Gretings, everyone, and welcome to this session on the economics of women's health. And thank you to the WEF for making this a mainstream session at the World Economic Forum. It's held, of course, in the context of the WEF's Women's Health Initiative, and that initiative was launched with the aim of obviously contributing to the health and well-being of the world's 3.9 billion women and girls. Now, it seems that we cannot state too often the case for investment in the health of women and girls. All the evidence tells us that obviously not only is it a good thing in its own right for women and girls, but it contributes to the overall economic performance of countries, families, that healthier women are part of more successful, more educated, more productive societies, that families with improved reproductive and maternal health are families which can report higher earnings in the longer run, that every dollar we spend on family planning services, and Nathalia, no doubt, would talk more about this, because it just has so many return benefits in many ways for health and economies. So, all up, it's a good thing, but why isn't there more of it than the question that immediately follows, and I guess those are some of the issues we want to explore with our panel today. Let's also acknowledge what an appalling setback COVID has been for the health and well-being of women and girls, particularly in loss of access during lockdowns in many countries to reproductive and sexual health services, but also the many millions of girls that we're told will never go back to school after the lockdowns because of impoverishment of families, the domestic violence that came from it, the list is long. So we've got setbacks and we've got big challenges with the sustainable development goals and gender equality. So, if we find wisdom of our panel today, we can go away with some insights and ideas as to how things can be speeded along. So, wonderful panel. I have right next to me the Minister of Women and Child Development of India. Next to the Minister is Kevin Ali, Chief Executive Officer and Member of the Board of Organon. Then, next to Kevin, Nathalia Karnem of the UN Population Fund, Executive Director. And way along the end, almost out of sight, but definitely not out of mind, is Mark Sisman, Chief Executive Officer of the Bill and Melinda Gates Foundation and let's acknowledge what tremendous support as the Gates Foundation has been of investing in women and girls. So, Minister, can we start with you? We need to have high-level political engagement in order to create a healthier, gender equitable and child-centred world. Tell us from your perspective why you think investing in women and girl child development should be such a priority. I think that if we lead from example and expressions of many a policy interventions in India with respect to health per se, there are a few takeaways from that experience. One of the largest and one of the most expansive healthcare programmes in India is currently under way called the Ayushman Bharat Yojana, which covers 100 million families from marginalised communities, from low-income group communities. They encompass close to services in 26,000 hospitals across the country where the government gives free support for medical support in over 1,300 diseases and at the same time, what it does is that it is transferable with a migration of people from one region to another geography. What it also does is, as it covers the huge expanse of the healthcare needs of those who are marginalised, it also brings to fore many achievements which have a societal impact or which have an impact with regards to some cultural narratives. I'll give you a very small example. People believed that in Indian society issues such as breast cancer, cancer of the cervix are not issues that will be popularly spoken of because women would be not as aggressive about their healthcare needs or for that matter in this segment not get the adequate support that they so desire. One of the outcomes of the health programme called Ayushman Bharat is that in the past one-one-and-a-half years there were over 130 million Indian women because of the support of this very programme have reached out to medical facilities across the country, gotten themselves scans for cancer of the cervix and cancer of the breast. After scanning, if they are in need of a medical intervention, have received that support from these medical institutions. Now this is a number which is unheard of especially in a segment of medication where people feel that they cannot be so culturally exposed. Which means that another interesting insight it throws up is that when women are enabled in terms of access and fiscal support there is not a single healthcare need that they will not address themselves. The other aspect which becomes a huge burden in terms of the financial aspects of any family unit is when you spend on pharmacology. And the Prime Minister was extremely keen to ensure that there is an available infrastructure in every district and every bloc of India which makes sure that any medicine that you need be it for cardiovascular diseases be it for diabetes be it even a stent it is available at prices which are affordable. Now that means when you enable a family to save on pharmacy needs that is an added plus to the family's income. Now in that matrix there is a special disposition for 40 female health related products. Let me give you a small example never in the history of my country from the ramparts of the Red Fort on Independence Day has any Prime Minister spoken of the availability of a sanitary pad for one rupee. That a male Prime Minister and with all my respects to the gender that I am speaking of could give India our first menstrual hygiene administrative protocol. So when we talk about how to put the gender agenda at the forefront of healthcare do we only take the refuge of let's say an insurance based programme like Ayushman Bharat? No. Where is the legislative need or gap that needs to be filled to complement our efforts for justice? For four decades in my country there was a bill pending legislative support which basically pronounced support through administration and medical communities for medical termination of pregnancy at 24 weeks. That it passed both houses of parliament without a whimper from any man or any political entity speaks volume about the maturity of the Indian populace and polity of sexual needs for women. That we have now enhanced maternity benefit for working women to up to 26 weeks is also something that we celebrate as women in my country. Apart from that I think that there is a conscious effort on behalf of the government to ensure that the whole life cycle needs of a woman's health is looked after by every government entity. For example, I lead the gender ministry in India. We run the world's largest nutrition program in the world. The Prime Minister started a flagship program which is an amalgam of 18 ministries in the government of India. It's never happened before. And we through our technology engagement service the needs and nutritional delivery at the doorsteps for 120 million Indian women and children below the age of six. It is a collaboration between citizens and government and it is a collaboration which has done us well especially in the pandemic. Ms Locke, with your permission given the time constraints, let me just expand beyond the relevance of let's say Aishman Bharat. Many a times we define health needs as the immediate health needs of a woman that needs to be addressed. There are evolutions in health needs especially given our labour markets especially given women in distress. So the Prime Minister led the establishment of emergency and crisis centres for women particularly in every district of my country. There are 703 such emergency crisis centres which are currently functional which were opened for business even during the global lockdown where we finance additionally 35 women's helplines and we have combined in our federal structure helped close to 220 million women in distress given them medical psychological and police help so that they can transition from challenges towards solutions. So if we look at the needs of women not only from let's say issues of cardiovascular diseases menstrual health but even mental health that is a huge prospect where we can see enhanced partnerships between the private sector and those who are policy makers. When you invest in the health of a woman you invest in the health of community because she is not singular to keeping or restraining that benefit to herself. When you empower her financially she tends to spend more on health and education. So let's look at health care from both perspectives not only from the infrastructural engagement but also when we fiscally empower women in other segments of society we give them more purchasing power in the health sector. Well thank you very much for putting all of those issues on the table and there's clearly very important elements of universal health coverage that you've talked about and also universal basic social protection as well and great to see the attention to the silent killers like breast cancer and cervical cancer and also the cause of menstrual hygiene which as we know is the lack of it keeps so many girls out of continuing with their schooling which is disastrous. So thank you so much for those insights. Kevin let's come to you as chief executive officer and member of the Organon Board gender equity and women's health are intrinsically entwined in the success of societies but we've seen women's health isn't always prioritised from your perspective why has progress been a bit slow and just make any comment you'd like to make about how you see this changing. Well thank you for the question. I would tell you that we could spend quite a bit of time just discussing that very topic and I'll try to be concise from the point of view of the biopharmaceutical sector which I am a leader of one of those companies in Organon. Look the sustainable development goals in terms of things like reduction and maternal mortality over the last 17 years it's the average of about 3 percentage points a year reduction when SDG you know basically says that it should be about 6 percent when we look at unintended pregnancy rates globally there about 50 percent 50 percent 5 out of every 10 pregnancies were unintended and so we all know that for many girls and many women that could basically lead them astray from being able to have their own development their own opportunities in life in terms of education opportunities to go after. Postpartum hemorrhage a woman dies every 3 minutes somewhere in the world from the complication of delivery which shouldn't be the case preterm labor there's about a million children a year that are born in a preterm labor state and the complications and the mortality and the morbidity associated with preterm labor not enough innovation has really actually been generated and focused on some of the things in terms of maternal care in terms of reproductive health for example unintended pregnancies in terms of a number of areas even I'll throw out fertility one would think that IVF therapies should be something that can solve some of the fertility needs around the world but when you look today even at the Asian Pacific countries and the Asian Pacific rim you need 2.1 in terms of per family in terms of reproducing the population in Korea it's .7 by the end of the century Korea will be half the size as it is today you can see some of the issues you read in the Wall Street Journal Natalia and I talked about this that China is actually about 1.5 China is having a population issue so all of that tells you that there's needed investment in the opportunities to bring innovation in that space and that's where the idea of organon was kind of born actually be a company that has many businesses but the direction of travel is really about investment in women's health to increase the investment in innovation if I give you a sobering statistic of the 37 products that were approved by the FDA last year only 3 were essentially targeting those conditions unique to women so there's much more that needs to be there now here's the good news the good news is there are green shoots of innovation across the world ranging from kind of the fast emerging area of femtech all the way to therapeutic advances as well we ourselves at organon have actually since the year and a half we've been live since we rang the bell at the New York Stock Exchange we've done 8 deals 2 in the medical device space 1 to solve the issues of postpartum hemorrhage 1 to solve the issue of some of the issues around any invasive hysterectomies all the way to new mechanisms of action for endometriosis preterm labour, polycystic ovary syndrome those are areas we're investing in because investment is the key now the reason there hasn't been investment over the years is very simple our industry the pharmaceutical industry is usually not gender focused they're agnostic of that they actually focus on the innovation in the R&D space whoever it actually supports but we feel their opportunities at organon to really invest in women's health not only reproductive health not only maternal health but in gynaecological conditions as well because the industry needs to see yes we believe this is a noble cause but is it a viable sustainable commercial enterprise and if commercially there are more and more innovations and more and more return on that investment then it will serve as almost a magnet it will magnetize the industry to start investing more in areas of women's health both distinctly women's health as well as those conditions uniquely or disproportionately actually impacting women everything from celiac disease to chronic cough to migraine to osteoporosis more needs to be done in the space that's the bottom line of innovation I think organon is being one that actually rings the bell that you can have a noble cause and sustainable viable commercial enterprise that ultimately can feed itself so it ultimately can go forward because any time we think of women's health as some sort of corporate social responsibility it will go up and it will go down depending on the time that we're in but if it's a viable commercial enterprise then it will be there for the long term Thank you Kevin Ryan, do you see green shoots? Are we going to overcome the barriers? I see green shoots precisely because women are no longer taking a backseat and as half the world's population the demands on the political system and I think we've had beautiful examples of transformation when women's needs are prioritized as well as the understanding that women themselves are stepping up to lead on these issues I think the examples that Kevin just put on the table for organon in terms of the wealth of possibility monetary wealth but also wealth in terms of health is wealth so from my perspective looking at certain barriers of why are women's needs not prioritized brings us back to this issue of making the case that evidence is not always enough so the transformation of the understanding of especially an adolescent girl of her human rights of her self-worth of her right to exist in a digital space of her right to not only lead but to consume products that are good for her and for her mental health these are the green shoots that not just the private sector but us as United Nations as public sector as regular citizens as fathers who support daughters we all have to embrace so it is disturbing that as we look across the spectrum of lack of priority COVID-19 told us everything we need to know about a health workforce that's almost three quarters female and midwives that UNFPA support were scrambling for raincoats of PPE-like barriers to be able to treat people in distress as has been alluded to the life cycle of women from pre-natal where nutrition is crucial and important all the way to older age and in a world of 8 billion many of us are aging but many women are voting with their feet when it comes to the size of their family I advocate of course for family planning and we've seen the wisdom by return of almost $10 for every dollar you invest in family planning and maternal health so the monetary case can be made but you also need to make the case for at a time when there is so much heterogeneity and different experiences in countries there are still 300 million women who want to access family planning that are knocking on the door of a clinic and nobody is there for universal health care as one of the key examples of sustainable development the woman who wants to limit her family size has to be catered to as well as the woman who is stigmatized because of infertility or frankly who is choosing not to have a first or second child because she can figure out the economics of trying to get a kid through school and college and the shoes and the books and everything else and that is the mission critical my last point is on geographic disparity and minister you alluded to this where you live you could be at the top of a hill in an island location your human right to health exists so looking at geography and innovation and some of the tech solutions that we can use to overcome those sound barriers but also just simple primary health care this is what is going to make a difference but listening to the voices of women who are saying this is what we need, this is what we want and we're not going to wait 100 years for the wage situation to equalize et cetera that's going to be the accelerator that we need thank you Natalia and of course in those years of waiting you're referring to it's the wefts own global gender gap the report which the figures for the year before the pandemic said 136 years to full gender equality then we have the horror year of 2020 reported on the 2021 report which said 136 years because that's how much things have regressed for women and then the latest one based on the 2021 data says 132 years so we're impatient aren't we we don't think that's an appropriate time to wait for full equality but the investments in this kind of area part of what's going to make the difference and that leads me to come to Mark Susan and say Mark from the perspective of the Gates Foundation what do you think of the most critical global health investments to be made now for women and girls so well thank you and thanks to the panel for already raising so many of the critical issues and actually where Helen started it remains as paradox even here we are at sort of Davos who's global prosperity at large where we know there is no single investment or set of investments beyond investing in the health education and agency of girls and women that has a better social and economic payoff full stop that's an uncontested fact but yet as a community whether it's from the Davos agendas to the foundation to the time frame of 132 vs 136 years it's as a world we are not remotely close to where we could or should be and so that does pull you into where and how are the investments that couldn't should be prioritized and shifted and at the Gates Foundation we've actually been to our own sort of learning where we've always prioritized health and women's health from our foundation in 2000 we've learned ourselves that we actually haven't always gone around it in a way that appropriately both listens to the needs of stakeholders brings in the communities targets particular opportunities need and you want to look at it across the spectrum so at one level one of the sets of investments exactly what the minister was just talking about in India and India has been a model in many ways of some of the things from the development of tools like development collectors that are able to collect the right agency that get you health and financial and economic and we think that is an incredibly important tool that can and should be spread in other parts of the world whether it's that linkage in on nutrition that we talked about because nutrition is such a critical enabler for both healthy pregnancies healthy birth prevention of morbidity and then providing those opportunities for later schools and access and more broadly the kind of medical interventions we talked about and this is how we've evolved our own thinking so for example there's both into the core research and development let's take an area where we are prioritising significant investment right now is there are treatments for anemia but investment in anemia which actually is one of the most fundamental challenges facing women and particularly women in pregnancy and the related effect now far, far short of what could and should be done so we are trying to pick areas like that where we think there are promising new interventions and new science that can be as priorities similarly in the area of nutrition the better understanding of the microbiome which there are lots of companies that are doing expanded research in to figure out how to do better weight loss but our research can focus specifically in what elements of treating the microbiome can actually be important in the antinatal and postnatal period for women and children and can you have again some transformative lessons we actually think the potential there is huge and so that's the kind of example of scientific areas where a foundation like ours can prioritize and target research and development is not naturally going there from private companies or others even though arguably it could or should be but we think could have a disproportionate effect but it's not just the development of the products it's also then the distribution pricing and access as Natalia was talking about some of that a sense of need say in family planning is how can you spread a different array of family planning products to make sure that women have full availability of choice there we've had partnerships including with UNFPA where you take some existing products which we know are of increasing popularity such as injectable contraceptives and what we would work with was a couple of private sector companies who didn't think there were markets in low and low and middle income countries and so we would arrange some deals in this case there will volume guarantees saying we think there is a market so if you have the price of your product we will guarantee as the Gates Foundation to make up if you don't actually make a profit at that price and reach your market they made a profit, they met their market twice as many women got access to the product as they would there are also ways in which you can produce or distribute the treatment or prioritize the treatment of new interventions we mentioned cervical cancer the HPV vaccine is a critical vaccine that has been developed and rolled out across much of the world and it's trying to, it's well short of what's needed is a major priority of Gavi providing you products including product research from some Indian and other companies around it at the Gates Foundation we were able to provide and do some research as a public good which showed the efficacy of a single dose of HPV is as much as the current thing of multiple doses that basically allows you to vaccinate twice as many children for the same amount of, again it's a study that anybody could or should have done potentially but it's an area where when you step in the gap in the public good that allows you to actually reach many more women so it's that combination of trying to identify both the key areas of research and development then the access of the products and then last but not least and maybe this can come back to that with the rest of the panel is that how do you then arrange the delivery of it through the public health systems through systems like India's significant networks and the Ayushman Barat Program through other tools because that's that last mile it actually has to reach the women and children that need to get access Yes and indeed a role of foundations I think to look for those niches which aren't being picked up necessarily by others and show what can and can be done so thank you for those insights. I'd like to bring out our audience in we've got a full room and the hands are going up already and we'll be gender equal and what we take so then you're first and you're next please introduce yourselves and maybe you want to wait for the microphone maybe stand up so people can see you as well Hello everyone I'm Sangu Delhi from Ghana and I'm a healthcare entrepreneur I run a tech-forward healthcare system with 65 hospitals and clinics across Africa and we have 7 million patients and we do this issue of women's health in particular on the African continent we're about 1.3 billion today we're about 15-60% of global population yet we're responsible for 25% of the global disease burden we only have 3% of global healthcare workers and 1% of global healthcare expenditure yet if you look at demographic projections by 2051 and 4 people globally will be African and the rest of the world's youth globally are going to be in Africa in fact more people are going to enter the workforce in Africa that year than the rest of the world combined so literally over the next 2 decades and change we expect over a billion babies to be born in Africa yet if we look at what's happening with our doctor to patient ratio and the chronic shortages that are starting to happen in the west every single day and the challenge I have in my hospitals are doctors and nurses being poached to go overseas yet we're the continent that needs these resources the most so pragmatically speaking what can we do to ensure that the continent that is going to be the world's future and is going to produce the future workforce will be able to have the right infrastructure and the right personnel for the future Natali, can I give you a go at that point well you've absolutely succinctly gotten to the heart of the matter which is equity and also the question of the future of the global world because Africa in a sense leads in the disease burden but also the innovation, the imagination and those young people who have to be equipped also come from Africa and Asia too will be part of the burgeoning population increase but the rights and choices of an individual girl but also of the nurse the doctor etc being buttressed at home makes so much more sense than trying to export them and or play the catch up so the wisdom of the African Minister of Finance health system universal health coverage system of building a workforce for example midwives who were trying to double the availability of midwifery looking at primary care but also making it more attractive for the workforce and many of them the preponderance of them being female is part of the solutions orientation that our panel represents today and I think that solution is coming from private sector actors who are the bulwark of the health system in Africa like everywhere else so the donated contraception that UNFPA provides is all very well and good but women are paying for services so thank you for the question and I think that really well summarizes the urgency of the types of innovation and social policy that we tried to put on the table Kristina so thank you can you hear me? I'm Kristina Lloyd and I'm the global leader of the fairings reproductive medicine maternal health portfolio and first of all I would like to thank all of you here and I'm really happy that fairing is a part of co-shamping this forums flagship this initiative which we're really proud of being here and I also would like to thank for joining us here and together and then you and UNFPA and Howard School of Public Health so that's fantastic so we are here in this coalition to try to work together and I think we are sitting here and everything we say should nobody say no we don't need that why don't we turn everything upside down we have to create a common narrative and this is also what we are doing and we are also creating a white paper based on data investments cases and we are trying to build business models that everyone can understand so and I would also like to say that listening to everyone here I'm going to call this an obstetrician myself I've actually been saving life during my days and then I was in healthcare with good equipment, medicine and everything so I do understand this is the purpose this is also what we as actually competitors are working together and this is the beauty of it I think so my question is back to the narrative that how can we do that to even more create this clarity of why it is a smart thing to invest in women's and girls health it's not about cost we are not talking about cost of healthcare we are talking about investment in healthcare this morning the same thing again so can you please tell me what could the narrative what could the story be to ministers of health and head of states and CEOs and so on so we can create a common narrative because we all have our stories and I'm so impressed listening to what you are doing so once again how can we create that and what could this question be and what can we ask them to do well I'm going to throw that question to the Minister of Women and Child Development of India because listening to you Minister I think there have been some very compelling arguments which have loosened the purse strings of the important things I think it's not about loosening the purse strings it is about spending what is in the purse mindfully there are two or three things that I would like to hear flag one is do we look at healthcare very myopically can there be a bigger narrative around women's health let me give you another Indian example the Prime Minister in 2014 when he took office spoke again very unusually about a very unglamorous subject which was can we build toilets for women now when he said that he spoke not only from a perspective of sanitation healthcare he spoke about it from an education point of view as Helen has said that there are many girls who drop out they are part of the menstrual cycle age in one year we built toilets in every government school in the country we curtailed dropouts however on a larger scale the government built 110 million individual household toilets now people would presume that there is a health benefit to it in 2013 there was a world bank report that because of lack of sanitation services there is a negative burden of 6% on Indian GDP so while he was addressing a gender justice issue he ended up addressing an economic issue but also a Lord Norda issue because there were reports out there in public that 40% of sexual violence took place when women went out to defecate so when we look at issues of women's health or women's dignity or justice there is a multiply effect when you try and reach one solution now apart from losing up the purse strings it is about partnerships so Mark is very eloquently spoken about what the Gates Foundation has done but what is significant about what he said is that they help fund the confidence that is needed to transition from failure to success to say that injectables will find a wider market till such time a partnership evolves from let's say a foundation like the Gates Foundation supporting industry impacting policy makers I think we need more and more players who will bridge that gap so apart from only looking at an initiative of women's health from the myopia of possible infrastructure or the myopia of only policy making it is us on this panel who are a part of the solution no individual entity in governance or the capital market or corporate infrastructure can be the answer alone I also feel that another myopia that we are inflicted by is when we talk about women's health we speak about women from a constituency of consumption how many of us are very focused on health innovators who are women who do frontier breakthrough work on research but do not know how to convert those innovations into enterprise because there are many entrepreneurial ventures innovations which are cost effective given the diversity of geographies which are culturally easier to ingest by many a countries when they evolve very organically from communities how much of our concentration from a health care perspective is even on those innovations lastly from a talent point of view I gentleman speak about the African challenge how do you address that challenge from an academic perspective we in India under the prime minister's leadership now have institutionalized health care education in every district of the country not only doctors paramedics, nursing communities those who are indulging in telemedicine it is a huge ecosystem that needs to evolve and find successive support across segments of policy making governance, civil society and corporates so if we start looking at the system as a whole we are addressing it as a coalition Mark spoke about in India a coalition of women who are entrepreneurial in nature 80 million of them they manage credit only within that segment of close to 30 to billion dollars every year they are available in every village in India they scale up and scale up on the supply chain from a crafts perspective agro processing perspective agents of change when it comes to health and when it comes to academics for women so how do we find new resources for communication with regards to women's health and lastly speaking as a mother of two kids what we do as women irrespective of our financial background we tend to put ourselves last when it comes to our pharmacological needs and diagnostic needs no matter who you are no matter where you are you do this as a woman your diagnostics needs are the last refuge in your healthcare framework so can we have more education and conversation around the diagnostic needs and the pharmacological needs because currently most of the conversation is about what do you do when you are in trouble how much are we investing or how much are we strategising with regards to preventive healthcare when it comes to women and young girls can I ask do we have Cynthia McCaffrey in the room yes Cynthia from UNICEF now take your questions Cynthia my name is Cynthia McCaffrey I work at UNICEF India and I actually have worked I feel like for four of you on stage because I've been at UNICEF for a long time so UNDP, Gates, UNFPA and now in India I work for the minister so so we're a partner but we're very proud to help implement the incredible very tangible initiatives that as you talked about Anjumandi frontline workers for example getting people trained my question is picking up on this point about women are beneficiaries but how to make them more of the shareholders and the decision makers around healthcare so that they're the real players when it comes to building this global health ecosystem let's start with Mark down the far end I can still see you it's a great set of questions and that is the fundamental issue there's no one set of interventions it's a whole scale of interventions from the models and examples that you do dress and bring in at a policy level with finance ministers and prime ministers who often don't have the same kind of leadership that the minister was talking about India need to be educated as to why and how this is so critically important and you can link in those economic issues it's about proving the products and the models so that you can show that that's true whether you're at a district level whether you're for the communities themselves for mothers to know if you're investing in this in the nutrition for your children or whatever it might be you're going to get these outcomes and then you've got the tools and things available for them but it's also about I started with that sense of a women's sense of agency and purpose and we know that that is still such a fundamental barrier for a whole range of those going well beyond healthcare but to take one example you refer to that by putting all of our health areas together our maternal child health areas into a wider gender equality team and we know that we've been doing this for a couple of years linking it to our women's economic empowerment it's allowed us for example to do work which we've been meaning to do for a while but they're not being completely silo-wised for adolescent girls and young women where you say for the agency for prevention for example we know that the highest incidence for HIV incidence remains 16 to 24 year old young girls and women particularly in sub-Saharan Africa it's not simply about schools it's a set of behaviors agencies understanding the motivation understanding the roots by which they might be able to access that kind of healthcare and that's true because it's that same group needing to access family planning products it's the same group we want to make sure staying in school and being educated it's the same group we want to be sure are perhaps joining some of those self-help groups as they come in more rural areas it's the same group who we hope are getting a ladder in a bank account for the agency and so on and so I think there's a short-term set of interventions around the specific things but there's also just a long-term connective tissue of building those connections and understanding that starts with basically providing power and agency to the women and girls themselves because that's the best way of demanding those outcomes and results time is always against us and we could get so much more from the panel and from the audience which we really don't have time for but I think we've had a wonderful mix of the practical examples from the Minister of what can be done Kevin loved your sort of can do, there's opportunities to innovate in this area UNFPA and Nathalia are always out there advocating making the case and actually delivering in real time to so many and Mark gates out there looking for the neglected areas and how to support women and girls in this area so some great takeaways I'm going to call on Shyam who's head of the health care practice here at the weft for his concluding comments Thank you Helen and as you said we are out of time so I'm going to be very quick here first of all thank you for moderating such an excellent panel discussion and we're so glad to hear from you Minister Irani from Kevin, CEO of Arganan from Nathalia UNFPA from Mark Suzman CEO of Foundation so you can see Gates Foundation so you can see you have the public sector private sector, United Nations and the charity for philanthropic organization here so bringing all this together listening to you that excites me that tells me that we are thinking about women's health we are going to do something about it this is an exciting time one thing I would like to just bring it to your attention especially to you Minister Irani and we were discussing this earlier today in a health care policy session we had two health ministers we had the health minister from Germany we had the health minister from India and we had a few finance ministers we had the ex prime minister of UK Tony Blair there in that session and it was very clear that now we are investing in health care we are talking about especially the finance ministers they were talking about health care as investment and not as a cost so this is really good to hear I want to hear the same thing for women's health that it is an investment and like our ex secretary general Kofi Annan UN Secretary General said investing in women is reducing poverty so that is very important and it's happening now so on the G20 side I know India is holding residency for G20 for this year we have been talking to Ministry of Health and Welfare I think it would be great for us all of us to lobby to highlight women's health as one of the health has ended up for G20 so that would be my request to you done and with that I know we are out of time so I would like to thank everyone for their support thank you


Hello, I'm Jeffrey Sachs and welcome to Book Club with Jeffrey Sachs. This podcast is a special edition because we're going to speak today with two of the members of the Lancet COVID-19 Commission, which I've been fortunate to chair. So we'll have three of us from the Lancet Commission talking about the final report of the Lancet COVID-19 Commission, which has been released at the UN General Assembly this month. It's a great pleasure and great honor to be with two very esteemed members of the Commission, Maria Fernanda Espinosa and Srinath Reddy. Let me introduce my two colleagues briefly and then we'll get started in the conversation. Maria Fernanda Espinosa is a world-leading diplomat. She was the president of the United Nations General Assembly during 2018 to 2019. She's from Ecuador and has been a leader in her country, a minister of defense, a minister of foreign affairs, and she is well known throughout the whole world for promoting multilateralism and social justice. Dr. Srinath Reddy is another extremely distinguished member of the Lancet COVID-19 Commission. He is president of the Public Health Foundation of India, a leading cardiologist of India as well and is also globally renowned for his leadership in public health and has served as an advisor in many capacities to the World Health Organization and to other global health activities and panels. Thank you for joining today Srinath and Maria Fernanda, it's great to be with you. We're at the end of a long labors releasing the Lancet Commission report after two years of work. I think it's right to say that when the Lancet Commission was launched in the summer of 2020, a few months after the start of the pandemic, we thought we'd have perhaps a year of work and the pandemic would be over and we would do a wrap-up. We would be able to do a review of what had happened. After all, when SARS broke out in 2003-04 in China, that pandemic was also very frightening, but it was controlled within a year, more or less. And I think I thought that this one would be something similar. Well, here we are more than two years after the launch of the Lancet Commission and the pandemic continues rather strongly with new variants, with thousands of deaths every day by one estimate around 3,600 deaths per day worldwide, with an estimate of perhaps 15 million people currently infected with one or other variant of this virus, SARS-CoV-2. So we're not done with this, but we did decide to issue our report so that we could gain some lessons and make some recommendations to the world. So that's the background. I should mention for listeners that the Lancet, for those who don't know, is one of the world's leading medical and public health journals. The editor of the Lancet, Richard Horton, a very esteemed leader in public health, invited me to chair this commission now a bit over two years ago I reached out to Dr. Srinath Reddy and to Maria Fernanda Espinosa and to about 26 other commissioners to join this effort. And in addition, we invited experts to be participants in more than a dozen special task forces on COVID during this period to give advice to the commissioners and to provide invaluable inputs into the final report. Well, here we are with the final report, but not the finality of the pandemic. And Srinath, maybe I will turn to you first. You have been a leader worldwide in confronting this pandemic and also a key leader in India, making recommendations, sometimes listen to, sometimes not, but watching very, very closely day to day, we can say, the dynamics of the pandemic. Could I get your general thoughts as we get started? Then I'll ask Maria Fernanda, then we'll turn to the commission itself. Jeff, as you said, we thought that the pandemic could be discussed in the past tense by the time we finish the report, but it is actually very much with us. And to some extent, it's a valuable lesson because we know that there are only two viruses which were actually, in a sense, eradicated. Smallpox and the one which was actually in the animals, which are in the pest. And other than these two, we have not seen any virus eradicated. And we know that respiratory viruses tend to stare out. The principal objective of this effort to combat the virus would have been to try and reduce the transmission so drastically so that people who are otherwise vulnerable to severe disease and death could have been best protected. And for that, we needed to control the transmission and also protect people with vaccines. And these two were the two efforts that should have been made very energetically right from the very beginning. But because of several faltering steps initially and some level of indecision, even midway, and then also seeing a considerable amount of politically motivated misinformation, misleading people's responses, we have seen the pandemic out of control in many countries. Now we have gained a fair amount of success, but there are many lessons to be learned from this pandemic as to how we could have handled it better and how in the future we ought to handle the pandemics much, much better with better preparation and response. Thanks a lot, Srinath, for getting us going. And Maria Fernanda, let me ask you for your your overall view more than two years into our work and going on two years, nine months into the global pandemic itself. How you see things? Well, first of all, I think that as Srinath mentioned, there were there are so many lessons that we can learn from the way humanity handled the pandemic. I think it was a stark reminder that we are as humans interdependent and vulnerable in that we need each other in that solidarity and concerted action in multilateral solutions We have witnessed that going along responses to not work regardless how powerful a country is your own country, the most powerful country in the world, you know, have had so many challenges in addressing and managing the pandemic. We also learned that strong healthcare systems and universal health coverage are critical, that we need to be better prepared. In terms of the actors, we also learned that it's not only about government. It's about local governments and cities. It's about civil society. It's about the role of the private sector playing a decisive role. And we also learned that science matters. And if there is one thing that works during the pandemic is scientific cooperation, even cross-border scientific cooperation in historical quick development of the vaccine. But again, you know, the governance structure, how to deploy the vaccine, how to make sure that we had like these vaccines for all, leaving no one behind and kind of model did not work. And we also knew that it was not only about having access to the vaccines, but also a deployment of health infrastructure as critical. We also learned that regions play a critical role, regional cooperation and integration. We have seen also good examples coming out of the African Union of ASEAN. A little later, in these two years, but Latin America and the Caribbean also came up with a well-orchestrated plan. And when we look at the global architecture, we have learned that we need a lot of cooling, a lot of restructuring, giving more authority to WHO, having a better orchestrated choreography among UN agencies and programs. We learned that we need more resources, more money in a better equipped and funded WHO. And at the end of the day, I think that we are in the process of rethinking the global health architecture. Just last week, there is a new intermediary from that was approved by the World Bank. The World Health Assembly has mandated for the negotiation of a new pandemic treaty that are intimating. The problem is that time is a mess, the sense of urgency. We only think that in 2024, we will have the first draft to start negotiating a pandemic treaty. We basically, the call will be for speedy action, for learning from experience, from understanding that strong health systems at the national level are critical, that we need the resources, especially for the middle-income and low-income countries, that we really need to build an overall multi-level governance choreography, a better equipped UN. Let's recall that the UN General Assembly did not have a plan B in terms of the working methods, even of the assembly under lockdown conditions. So there is a lot of lessons learned, some success stories like the scientific cooperation to develop the vaccine, but we really need to retool our institutional staff to deliver better and to be better prepared. Let me put some numbers on this. Our report is pretty negative in terms of response for one overwhelming reason, and that is that the current estimate is that around 18 million people have died so far from this pandemic. So we're talking about a staggering burden of disease, a staggering shockingly high level of mortality, and we know how much disease has gone along with that mortality and how many people are struggling with long COVID till today. So this is a disease outbreak that was not effectively controlled. It was not controlled after a few hundred people died or a few thousand people died, were in the many millions. And while there are uncertainties about the numbers because it's not the case that each death from COVID is reported, it's not the case even today that there is a standardized reporting system and that we have truly accurate and precise numbers. Best estimates are something on the order of 18 million deaths. So you emphasized, Marie Fernanda, and I think our report really turns to this on almost every page.  We first observed the outbreak of COVID in Wuhan, China. It's not absolutely sure that that was the first place of the pandemic, but it was the first place that an outbreak was observed. And the observations are from December 2019. I think it's right to say that by the time this was declared to be a public emergency of international concern, that the phrase of art adopted by WHO towards the end of January 2020, the virus had already spread quite widely. It was already in many places in the world. And we know that within a few months after that, the virus was already in all parts of the world. The response from the start, I would characterize as each country basically on its own. WHO, the World Health Organization, made an announcement warning the world that there was a crisis. And it made that announcement in the final days of January 2020. But then, to my surprise, rather than high-level officials quickly consulting each other, putting together working groups that would work together on this, we had national leaders doing whatever they felt they would do. And in some countries, national leaders ignoring this news altogether so that whatever was done was even left up to local officials or individuals. I recall vividly the early days of this news in the United States. Donald Trump, who was president then, told the American people, don't worry, it's nothing. Won't bother us, won't affect us. Well, that's now in a perspective of an estimated 1.2 million deaths in the United States. Of course, I'm referring to the estimates, not the recorded deaths, but a huge number of deaths, absolute disaster. It did affect us in the United States, but Donald Trump, as president, found it inconvenient, let's say, because 2020 was an election year. He didn't want that news in an election year. And for several weeks it was mass confusion. There was also mass confusion, because we were told, don't worry about face masks, which is quite interesting. Even our public health officials said, don't worry about face masks. Now they say they didn't want to run on them. There was a limited supply. They wanted the health workers to get them, not the public, but there was a lot of confusion. And that confusion triggered a lot of conflict and consternation that has lasted until today, except more or less in one region. And that is the Asia Pacific region, or what WHO calls the Western Pacific region, maybe because that region had experienced sorrows directly. People first were very suspicious from the start. Some countries said, you know, there's something going on in China. We're going to limit travel right from the beginning. And flights were stopped, or screening took place very rapidly. Some of the countries in the Asia Pacific came up with test kits very, very fast. China went into an early lockdown. And throughout the region, people put on their face masks because they had been used to it in the SARS period and some other epidemics, flu and some other epidemics that had hit the Asia Pacific region. I mention all of this because in the Asia Pacific, more or less what Srinath said and recommended back then and just now, lower transmission rates dramatically actually were that was achieved in one part of the world, China, Taiwan, Hong Kong, Australia, New Zealand, Korea, Japan, not perfectly, but the transmission rates were kept quite low and the death rates kept quite low. Let me ask you, Srinath, how it was in India, of course, a vast complicated society, many poor people, many slum regions, a lot of a lot of variation across a vast country of 1.4 billion people. But you were watching and making recommendations from the start. So how did it play out in India? It is a mixed experience in terms of some things which were done well and some things which were not done very well. Fairly early on, there were flight restrictions from China. But then again, there were some super spreader events. But a very prolonged national lockdown was imposed in end of March 2020 and that was eased only in June 2020. That did enable the central and the state governments and the health systems to really prepare for a possible spread of the virus in a much larger area in terms of a much larger dimension. And we saw that the first wave was reasonably well controlled and there was very good coordination between the central government and the state governments. But we experienced the shortages of masks, shortages of personal protection, other equipment as well, test kits, and of course ventilators and oxygenators. So India decided that we were going into a self-reliance mode so that we'll actually step up our production. And to that extent, I think India continued to go that path with some success. But where we landed into problems was by early January when it appeared. January 2021. When it appeared that the virus had indeed faded out, despite the fact that now the Alpha variant had already landed in India, there was a feeling that we could go ahead with life as normal. A number of super spreader events were permitted, whether it was elections to the local bodies of the state assemblies, religious gatherings, sports tournaments, and unrestricted travel, and very little emphasis on COVID appropriate behavior at this point in time, though that advice was given during the first wave in the latter part. And this resulted also in the Delta virus variant emerging in India and having a devastating effect in March to May 2021. And millions of deaths. Several deaths. I mean, the numbers are disputed, but there were several deaths, certainly. And therefore, with a lockdown being followed by laxity that meant that we gave the virus and the emerging variants a super highway to travel. And the rural areas which were not initially affected in the first wave were now open for the virus to spread very fast. And we saw the virus really claiming territory everywhere and claiming lives everywhere in India. And that was the problem. But then we managed to get a ride together later on. And by the time Omicron came in, I think we had a much better response nationally organized. But this has been still a little patchy across the country. Some states have done exceedingly well throughout. Some states have done somewhat well in the first wave and later in the Omicron wave. But most states faulted during the Delta wave. Maria Fernanda, can you give a perspective from Latin America again, a large region with a lot of variation? But it was a pretty heavy hit throughout Latin America. Well, it was like a movie of horror. I have to say, Jeff, even in my own country in Ecuador, the first wave hit so hard because we have weak health systems. Because of the austerity policies that we all know, governments were cutting down in healthcare workers even before the pandemic. And then, of course, there are better situations than others. But let's recall the horror movie of Brazil, the horror movie of Ecuador at the beginning, where dead bodies in the middle of the streets staying there for days because they were, the infrastructure was not right, but also the protocols, the decisions on time. And that brings me on the regional integration mechanisms were so weak at the time. There was no regional response, for example, regional procurement for the scarcity of protective equipment. So there was no regional orchestration of the response. And countries are small in Latin America. Most of them excluding Mexico and Brazil, basically, we were incapable to share experiences with practices among us. We think a year and a half later, unfortunately, a strong response from the lack of community of Latin American and Caribbean countries, shaping this public health reliance plan. But that was a year and a half later, after so many hundreds of millions of deaths. So the point here, and just following up to Srinac, during a pandemic, a virus does not respect national borders. That is so clear. So what we need is global protocols, global responses. We need international health regulations to be bold and mandatory for everybody. Otherwise, for the next pandemic, we will say, oh, that was a success story. This was an interesting case in New Zealand, or this particular city. We need international health regulations that are binding, protocols that everybody follows, and not only in terms, in the case of COVID, in terms of the social behavior, the social distancing, the equipment we had to use, the use of masks, but also in terms of the supply chains, the shipping companies, the airlines, and there are multilateral organizations that have to deal with this. The International Maritime Organization, it's a UN organization. The International Civil Aviation Organization, it's a UN entity. And WHO should be on top and to say, airline companies should behave this way, A, B, and C, and not leave to the freedom of each airline company to have their own protocols, to invent their own rules, as same goes for schools, for example, which were, you know, at one point, the spaces for transmission, especially in Latin America. So what we have learned is a lot. Regional integration is extremely important. Global orchestration is important. It's important that during a health emergency, WHO keeps its authority role on top of everybody else, including on top of the multilateral financial institutions to ensure proper supply chains, to do, you know, what the international health regulations should be doing right now. Thank God, now we are in a profound review process of international health regulations as part of the treaty, of the pandemic treaty development process. I think it's really worth underscoring this rather striking fact that after the pandemic broke out, after the world was notified of the pandemic, after the early wave was seen worldwide, the actual decision making was not multilateral in almost any case, but rather went to national governments and depended on the personalities or the vagaries or the understandings or the misunderstandings of national leaders with very little role of international guidelines, much less international protocols taking effect. If you think about the Americas, I mentioned Donald Trump. He had his own views and his political motivations, but we saw the same in Brazil with the Bolsonaro denying that COVID was going to hit Brazil. We saw the same thing in Mexico with the AMLO president of Mexico saying, don't worry about this, go out, live. In other words, absolutely dependent on personal or political agendas of national leaders with very little content, I would say from systematic public health or international guidelines. And I recall as part of our commission's work speaking with the global civilian aviation authorities and there were no rules. They were basically making them up as we went along. I think the clear point of all of this is both a lack of preparedness and that meant that most regions were not only not ready, but not especially informed of the public's, even less informed about what to do. Again, with the Asia Pacific standing out probably because of SARS, having hit the region 15 years earlier. And so for a lot of that region, it seemed like a sequel and the protocols were a bit better understood, but also because of the vagaries of national politics. We all know that the debates over lockdowns became ferocious in most of the world. I think it's worth following up on Srinath's discussion of India to make a logical point, which is not so logically understood, I would say not so often understood. When an epidemic disease or a pandemic, meaning that it's an epidemic in all parts of the world, breaks out, there will be stages and even in the best public health response, there will be stages. First, the outbreak itself, then some spread within the community. Now, then came lockdowns in many places, including I think rather heroically in India, for example, where a lot of poor people faced a lot of hardship, but the government said we have to lock down to slow the transmission. But many people until today have attacked lockdowns as something that is absolutely devastating and destructive without understanding a basic point. And that is that lockdowns are meant to be temporary measures to be lifted once the transmission is down, not giving up on control but using other more precise methods of control. And I think this is a point not well understood. The idea is to go from lockdowns to other public health measures like testing, tracing, and isolating people who are infected, using the public health system to identify outbreaks, and continuing with masks and control of the so-called super spreader events or huge events. If you do a lockdown and keep it, it is devastating. If you do a lockdown and eliminate it and just go back to business as usual, the virus comes back, business as usual. The full epidemic comes back, business as usual. So the error of a lot of countries was first to ignore the virus or to pretend it would go away or to pretend that there's nothing to do. Second, to have a lockdown, usually a quite controversial step, but to fail to follow it up with the appropriate controls for the longer term that are more targeted, more precision-oriented, less onerous, but still present. And Srinath mentioned the fascinating and really sad part of India having gone through a tough lockdown, having gotten the virus really under a lot of reduced transmission, potential control, but then because of the reduction of transmission, the feeling in early 2021, a year after the start, that one could go back to normal life and then came new variants, especially the Delta variant in the spring of 2021 and the devastation that followed. Now, all along the idea was that these public health measures, whether it's a lockdown, whether it's testing and tracing and isolating, whether it's wearing masks, whether it's stopping superspreader events were to be followed by more openness once vaccines and medicines and treatments would come as soon as possible. And there we had good news because the vaccines that came along came faster than ever before. And that was a very positive sign, but I think we all can add some reflections on the fact that when the new vaccines came, the world once again was not ready for cooperation on ensuring the proper reach of those vaccines, even for vulnerable people within countries that had developed or produced the vaccines, much less for poor people in other parts of the world that were not producing or developing vaccines, but depended on the rest of the world for the vaccines. Maybe, Srinath, you could reflect on that phase of the epidemic when the vaccines really started to be available in 2021. I believe it's absolutely important to have had global solidarity manifest itself at that point in time. The vaccines did become available, but the mRNA vaccines, for example, were hoarded. The cost was prohibitive. The conditions for providing them to low and middle income countries were sometimes exploitative in terms of asking for sovereign assets to be pledged, permanent indemnity to be granted, reluctance to share technical expertise and technology transfer. India, of course, managed by producing its own vaccines, but that doesn't mean that countries will have to always depend upon their own resources, especially since vaccine production capacity is not well distributed across the world. It's not just the capacity to receive vaccines from elsewhere and distribute, but I believe the scientific ability and the technological capacity to produce a number of these vaccines and drugs also must be well distributed across the world. That's where global solidarity would come in. And some of the high income countries which hoarded the vaccines and were reluctant to share them learned the lesson also that the variants that developed in under vaccinated populations will sneak through their defenses and re-enter their populations and cause fresh outbreaks again. So truly, it is absolutely necessary for all countries to be together in containing the virus when a pandemic strikes. And the vaccines have had an impact in terms of preventing severe death, hospitalization, and severe illness, hospitalization, and death. And we should have made the best use of them. Initially, when they were in short supply, the people who are most vulnerable, whether they were the elderly or those with comorbidities or those when confined group crowded conditions, they are the people who should have been protected. But once they became available in abundant supply, we should have actually ensured that the scale of distribution was globally available and would have protected the global population so that the weaklings do not really now begin to produce variants that get back into other populations and recycle the entire infection all over again. I think it is absolutely essential that this scientific capacity is also well distributed and not treated as a matter of charity. Maria Fernanda, you've been campaigning on this issue and with a lot of reach, obviously, is one of the world's top diplomats. What's happened? Why has this been so hard? Why aren't we much farther along on the equitable access to the medicines and vaccines and other commodities to the sharing of scientific capacity and production capacity? What's going on if you can help listeners to understand? Well, I would say sometimes it's very difficult to explain human behavior. We knew that the vaccines for all formula was the big protection against the pandemic and we used this phrase that has been repeated millions of times that no one is safe until everybody is safe and in spite of that we saw countries, rich countries, hoarding on vaccines, buying four and five vaccines per person in their countries where in the time for the poorer countries, the developing countries to have access to the vaccines was huge in many, many months that we could witness that poor countries could not even have access. And once they have access, then it comes what you need to deploy the vaccines on the ground, the health infrastructure that is so weak in so many countries of the global south. As we know, there was a multilateral mechanism that was established to guarantee the access of vaccines to all, especially the developing countries, the COVID, the COVID facility, which was a huge, a multilateral fund with the participation of the private sector, of the pharmaceutical companies and basically this COVID facility was chronically underfunded. They didn't have enough money and they didn't have enough supplies and there were fights among countries who to give the vaccines to. Is Ecuador more important than Bangladesh? Who is more important? You know, the discretion of providing the vaccines to one country or another, meaning again, the multilateral response, the COVID facility did not work in the way we would have liked. And it means that we need an improved COVID plus facility both to resolve the problem of underfunding and to resolve the problem of distribution and decode. And the other issue that you mentioned, technology transfer, the issue of intellectual property rights to the countries.  You know, and it's partially true what we need is proper technology transfer when we are dealing with a health emergency worldwide. So the trade, the finance sector, the health sector, and the political sector have to come together to ensure that responses, that the solutions are accessible by all, regardless of your income, regardless of the place of the world where you are.  And I think that the moment we're living, the shaking of a new pandemic treaty or agreement, the review of international health regulations, this intermediary fund that was just established last week under the umbrella of the World Bank. I think that we need to learn from experience. We need to do things better and we know what to do. The issue is the political real, the generosity, a new culture of multilateralism. Well, our report is really grounded on this case for global cooperation in many specific areas that we have discussed. I want to close our discussion with one of the most contentious and still unsolved issues just to bring everybody up to date. We looked also in the Commission at the question how this pandemic arose in the first place. We didn't reach any conclusions because nobody has firm conclusions to this moment. We still don't know where the virus SARS-CoV-2 that causes COVID-19 disease, how it arose, where it came from. And I think that it's worth pointing out that this is not only a scientific and practical puzzle of the highest urgency, but another case where there hasn't been adequate global cooperation to find out something that we need to find out. I'll just do a quick summary of this and ask either of you to jump in on any of these points. But to summarize what we learned in two years, we learned that there really are two viable hypotheses. One is that this virus, which is like the virus that caused SARS, also emerged like SARS from an animal that infected a human. And this is certainly a possibility. It's how many new diseases emerge as a so-called zoonotic transmission. And we know that ultimately SARS-CoV-2 is a kind of virus, a coronavirus that is in bat populations, a Sarbacovirus. So in some sense the ultimate progenitor of this virus is in nature. But then there's a second hypothesis that must not be dismissed, because unfortunately it is also quite real. What we have come to understand better in the last two years is that there was a tremendous amount of laboratory research on SARS-like viruses and manipulation of those viruses in ways that were not safe or overseen, let's say, and in conditions that were not adequate in terms of biosafety. Dealing with the very dangerous pathogens, scientists man those body suits that you see in pictures, but that was apparently not the case in working on the SARS-like viruses in the research leading up to 2020. Now we know that teams of U.S. scientists and Chinese scientists were working together on this. So this was not China alone or the U.S. alone or any other place alone. It was a global collaboration, which we generally like. The U.S. government was funding a lot of this research, especially the National Institutes of Health, but also other parts of the U.S. government. But what we have found, unfortunately, is that some of this research was clearly quite dangerous and at least potentially could have given rise to the pandemic because what the scientists were doing was actually genetically altering the naturally collected SARS-like viruses to see what would happen if they had different parts of their genome changed. One notable set of experiments involved a part of the SARS-like virus that was a target for research involved in the so-called spike protein that we all have come to know so much about. And there was genetic manipulation of the genomic sequence of the spike protein, putting in something that scientists call a furan cleavage site, apparently, as a target of this research. Well, suffice it to say we are stuck till today with two hypotheses, both of which are viable. And we heard a lot in the commission from scientists who said keep open the investigations on both hypotheses because neither is settled. Absolutely not certain that it came from a market as has been sometimes said in the news. There's lots of possibility that it came from a laboratory instead. Keep open the investigation. But here I'm afraid we also found that governments have not been forthcoming. One of the reasons we know about some of this research in the U.S. is that the research protocols or proposals were leaked, for example, from the U.S. Defense Department. Otherwise we wouldn't even know about the proposals because the U.S. government wasn't talking. So this is something that we grappled with. We heard a lot of controversy inside the commission, from outside the commission. I think we reached the right decision by emphasizing you can't even put a clear probability on this. Both hypotheses are viable. Both need openness and transparency by all governments involved, China, the United States and others, to get to the bottom of this. One of the things we surely said, though, even without knowing what happened in this case, we do know that dangerous research is underway that needs biosafety, scrutiny, and regulation. And so this was one of the very clear recommendations that we do make in the report about this origins issue. Maria Fernanda or Srinath, I don't know if you'd like to add anything to that. Well, I can come in initially and let Maria close. I believe this gain of function studies can be very dangerous. We know that scientists in their curiosity to find out whether manipulating the virus in the laboratory to increase infectivity, increase virulence to study immune escape is not necessarily to produce weapons of biological warfare. But even assuming that they were trying to find out what might happen if the virus changes its nature, this kind of a dangerous play in the laboratory is something that should not go unsupervised by responsible agencies with a lot of public accountability as well. You cannot have a laser fare approach in a freewheeling manner that you can play around with viruses, and then which can result in accidents, even if it has not happened in this case, it can happen in the future. I don't think responsible scientists should behave like curious kids poking into a hardnet's nest. I think it's absolutely necessary for us to have proper global regulatory frameworks for this so that we do laboratory research in a very well guarded supervised manner with accountability both to the wide scientific community which is there globally and also most importantly to the public. Yes. Fantastic. Thank you so much for very important words. Maria for that. Well, I would say three messages, Jeff. The number one is that science matters. And when we are dealing with a health emergency with a pandemic, I think that independent science should be at the top. That's why I think that a form of the scientific council of WHO should have a stronger voice, a sort of IPCC, the Intergovernmental Panel on Climate Change for Global Health. So I think that we need a body of authority looking also into the biosafety protocols for this kind of research. The number two message is why is that we need to know about the origins? Why we need to know? And I think because to be better prepared, because to be more sophisticated in the way we respond in terms of treatment, in terms of the vaccines, but we have a moral responsibility here with the families of the millions of people that died. And I think we owe it to them in a way. And perhaps my third message here that is connected somehow is that 2023 is going to be a very important year for global health. We will have two summits, the universal health coverage summits.