Below is a lightly edited, AI-generated transcript of the “First Opinion Podcast” interview with vaccine and global health expert Seth Berkley. Be sure to sign up for the weekly “First Opinion Podcast” on Apple Podcasts, Spotify, or wherever you get your podcasts. Get alerts about each new episode by signing up for the “First Opinion Podcast” newsletter. And don’t forget to sign up for the First Opinion newsletter, delivered every Sunday.

**Torie Bosch: **Amid massive cutbacks to health funding, Seth Berkley says that global health organizations face a “devil’s choice” around vaccines. They can focus on bringing much-needed immunizations to people now or get ready for the next pandemic. And it’s coming.

Welcome to the “First Opinion Podcast.” I’m Torie Bosch, editor of First Opinion. First Opinion is STAT’s home for big, bold ideas from health care providers, researchers, patients, and other leaders who have something to say about medicine’s most important and interesting topics.

Today I’m speaking with Seth Berkley. Seth Berkley is an epidemiologist and served for 12 years as CEO of Gavi, the Vaccine Alliance. He also co-founded COVAX and is the author of “Fair Doses: An Insider’s Story of the Pandemic and the Global Fight for Vaccine Equity.” After a quick break, I’ll bring you a conversation about vaccine access and the next pandemic.

Dr. Seth Berkley, welcome to the “First Opinion Podcast.”

**Berkley: **Thanks for having me.

Bosch: So my first question is: Have you gotten your Covid booster and flu shot yet this season? And if so, was it any different than in years past for you?

Berkley: Well, I live in Geneva, Switzerland, so that’s important to understand. I have gotten both my flu shot and my Covid booster. They were easy to get here, no difficulties and no controversies.

**Bosch: **Is this a moment in which you feel lucky to be living in Switzerland?

**Berkley: **I mean, it’s a mixed bag. Of course, Europe is beautiful. The thing about Switzerland that is lovely: it is a country that has the rule of law that respects science, that respects academic institutions, respects institutions, and expert opinions. And obviously in my home country right now, there is some shift in some of those things, which makes it difficult to watch from over here, because of course, in the areas that I work on, vaccines and health science, we’re not seeing necessarily good decisions made.

Bosch: How does it feel to be watching what’s happening in the U.S., especially around vaccines, from abroad right now?

**Berkley: **Well, it’s hard to believe. And part of that is that if you look at the arc of history, which I like to do, the U.S. has played such an important role over the years in driving science forward and setting very high standards for science and driving research and having biotech companies and creating new tools, and to see the U.S. make a complete 180 on that and to now be having conspiracy theories as some of the policies of the U.S. government, seems very strange indeed. Of course, people ask me to explain it. I have a very hard time being able to explain that given what history has taught us.

**Bosch: **So we’re talking right after the release of your new book, “Fair Doses.” Can you tell us briefly about the book and then I’ll ask you a little bit more about it?

Berkley: Absolutely. So the reason I wanted to write the book is I think the story of access for vaccines is a really interesting one. And so really that’s kind of the body of the story. But of course during Covid, when I was the CEO of Gavi, the Vaccine Alliance, which of course I’ll explain later, we were worried that if vaccines were able to be produced, they wouldn’t get to those who needed them in poorer parts of the world. And so we created an organization called COVAX to try to make that happen.

And you know, of course that wasn’t perfect. It was the fastest rollout in history and very successful. But there were delays, there were problems with vaccine nationalism, there were problems getting access, and I thought it was critical that we tell that story in detail. And that’s particularly important because it is evolutionarily certain that we will have more outbreaks, more pandemics, and frankly, they could be significantly worse than Covid was. And therefore, it’s very important for the world to understand what worked and what didn’t. And that’s really the other part of the book.

**Bosch: **Yeah, it seems so much of the discussion about the pandemic these days is largely critical, with a focus on what public health got wrong, what it should have done differently. I’d like to ask you what you think public health and global health got right in 2020, 2021, at the height of the pandemic.

**Berkley: **Let me just start with one thing that’s wrong because I think it’s important into what it got right. And that was the communication. It’s communications, communications, communications.

And what we know in a pandemic at the beginning is, we know nothing. And so one of the challenges is you want your experts, the people who have the best knowledge to say what they think would make sense. But it’s not definitive based on science. And then as you have the ability to observe, to collect data, to understand, then of course you’re able to give better recommendations. And sometimes you have to completely reverse those recommendations, not because science is inaccurate, because you’re starting with nothing.

I mean, for example, you know, how do you come up with six feet social distancing? The answer was that was a reasonable amount if you know something about droplet spread and aerosol spread, etc. But it wasn’t based on a study that was done right before that to be able to do it. So the communications, I think, in a sense, was the big challenge.

But what did we get right? Well, first of all, I have to say that as a pundit, I was asked: How long is it going to take to make a vaccine? The answer first was maybe we couldn’t. But if we were going to make a vaccine, the fastest one before had been the mumps vaccine, was four years. And so here I said, “Well, maybe in an accelerated fashion, two years.” Well, it was actually 327 days. So that was extraordinary.

The second thing that we did is we set up COVAX. And although we didn’t get doses out exactly at the same time, 39 days after the first jab in the U.K., we had the first jab in a developing country. And ultimately, we were able to deliver vaccines through COVAX, 2 billion doses to 146 countries.

But also, if you looked at the coverage in developing countries, about 57% of the population received a primary dose. And that compares to about 67% a global average. So not quite equitable, but better than it ever been before. And lastly, I’d say we saved lots of lives, lots of lives around the world. But of course, the tragedy was in places that didn’t believe in science that made this a partisan issue. We saw people, have avoidable mortality, avoidable cases and complications because they didn’t follow the best guidelines possible.

**Bosch: **You know, we have a bit of an American centric point of view I think, a lot of the times, those of us in the U.S., and of course we’re seeing tons of politicization around vaccination as you mentioned. Can you talk a little bit about what you’ve seen in other countries, particularly in the developing world, around vaccination? Are they having similar conversations?

Berkley: Well if you go back and talk about vaccine hesitancy more generally, vaccine hesitancy has been there since the first vaccine. The first vaccine was smallpox vaccine, and right after they were first used, there were wood cuttings of people with cows’ horns growing out of their heads because the virus was isolated from cows. And so there’s always been vaccine hesitancy.

But in this case, it spread like wildfire because of social media at the speed of light. And what’s interesting is traditionally high-income countries like the U.S. actually had more of a problem for vaccine hesitancy. Why is that? Because we don’t see these diseases anymore.

So when we talk about routine diseases, you don’t see measles cases. You know, many physicians hadn’t seen any. Of course, we see a lot right now, but we hadn’t seen them. We don’t see other diseases, tetanus and pertussis, etc. So people aren’t aware of those.

And of course, then they give a vaccine and they then see a child cry or have a fever and they say, “Well, you know, do we really need to do this? Why are we doing this?” In the developing world, you just have to look down the street. Auntie’s child died or had a severe illness, or you see this, or you yourself had had an illness. And so people are much more keen to be vaccinated.

Of course, that changed during Covid because the rumors that were flying around: both intentional disinformation from Russian bots, Chinese bots, etc., but also misinformation that was provided by politicians ended up spreading like wildfire. And of course, what happens then is people say, “Well, gee, if politicians are saying this, do they know something we don’t?” And then it becomes much harder to try to resolve that hesitancy, which normally is done through local experts, doctors, nurses, village chiefs, church leaders, etc., etc. Those are the people who have confidence and they can bring truth to the populations, but this was much more difficult in this circumstance.

**Bosch: **And are you seeing that continue — the places that were hotbeds of Covid vaccine misinformation now more broadly vaccine hesitant as well?

**Berkley: **That’s absolutely happening. And obviously it has been tamped down now, but the rumors continue. And the rumors don’t just continue in broad daylight, but they’ve also been passed in things like WhatsApp groups and in private messages, and that makes it much more difficult to try to pass some information to correct any misjudgments that people have.

**Bosch: **So as you write in the book, one of the things we need to do is take lessons from the Covid pandemic because we will face another pandemic. Can you talk a little bit about your concerns about how vaccine hesitancy could end up playing out in the next pandemic?

**Berkley: **Absolutely. First of all, the U.S. is withdrawing from mRNA technologies. They’ve actually stopped doing research on a lot of those technologies. They’ve made it much harder to move those forward.

Now, I’m not going to argue that an mRNA vaccine is somehow the new perfect shining bullet, silver bullet. But the thing about mRNA vaccines is they are the fastest way we know right now how to make a vaccine. If you look at the experience in Covid, it was from the time the genome was originally published, it was 42 days, I think, until we had the first vaccine in a vial and 63 days before it was able to be injected. Nothing else can move at that pace.

And of course, if you had a pandemic that was more severe than Covid, every minute counts. And so I don’t understand why we’re tying our hands behind our back in technologies like that. If you are concerned about safety, for example, or understanding them better, the solution isn’t to pull away from them. It would be to double the amount of research so that we better understand them and learn more about their process. So I think that is going to make a difference. I’ve heard political leaders say, for example, we will never mandate masks again. And I say, “Well, if you had a respiratory disease that was causing a 50% or a 70% mortality rate, you wouldn’t use masks?” They’re like, “No,” well, I don’t believe that. But the point is we need to understand each situation on its own merits and learn from what we did, and of course, use the best technology possible for the moment to try to get the protection that we need.

**Bosch: **Yeah, it occurs to me that they say in the military that you fight the last war, right? Do you think that there’s something similar in public health where we’re fighting the last pandemic with each new one?

**Berkley: **Well, absolutely. I talk about this in the book, what happened is we thought flu would be the next big pandemic. Obviously, we have the 1918 Spanish flu pandemic, you know, which was a terrible worldwide pandemic. And so plans were made to get ready for that.

And of course, bang, it turned out to be Covid-19. Now, the good thing was we had had two previous outbreaks of a coronavirus infection, SARS and MERS, and it’s not good because we had those outbreaks, but research had started on how you design a vaccine for those pathogens. And that’s why at the time Covid began, we actually knew how to make a vaccine for coronaviruses. And that’s really important because the success rate was incredibly high for all of the different candidates that were brought forward. Normally success rates for vaccines are around 7%.

And so if you really have to have a vaccine because you’ve got some new raging disease, what you want to do then is have lots of shots on goal. And that’s why many countries didn’t buy one vaccine. They bought many vaccines because they didn’t know which of any of them were going to work. And so we were lucky, in fact, in this case that we had done that research. And this just shows the power of doing that research ahead of a pandemic. We never took either of those vaccines into licensure and never finished doing them, but we solved those scientific problems. And there we were having that preparation done when Covid hit.

**Bosch: **On a scale of one to ten, how prepared do you think the globe is for the next pandemic?

**Berkley: **Depends obviously what you judge the scale on, but low. I would say two or three. You know, we were not prepared for the last one. And since then, there are some things that are better, but we also don’t want to talk about the pandemic. We don’t want to discuss it, and we really have pulled resources dramatically away from the institutions that do the work to prepare for these types of activities. I mean, today in the White House, there’s nobody in the National Security Council who works on these issues. At CDC, they fired and got rid of many of the staff who do this work. Research in these areas has been pulled back.

So we have those types of issues. The U.S. has withdrawn from WHO. WHO plays an important role in helping other countries, etc., etc. So we are not well prepared. And one of the arguments that I’m trying to make is that this is critical to global security. Here’s a statistic that people don’t know. More Americans died during Covid than military casualties of Americans in all wars together since the Civil War. So when you think about it, we spend a trillion dollars on our military trying to be prepared to fight and to deal with security issues, and we’re pulling away from something that is evolutionarily certain to happen. And this is really one of the challenges.

**Bosch: **I mean, it must be really frustrating for you to know that statistic and then hear so much of the narrative in the U.S. and perhaps elsewhere that we overreacted to Covid, that it wasn’t actually that big a deal.

**Berkley: **I mean, I don’t know what you say to that. Obviously as a physician, as somebody who is known for the work I did during this period, I’ve met many people who spent long times on respirators, who lost their loved ones. And given the number of deaths that occurred, and by the way, more Americans died of Covid than died of Spanish flu, which was seen as the terrible disease. I don’t know how anybody can say it was no big deal. Now, there was obviously panic at the beginning, and thank goodness it wasn’t a 10, 20, 30, 40 percent mortality disease. And thank goodness we were able to create a vaccine, which of course, you know, didn’t work great to prevent infection. It did at the beginning, but as the new variants came, it didn’t, but worked very well to prevent deaths and severe disease. And so that’s where we ended up. We may not be so lucky next time.

**Bosch: **Given what’s happening with the U.S. government, with vaccine hesitancy elsewhere in the world, what do you think that global health organizations can be doing right now to prepare for the next pandemic with these new limitations?

**Berkley: **I mean, the first thing that that we have to talk about is what I would call is a “zero dose.”

That’s a concept that’s important in the work we do on vaccines. So if you go back historically, go back to 1975, less than 5% of people in the world received even a single dose of vaccine. Not all the doses, but a single dose. And today, that number is over 90% of children receive a vaccine through the routine vaccine system.

That last 10% are the so-called zero dose. That’s where 50% of the under-5 mortality rate is occurring. And two-thirds of those are living in poverty. So if we could extend the health systems out to them, we prepare better for being able to provide interventions for them.

But the other thing we also do is we provide an early warning system. And if I go back to the terrible Ebola outbreak in West Africa in 2014, that occurred in a rural area between three different countries, and it took a very long time to make that diagnosis. By the time they made the diagnosis, it had spread into a number of urban centers and ended up spreading and causing disease in many countries around the world. That’s what we’re trying to avoid.

So the critical issue here in peacetime, is building better systems and better surveillance systems, etc. Now, the challenge, of course, is that the global health institutions are reeling from the cuts that are going on now. And although they understand this is important, they also don’t want to stop their routine work. And so there’s a little bit of a devil’s choice. Do we, you know, continue our routine work and stop the work on preventing pandemics, or do we do the work on preventing pandemics and then stop some of the routine work?

And the last thing I’d say is the reason this is not a smart decision is the more we do around the world in preparing the world for it, the safer we are as a country. Of course, that’s not the only reason to do it. I mean, there is a humanitarian reason. But if you look at diseases, for example, measles was eliminated in the United States. So every time there’s measles outbreaks, it’s because there’s been new measles cases that have come in from elsewhere. That’s going to be the case with many diseases now. And if we let diseases run wild in other countries, it’s going to increase the risk for us. And so I think this is the information that if people understood I think would change their behaviors.

**Bosch: **So you said 10% of children around the world are zero dose. Where are most of those children? Are there particular countries?

**Berkley: **Well, I mean, you know, there there’s obviously a large number in fragile countries and in Africa, but there also are in South Asia and other countries. And the interesting thing is the distribution of these people. They used to be all the way in the distance, you know, that was hard to reach. That’s less the case now. Most of the underimmunized kids are either in urban slums or are displaced, you know, peoples, whether they be refugees or in displaced people camps. And so it just requires different strategies to go there.

But again, this is important because if you think of an urban slum, what an explosive environment for spread of infectious diseases, given the fact that you have a lot of density and people moving in and out and people maybe are there illegally and so they’re not so, you know, registered, etc., etc. So this is exactly the type of challenges that one needs to deal with if one wants to solve these problems.

**Bosch: **Are there any projects going on right now in particular that that give you hope?

Berkley: There are many things. First of all, the science is spectacular. I mean, we’ll see whether it sustains itself, but people are now making vaccines against tumor antigens. And so it’s going to be vaccines against cancer. We have our first vaccine against malaria, you know, a parasitic disease. And we already have a couple of vaccines against cancers, you know, hepatitis B against liver cancer and HPV against cervical cancer. So we’ve got this amazing science that’s going on, and new vaccines are going to come if we allow the science to continue.

The other thing is we’re beginning to learn new ways of delivering vaccines. So patch technologies, which can be heat stable, and those can be administered by non-trained health workers or even parents can do it. They could get it in the mail and put it on their kids. I mean, so you have that, you have max vaccines that are given through the mouth or nose, and they may give local protection that’s better. So there’s a lot of excitement in the science.

Also, we now we have new institutions. CEPI, the Coalition for Epidemic Preparedness Innovations, who was my co-founder, Richard Hatchett for COVAX. They were set up to try to make vaccines for diseases that are of epidemic potential where there isn’t a market. This is the real challenge. In very poor countries, there isn’t a natural commercial market, and so you need to subsidize it.

Of course Gavi, the Vaccine Alliance, where I used to work, has a whole set of programs to try to move forward to try to help African manufacturers get over the hump of being new producers in also trying to work to have a zero-day financing available. This was the single biggest problem we had. When we decided to do COVAX, we had no people, we had no money, we had no authority. And so we had to build that. And so by the time we began to raise that money, you know, high income countries had put orders in for not just one, as we talked about before, but many doses of vaccine. And so it was very hard to get vaccine doses early. And so these are all problems that can be dealt with, but what they need is the forethought to plan it during peacetime and be ready to go.

**Bosch: **Can you talk a little bit more about setting up manufacturing in African countries? What are some of the challenges being faced there?

**Berkley: **The challenge is that vaccines are extremely difficult to make. And just to explain simply why that is: if you, Torie, wanted to make a drug in your garage, if you did the process and then you could test it and you say, this is the right chemical, in essence, you’ve made that drug.

Because vaccines in general are living things, except with mRNA, are made from living things, you really can’t measure at the end that that is exactly the thing you want it to be. So the way you have to do it is you do a clinical trial of a product, and then you have to show that the process is always exactly the same. So the number of regulatory steps and checking steps is just incredible. And so it becomes very difficult, very expensive to make vaccines, and there’s quality assurance, quality control is critical.

So for new manufacturers, building the plant is hard because it’s a complicated thing. But you know, those can be done pretty easy in a turnkey operation. What’s hard are getting these systems in place and that obsessive attention to quality and making sure that every single run out of producing a vaccine is exactly the same. And so as you’re trying to move to new places that haven’t made vaccines before, it’s the challenge of getting that manpower, getting people trained, having the universities put people out in bioengineering and regulatory science, all of that, and then to build it up.

So there is no question Africa will get there. We at Gavi were buying vaccines from a pre-qualified manufacturer in Africa, you know, for 20-plus years. And so it can get there, but for some of the new places that want to start, it’s going to be hard. And when the first dose rolls off the conveyor belt, of course, it’s going to be very expensive. And so this African vaccine manufacturing accelerator that Gavi put together was to help those companies to say, for a period of time, we’ll subsidize those doses so that you can compete in a tender for reasonable priced vaccines. And of course, eventually you’ll have to get there on your own, but this will give you a leg up during that period and to try to help encourage this this work.

And so one of the reasons we are better off now is because developing country manufacturers stepped in a big way, as did contract manufacturers. We were able to make 11 billion doses of vaccine in 2021 alone, and that’s much more than any of us had predicted would happen. And so the capacity is better than it was.

**Bosch: **What’s something that you’re most proud of from your time at Gavi?

**Berkley: **For me, the thing that makes me happiest has been the rollout of these new vaccines and then seeing them get high uptake and saving lives and making a difference. And it’s been interesting to watch because most recently the malaria vaccine. Malaria is a disease that is killing hundreds and hundreds of thousands of children every year. In many countries, people get malaria many, many times a year. It’s horrible. It’s their biggest problem. I mean, seeing the lines of people lining up to get the vaccine, and it’s not a perfect vaccine. But you know, for every 200 children you vaccinate, you save a life. That’s pretty good. And so watching that type of enthusiasm for a tool that can make a difference is really exciting to see.

**Bosch: **Well, we have to wrap up in a second, but my last question is, what’s something that I didn’t ask you about that you’re thinking a lot about right now when it comes to vaccines?

**Berkley: **We didn’t talk about the economics of vaccines. And I think that’s an important issue. I mean, one of the things that Gavi did, if I had to list two or three things I’m proud of, is if you look at the 11 vaccines that WHO recommends for all children in the world, there are regional vaccines on top of that, but the ones that everybody should get, they cost about $1,300 in the United States. In Gavi, we were able to get that cost down to $24. And the challenge is to try to continue to reduce those prices while keeping the quality up, because of course what we ultimately want are countries to pay for their own vaccines. And so if we’re able to do that, not just for the poorest countries where Gavi is working, but for middle income countries, and frankly, maybe for high income countries in the future, given the difficulties in in health care budgets, this would be an amazing thing because it would allow us to get vaccines out even more than they were already out there.

**Bosch: **Seth Berkley, thank you so much for coming on the First Opinion Podcast today.

**Berkley: **Thanks for having me.

**Bosch: **And thank you for listening to the First Opinion Podcast. It’s produced by Hyacinth Empinado. Alissa Ambrose is the senior producer, and Rick Berke is the executive producer. You can always share your opinion about the show by emailing me at [email protected]. And please do leave a review or rating on whatever platform you use to get your podcasts. Until next time, I’m Torie Bosch, and please don’t keep your opinions to yourself.