains, for example. So similar to sugar could be refined carbohydrates, which could have a similar mechanism of action. So that's where I would say that we have to start.  The other important nutrient of course is sodium. Sodium is actually the number one killer. If you look at that number, I gave you eight million deaths every year from unhealthy diet, and then you say, okay, which other components of unhealthy diet you're looking at, then you have sodium—excess sodium, which is number one—then you have a number of insufficient intakes. So, you have insufficient intakes of whole grains, fruit, vegetable, legumes, and then you have high intake of fat, trans fat, red meat. So, sodium is the one we have—and of course, you know, sugars. So, sodium is the one nutrient we have to address together with sugar if we really want to, you know, make a big change in people's health. FRIEDEN: Great, now we've got some questions from the group. Let me start with Valentina Barbacci. You can—you can speak. Q: Yes, wonderful. Thank you. Can you hear me now? Wonderful. Valentina Barbacci, based in London here, Term Member at CFR but also based with CEN-ESG. I'd be grateful for your thoughts with regards to the impact of endocrine disruptors and hormone blockers that are increasingly showing up in various you know, not just food, it's also baby products, you know, hygiene products, all sorts of things that are from—range from adult to infant care products. So, it's also in foods but predominantly in health care products as well—sorry: self-care products. And what can be done to bring on sort of voluntary disclosure directives that might then eventually lead to mandated disclosures, much like we've seen with TCFD and TNFD mandating climate and biodiversity disclosures that were initially voluntary, but have now become—or are becoming—mandated so that this kind of tip the—tip the curve a bit and perhaps that we could see something in the health side with regard to that? Maybe I'm naive and optimistic, though I welcome your thoughts. BRANCA: No, I think you're right. It's a very important topic. When we’ve been looking at obesity, we've been trying to be thorough, and really look at many different outcomes, including endocrine disrupters. It is a possible mechanism. Of course, it's an important mechanism also for other for other aspects. But for obesity, we didn't really find a major role in endocrine disruptors. Definitely the endocrine disruptors have a much greater role for other aspects of health, including reproductive health.  So, from the food point of view, you're quite right, you know, we would need to look at it more carefully. I think in Europe, there's been much more experience—there have been some interesting reports. So, I think it's been looked at more carefully. I think we are, we're not ready with that. I think we need to do much more work to be able to describe the issue. And then maybe come up with some recommendations. But it's on—you can imagine, you know, the list of things we need to look at, it's very broad food system is very broad. Endocrine disrupters is definitely one of them. It's a large category of products. It includes some products, which are already regulated, you know, such as some pesticide plus other products which are not regulated. So, you know, thank you for reminding me that but you know, I think we are only partially able to respond to them. FRIEDEN: Next is Joel Cohen. Q: Thank you for this excellent presentation, Mr. Branca. My name is Joel Cohen. I'm a professor at the Rockefeller University and Columbia University in New York City. I'd like to ask your views on dealing with childhood stunting. Approximately a hundred and fifty million children under the age of five are stunted due to chronic undernutrition and infection. That's twenty-two percent of all the world's children. At the same time, according to FAO, the world produced 2.8 billion metric tons of cereal grains last year. At four to five people per metric ton, that is sufficient to feed adequately the calories required by eleven to fourteen billion people. We have a population of eight billion people. And yet twenty-two percent of all the children are chronically undernourished. And the reason is that only forty-three percent of the cereal grains go into the mouths of people and the other fifty-seven percent go into animals and machines. I am worried about the future of our species. And by the wastage of one fifth to one quarter of our potential problem solvers by starving their brains in childhood. Could you help me understand what would be the most effective steps to dealing with this problem? Thank you. BRANCA: Well, thank you, Professor Cohen, this is a wonderful question. And you got all the numbers, right. And those are very compelling numbers indeed. So, when WHO suggested global nutrition targets to the World Health Assembly, we had stunting, you know, in as the first one. And, you know, 2012, the target was to reduce by thirty percent the number of stunted children by the year 2025. And since then, there has been actually a good reduction. But some countries, particularly the countries in Africa or in Latin America, have been successful in making progress towards these targets. South Asia, unfortunately, has been not able to respond, at the moment actually, the largest number of children with other stunting and wasting is in South Asia. So that's where the biggest part of the problem is.  Stunting is not only a food issue, stunting is a combination of issues—is about access to health and health care. It’s about clean water, it’s about adequate care by caregivers. So, there's been a reduction of stunting, because of the improvement in food security, or health care in some parts of the world, but not in other parts of the world. We're not going to achieve the 2025 targets, unfortunately. COVID made things worse. So, you know, if we have a curve of reduction, that curve actually flattened, and we had many more children who didn't stop their progression to stunting. Because, you know, food insecurity hit, families were economically hit, the services were stopped, immunization decreased. So, all of that affected stunting.  In terms of food, I think what is important to remember is that I think you've made a, you know, incredible calculation of the energy side, it's actually not just the energy side, it has to be nutritious food. It has to be access to plant food, but also some animal source foods, which, you know, a small amount of animal source foods are critical—doesn't have to be meat, it can be eggs, it can be dairy, in some parts of the world, it can be insects—that needs to be part of the diet of stunted children.  We have, unfortunately, big problem of the variety of food that children eat. We have an indicator called the Minimum Dietary Diversity, and you know, you can really see there's a correlation between those stunting rates and having diets which are very little diversified, you know, almost, you know, a couple of items only per day, per child. And then you have the combination of wasting and stunting. So, there are crises that generate acute malnutrition, and then repeated acute malnutrition crises are going to increase the problem of stunting.  So, in a nutshell, you know, the response can be there, I think there's quite some investment done by countries themselves. I mean, we've seen many more countries that are home to these stunted children also scaling up a response so that—that's good news. But South Asia still has a lot to do. I mean, Indian government has set up an important program to address the stunting of children. It's about social protection. So, we need to have much stronger social protection system. Pakistan had a very good social protection system, for example. I think India is the same in some states, but it needs to scale up. So, you know, probably it's not only a food security issue, but it's a combination of actions that governments should take. FRIEDEN: Francesco, I've heard a calculation or an assertion that each episode of gastroenteritis in a developing child—in a young child sets them back a few months on their growth curve. And I think this is the point you were making, that it's not just about calories in, it's also about clean water and vaccination and health care. BRANCA: Oh, yeah, absolutely. Actually, you know, this is something that we in nutrition, learned, you know, in our 101. There was a famous study done in Guatemala, by a gentleman called Leonardo Mata. It's a beautiful book he has written and basically was looking at, you know, the weight and the height of children longitudinally. And you could see that, you know, these children had, you know, the growth curve was, you know, like, like stairs. And then, you know, the ideal curve is like this, and then, you know, they were progressively, you know, detaching, you know, you know, they have this infection here, and then, you know, they have, you know, the poor season there, and then progressive is like that. So, absolutely, I don't remember exactly the mathematics there. But you know, it's something that happens progressively also because of a degraded environment.  We're going to see more of this because of the climate change, because climate change is going to have you know, even greater problems to the quality of water to the accessibility of water, you know, plus the seasonality of food which is going to become worse. So yeah, we need to have a much greater investment if we want to really you know, bring down the number of stunted children, and I totally agree with the previous speaker that this is something which is completely unacceptable from moral—but also, you know, this is the future of our society. And we use this phrase we need to make investment to—in brain infrastructure. I mean this is this is the future of the world and of society so, societies will fail if they don't address the standing issue. Professor Cohen, thank you. FRIEDEN: Thank you, let's, let's spend a minute on the front-of-pack warning that was really piloted in Latin America, it has now spread to most of the continent or much of the continent. What's your take on how impactful that will be and how we can get other parts of the world to take that up? Europe has gone a different route, as you indicated its route that's not likely to have the same impact, can that be changed? In the U.S., I'm afraid the current Supreme Court might preclude this type of activity. It's problematic from a current legal interpretation. Corporations apparently have the same rights as people in the U.S., and it's considered compelled speech, so, it would be a violation according to the current legal regime of the First Amendment. I don't think a different reading of the of the law would have supported that, but it's probably out of the question in the U.S. in the foreseeable future. But globally, what's the potential for geographic expansion? How can we get there, and how important is it? BRANCA: So first, maybe the impact and we're looking at data. And we need to see data. I have seen some very interesting data from Chile, I believe, that are demonstrating that actually, the impact of warning on the consumption, for example, on sugar sweetened beverages was about twenty-six percent. So even more than the taxation of sugar sweetened beverages. So, you know, it seems that it has an impact on purchasing choices of people. It's quite interesting, because, you know, the wording are simple. And everybody understands them, including young children. So that's, that's, I think it's incredible power of persuasion. So, so that seems to be good. Is it going to have eventually an impact on the overall change in the diet? That's something to be seen. So we still do not have data to say, okay, this, this has, for example, reduced obesity rates. We don't, but probably because we, we need to have a combination a package of policies, but definitely warning labels may be an important measure to take. Also, because it might for example, help on some of the difficult actions, which is the sodium reduction. So, labeling has always had a good impact on sodium reduction. So, we, we should be able to say they work and we're collecting data now in the many countries in Latin America that are doing it, it's actually not just South America. Israel has done this; Canada has introduced a similar—not exactly the same but in a similar scheme. So, we need to see what happens there.  Now can this expand? Other parts of the world are using different systems so rather than saying you know, you shouldn't—you're discouraging this particular food because it has too much I too much fat, sugar, salt, we're saying okay, this is a food and you know, overall, the combination of its characteristics make—places it into a favorable or disfavor category you know. For example, France has developed called the Nutri-Score system, which is a great from A to E. A being, you know, the green one or the one which is sort of favorable, you can eat basically, you know, as much as you like. E is the is the category in red, which is discouraged. So, that somehow is an advice to moderate consumption of the categories in the E or in the higher is scoring. A similar system is the one used in in Australia, New Zealand: the five-star system.  In reality, you know, if the outcome is the decrease in consumption of an item, the warning seems to be more effective than other scoring systems. As you say, there are challenges there, definitely the warning system is fought very, very strongly from—by the corporation, and you know, because this indeed affects their choice capacity. The warning symbols are also used to connect to other policies. So, for example, you know, products with the warning symbols cannot be distributed in schools, or products where the warning symbols cannot be marketed. And so, basically, you know, this system allows a combination of policies, which are shaping people's choices. So that's, I think that's the secret of its effectiveness.  I think, you know, if we're able to demonstrate its impact, it's something that has a future. I have something quite interesting from a colleague studying the addiction of—to foods. And that is the fact that I think the argument for having legislation against tobacco in the U.S. is exactly the argument on addiction. So that goes beyond, you know, that maybe could be a way to respond to the issue of the freedom of speech, something that, you know, affects you beyond your choice should be discouraged by public policy. FRIEDEN: If only public policy were so rational in the U.S. We have time for one more question, if there's any question from the group. Meanwhile, let me ask you about the kind of best-case countries. Are there countries where you think there's a real possibility that we will substantially reduce sodium intake or turn around the obesity epidemic, because we don't have great success stories? We've seen in in various areas—Denmark, taking the lead on trans-fat, Chile on the front-of-pack warnings—but in terms of actual impact on some of these really difficult problems, we haven't seen any countries stepping up and achieving that kind of outcome. Do you see what the ingredients might be, or which countries might be most likely to succeed or to at least undertake the effort? BRANCA: I'd like to be optimistic. I mean, we have learned from countries. I mean, the whole nutritional epidemiology has been developed based on the case of Finland many years ago, who reduced dramatically the intake of saturated fat. I mean, they were dying of cardiovascular disease, you know, more than anybody, anybody else in the world. And it was changed, and it was a lot of change in the food system. It can be done. Finland was also good at reducing sodium intakes with a combination of policies, particularly the labeling, but you know, negotiation with the company's public food procurements. Now, the UK has done some interesting work, at least they brought down a couple of grams. Nobody has really achieved the WHO recommendation of five grams per day, but many countries have brought down the levels of consumption to nine grams, you know, from very high levels. So that's, I think, already good news. But there are others who are promising. I was talking to my colleagues in Washington about Colombia. Colombia has very tight benchmarks for sodium in foods, and they now have introduced a food taxation law that actually might target those foods. So, Colombia is an interesting one, for sodium. For obesity. We're really, you know, all you know, looking into what—looking forward to what Chile is going to tell us about childhood obesity. They've really done very good things, very, very effective. Portugal is an interesting country. They have also introduced taxation of sugar sweetened beverages, reduction of marketing for—to children. And you know, I've seen data—I mean, I always want to see maybe two rounds of surveys, but you know, the first round of surveys you know, there's an obesity surveillance initiative in Europe. And you know, Portuguese children seem to be less obese than they used to be before. So that's good news. So, I think we need to keep pushing, we need to keep collecting the data. We need to keep looking for advocates. And, you know, I want to be, I want to be a bit more optimistic. FRIEDEN: Great, thank you. We're almost at time. But we have a quick question again from Valentina Barbacci. Very briefly, please. Q: I’ll make it super quick, I just love this topic. Could you speak to a little bit—regarding the studies that you found in other countries—could you speak to the environment and Tom, you mentioned the U.S. environment—legal environment—but the research environment whereby studies that aren't tied to drugs or drug resolutions are not funded? But we seem to have very good examples of studies elsewhere in other countries. And so how can we raise the profile about that—you mentioned obviously support, but could there be other investment that goes into funding those studies on a larger scale to support further rounds of data? And would it be a philanthropic model? Would it be another type of model that you would recommend, something that doesn't, you know, corrupt—corrupt, the studies itself, as we often see now, and it can be tragic when that happens? BRANCA: You have a very important point. Because we have a challenge actually in finding the resources to address—in general non communicable diseases—but now these aspects of nutrition? I think we have to rely on philanthropists. I think Bloomberg Philanthropies has been absolutely instrumental to what is happening in Central and South America. Supporting civil society, supporting independent academic research; I think that that's a model we have to we have to still rely on. Potentially, there are other ways to do that. And I think Europe has some good independent research. The European Union has funded seventy-five million of a joint action bringing together thirty countries on the prevention of non-communicable diseases, it’s exactly targeting the good practice for policies. So, philanthropists, and, you know, large funding institutions, which of course, are government related. That's what we need. FRIEDEN: Great, well we're just about a time. We heard exciting things from Francesco about a clear way forward on obesity with taxation of sugar sweetened beverages, clear warning labels that will discourage consumption, stop marketing food to children—and I would say maybe not just children, but marketing, unhealthy food, generally—healthy public food procurement policies, promotion of physical activities in schools; that the best buys have been updated. There's an economic case to make, there's technical clarity. Certainly, we always need to know more, but there's much that we can do with what we know now. Francesco, I'll give you the last word, is there anything more you'd like to say or last words of wisdom on healthy eating for long, healthy, productive lives? BRANCA: Well first of all, thank you very much for this opportunity for the very stimulating questions. I’ll think more of what we can do about endocrine disruptors, but what is most important is the fact that this kind of conversation and having a community which is—we keep thinking is really important. So, looking forward to your reflections on this. From my side, I must say that we will be going further in creating also collaborations and bringing together the countries who are willing to work together. We have what we call the action networks. So, bringing—coming together to help each other or making better action and then I think that the success will encourage us to go even further. FRIEDEN: Great, thank you very much and back to CFR to close us out. Thank you so much Francesco. And thanks to the group for joining and great questions. We look forward to validating the optimism you feel that we will make real progress making our food environment healthier. Certainly, the link you sent in the comments you made at the outset made clear how much is at stake in our health, in our economy and in our environment. Thank you all so very much.