March 21, 2022

3 Billion Shots, Part Deux

3 Billion Shots, Part Deux
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A little while ago, I had a conversation withDr. Madhukar Pai about vaccine equity.

In it, I tried to understand why and how developed countries were spending billions on COVID vaccine boosters, but so relatively little in low-income countries.

Not to say that nothing has been done, but it’s a pretty clear-cut case where whatever we have done, however complex the system, it’s nowhere near enough.

I can’t be more clear here. This will affect you.

We’re handing out 21 million shots a day across the world, and yet, 36.8% of the world’s population –2.9 billion people – still haven’t received a single shot.

87% of people in low-income countries still haven’t received a single shot.

The international organization that was supposed to shepherd this whole endeavor to vaccinate the world,COVAX, has, however you squeeze it, failed.

I want to understand technically what the issues have been, but also as always, to understand why we do what we do when it’s so morally corrupt, when it costs so many lives, and even when all of the evidence tells us that it will come back to bite us.

My guest today is Gayle Smith.

Gayle served until recently as Coordinator for Global COVID Response and Health Security at the Department of State and has recently returned to her role as the President and CEO of theONE Campaign.

Prior to the ONE Campaign, Smith was the Administrator of USAID, where she led a staff of more than 10,000 people working to end extreme poverty, foster sustained and inclusive economic growth, and promote resilient, democratic societies all over the world. 

Smith has also served as Special Assistant to President Obama and Senior Director for Development and Democracy at the National Security Council, where she helped lead the U.S. and global response to the Ebola crisis in 2014 and 2015, and as Special Assistant to President Clinton and Senior Director for African affairs at the National Security Council.

If anyone can help me understand where the US, in particular, has fallen short of helping to vaccinate the world and get us out of this thing, it’s Gayle.


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Quinn Emmett:                                          Welcome to Important, Not Important. My name is Quinn Emmett, and this is science for people who give a shit. A Little while ago, I had a conversation with Dr. Madhukar Pai about vaccine equity. In it, I tried to understand why and how developed countries were spending billions on COVID vaccine boosters, but so relatively little in low income countries. Not to say that nothing has been done, but it's a pretty clear cut case where whatever we've done, however complex the system might be from soup to nuts is nowhere near enough. And I can't be more clear here. And I think we were in that conversation and we will today, that this will affect you. So we knew and we still know that the Delta variant was first identified in India. We knew that Omicron can be traced to South Africa and England and Botswana and even the US, possibly from an immunocompromised person.
                                                       Right now we're handing out about 20 million shots a day across the world. And yet about 37% of the world's population, 2.9 billion people still haven't received a single shot. 87% of low income countries, the people in those countries, 87% of them still haven't received a single shot. The international organization that was supposed to shepherd this whole endeavor to work with governments around the world to vaccinate the world, COVAX, has however you squeeze it, failed. And that's because of a number of reasons. I think I understand, but I want to understand better so that we can all do something about it, which of course basically sums up the entire point of my conversations of this podcast.
                                                       Why didn't those countries get the chance to buy more mRNA shots? Why didn't we give them the intellectual property to develop them and produce them themselves? Why didn't we ship them as many as we bought for ourselves when we had too many and continue to have too many? Why didn't we help build distribution efforts in those countries when we knew so well how hard the routine vaccination process is there as it is? What did we learn from PEPFAR and George W. Bush? I continue to want to understand better, not only what the hell we're doing here now in the second year of vaccine availability, but how we got here. And not just in the past year plus, but historically with HIV and AIDS, with tuberculosis and malaria and Ebola and Zika, with extreme poverty.
                                                       I want to understand what it means for more volatile today and tomorrow with real world climate effects growing. When we need to urgently mitigate to prevent more heat and sea level rise and storms. When we need to adapt to what's already baked in, especially again, in the Global South, where they've been feeling the very real effects of climate change already. To understand what it means as we rush towards cleaner power, but also dismantle fossil fuel infrastructure and industry, but in a just transition, but still not fast enough for one to replace the other. To understand while millions of folks in the Global South are still using wood stoves and feeling the air pollution effects of those because they don't have another choice. I want to understand technically what the issues have been for this particular issue, but also as always to extrapolate. To understand why we do what we do when it's so frankly, morally corrupt and self-defeating measurably when it costs so many lives. And even when, again, all of the evidence tells us that it will come back to bite us. We can do better.
                                                       My guest today is Gayle Smith and Gayle served until recently as Coordinator for Global COVID Response in Health Security at the Department of State in the United States and has recently returned to her role as the President and CEO of the One Campaign. So in Gayle's history, she has served as a top advisor on development issues for two American presidents and is one of the world's leading experts on global development. Prior to the One Campaign, prior to the State, Smith was the Administrator of USAID, a huge role. She led a staff of 10,000 people working to end extreme poverty, to foster sustained and inclusive economic growth and promote resilient democratic societies all over the world. Complicated endeavor on its own.
                                                       Smith has also served as Special Assistant to President Obama and Senior Director for Development and Democracy at the National Security Council where she helped lead the US and global response to the Ebola crisis, which we'll talk about today in 2014 and 2015. And also a Special Assistant to President Clinton and Senior Director of African Affairs at the National Security Council. Very clear to me that if anyone can help me understand where the US in particular has fallen short of helping to vaccinate the world and get us out of this thing, it's Gayle. As a reminder, you can always send me questions, thoughts, or feedback at You can find me on Twitter @quinnemmett. Gayle Smith, welcome to the show.

Gayle Smith:                                           Thanks for having me.

Quinn Emmett:                                          You're very welcome. I'm honored and thankful that you're taking the time to help us understand this enormous complex beast that is trying to get the world just a little bit more vaccinated along the way. Gayle, we like to start with one important question, it sets a tone a little bit. It's a little bit tongue in cheek. We usually get something good after the guest cackles at me for a second. So instead of tell us your life story as interesting that it is, I like to ask Gayle, why are you vital to the survival of the species? And I encourage you to be bold and honest and however you want to shake it.

Gayle Smith:                                           Well, I'm one of those who kind of believes nobody's indispensable. But if I were to say, why am I vital? I'd say two things. Number one is I'm one of those people who I think will leave the world better than where I found it in the places where I can have an impact. And the second is I think I probably help the shoe industry significantly in terms of job creation and productivity.

Quinn Emmett:                                          I love that.

Gayle Smith:                                           Even though, who needs is during a pandemic? But I maintained my commitment.

Quinn Emmett:                                          We just moved across the country. And one of the things that made this back and forth, we've been doing for the past few years work for my wife and I, we had three kids under three at one point was, Gayle, pros and cons believe me. If you're going to order diapers, it's better to just order for all of them. But was we basically had redundant wardrobes, my wife and I, because we're adults and our sizes don't change. And then we moved and we realized we had two wardrobes. And so all I've, like you said, who need shoes in pandemic? I'm going through work clothes going, why do I ever need anything with buttons literally ever again? I don't think I do.

Gayle Smith:                                           Exactly. I have a whole closet full of things. I mean, I worked in the past in the White House and recently took a break from the One Campaign to work in the State Department, that stuff is now in the closet and it's like, where is that going to go? Why does one need anything other than sneakers?

Quinn Emmett:                                          I sent my wife a text the other day and I said, do you prefer the brown shoes or the black shoes? And she's like, who cares? Doesn't matter. Grab your Allbirds and wear them to whatever thing, there're no rules anymore. Thank you for your honest answer. So let's get to this thing a little bit again. I want to try to really understand this better. I try to, as I tell people, get a 201 or 301 on these things before the conversation. So it's more of a conversation, but obviously I don't have all of your incredible experience by any stretch. Let's get to a place where our listeners, our community can get it. And also try to continue to apply themselves in some way for the morality of it, for the billions of lives that are still out there at stake. And because it is the only drivable way to really move to a different stage of this.
                                                       So it is March apparently, somehow already, it has been 15 months maybe some we've had an assortment of vaccines available to the public. And yet at that point where I think checking our world and data this morning, about 37% of the world's population still does not have a single shot and 87% of people in low income countries still haven't received a single shot. I want to be as comprehensive and truthful as we can be about this though. I mean these vaccines, at least for instance the mRNA ones which have taken decades of work among an amazing scientists and federal government dollars to get them there, the speed at which they were made available, the efficacy of these things.

Gayle Smith:                                           It's phenomenal.

Quinn Emmett:                                          They are truly, people have stopped me when I've said this, but I do believe it's true, they are among our greatest achievements, full stop. No one expected these in any stretch before 18 months from when we got to work at the very least, because that's just not how these things have worked historically. But here we are, we are 15 ish months later, 37% of the world doesn't have a shot, that's almost 3 billion people. 87% low income countries don't have a single shot. After your work the past year, are those the numbers you've expected in March 2022.

Gayle Smith:                                           They're the numbers I feared. I was hopeful that we would be able to galvanize the world to adjust those somewhat. I mean, given the way the system is built, I think it's fair to assume there's going to be a disparity. There's a built in disparity between coverage in wealthy countries and coverage in low income countries. That it's a gap as enormous as it is I think a product of the fact that the world hasn't yet come together in such a way it is to get that balance.

Quinn Emmett:                                          Let's take a step back. Why did you come back to government work? Obviously with the One Campaign, you work with any number of them, but why did you decide to come back to the State Department to do this work the past year?

Gayle Smith:                                           So there I was... Okay I did eight years in the Obama Administration. And in the last couple years I was the Administrator of the US Agency for International Development. Fantastic job. And one of the things I worked on during that administration was the Ebola epidemic, which I imagine most people remember it was frightening, it was alarming. Three countries just totally besieged by a lethal and really ugly virus, right? So there was a big international effort led by the US and African partners to tamp that down. I joined one because it had been so effective when I was in government and I had the opportunity to lead it, so I seized it. I had not anticipated going back into government. Having served twice, I was ready to do what I was doing, but then I got a call from the Secretary of State who in is the Secretary of State. He's also a very nice guy.

Quinn Emmett:                                          He seems pleasant.

Gayle Smith:                                           And I have known Tony Blinken for a long time. He's a really decent human being. And he said, "Hey, could you please come back and do this?" This was help ramp up the US response to the pandemic and help within the department sort of lay the ground for the work that's going to have to transpire over the coming years on what's called Global Health Security. How do we get ready for these things in the future so we don't repeat what we've all been through for the last two plus years? And I hemmed in hot and I said I would do it on a temporary basis, get it stood up. That I'd come in for six months, I stayed for eight. I'm glad to have done it. It's an area I have worked in, I know the players, I know the agencies, I know the tools, I know the budget. So it was kind of a natural. So I was asked and to anybody who's never done it, public service is also something it's inspiring, it's an opportunity. And it's also something that if somebody asks you to serve, it's very hard to say, no.

Quinn Emmett:                                          I appreciate that perspective certainly. My friend is a submarine captain and I'm drinking from... I got a mug when I visited.

Gayle Smith:                                           There you go.

Quinn Emmett:                                          Every time I think my work life balance or travel or whatever it might be is complicated, I think about the fact that he's had two Halloweens with his kids in 12 years or whatever it might be and growing up in this area, which is just filled with military and all kinds of things like that and friends in the government. I find you, you say yes and it makes an impression. It's like how everybody should be a waiter at some point in their life, just to understand how to treat people.

Gayle Smith:                                           And how to serve.

Quinn Emmett:                                          How to serve, exactly. Not to reduce your enormous complex years of service, but why do you feel like they came to you with this? Everyone in the world's vulnerable, we're trying to make these new vaccines and old vaccines. We're trying to figure out how to distribute them, one administration to the other profound lacks of trust, but also expectations. We're dealing with climate. We're dealing with all these things. Why do you think they came to you to say, how can we build this thing?

Gayle Smith:                                           I mean, in many ways it was a bit of a natural choice having run USAID, having been one of the leads in the response to Ebola. But I also have a long history of working on crises, whether they are conflicts or famines or earthquakes or health crises. So I think it was somebody who had the combination of the experience, the skills, could hit the ground running because our government is complex. I mean, there's a ton of agencies, a ton of rules, lots of mechanics, who does what, who's got jurisdiction, what's allowed, what's not allowed. And somebody who I think within the administration and externally has a reputation, I think is a team player.

Quinn Emmett:                                          Because when you go to work on Ebola, right, or any of these crises, we had Zika, we had now COVID any of these things they're going to keep happening. If there's anything I've learned from all my new infectious disease friends in the past couple years, it's, we've got to get them about seeing these coming, right.

Gayle Smith:                                           Get ready for more.

Quinn Emmett:                                          They've been saying it forever. They're like, look, this is what I told you because of these both in ways, whether it's where we're living in built environments, right? Or it's the enormous societal and economic fault lines that are just built into the power structures and so that's why different people have suffered because of these things once we're exposed to it, whatever it might be. When you go to work on one of these things, it's not I'm not just going to work on Ebola, I'm not going to work on Zika unless you are literally doctors without borders, right, partners in health, you're on the ground doing that.
                                                       Like you were saying, it's about working on the machine that works sometimes, works another times, so many competing interests, so many complications. I'm curious, coming into that about your expectations and at the end of your tenure, how much did it seem like top-down vaccine equity, which is to say vaccinating the rest of the world. If the end of this virus was everyone, how much was vaccine equity realistically sort of day to day, week to week a priority for the Biden Administration from the top-down? How did that compare to your expectations?

Gayle Smith:                                           I think it was a big priority, because the biggest focus and you work with a team so, but I was able to work on a number of things. But the big thing and the most urgent thing was ramping up increased vaccine delivery. So part of that was moving funds. We were fortunate to have funding in the COVID response legislation from the health for international. So move that money quickly so the vaccines can be bought. And then we built this platform for sharing vaccines. I think as everybody knows, the US had and still has more vaccines than we need, so how could we share those? And then the big decision, because even with sharing vaccines, even with increasing our financial contributions to buy vaccines through multilateral organizations to the billions plural, there were still an acute shortage. So that's when we bought the first 500 million and then the second, so a billion vaccines to be donated immediately.
                                                       So there was a real focus I think on calibrating that balance between extensive coverage here and next to no coverage there. I think the other thing that was in play that was really significant, it seems obscure but it was key, was for the administration to support what's called a TRIPS waiver, the temporary waiver of intellectual property rights, just to get more vaccines produced. Now, that wasn't necessarily going to deliver vaccines immediately, but it was a really important signal that we've got to have a different arrangement. This is an extraordinary time and business as usual isn't going to be big enough. So I would say the vaccine equity was key. I think we're still far from it and part of that is because the system is built basically with inequities in it and it's not built for crises. And overcoming that takes more than just doing more than anybody else, which is what the United States is doing. We got to fix the system, right. We got to get people around the table and say, hey, looks like we need new rules for times like this.

Quinn Emmett:                                          Sure. And one of the topics we cover here is AI ethics. And there's this idea it's called the alignment problem, which is essentially, it's not the data, it's not the algorithms. Those have plenty of problems. It's the people writing them or collecting them. It's how did those people get chosen to be those people and what are the incentives for how them to design those things? And like you said, these are enormous systems and I'm not interested today in just being like the blame goes here, I'm interested, like I said, really understanding the machine and the problem because anyone who says it's one piece of this puzzle and that's the problem is not that is operating in a vacuum, which is how government or any of these things work by any stretch. So what was your relationship with the COVAX entity and kind of how did that develop along the way?

Gayle Smith:                                           We worked very closely with COVAX. Of course the US Government many of us know GAVI, the Global Alliance for Vaccines, which is the foundation that COVAX was built on, it's done a good job for many years. So we worked closely, I mean, day to day, week to week, pretty constant consultation with both COVAX and then a mechanism that was built in Africa by the African Union called AVAT, which was also buying vaccines and distributing them in Africa. And again, that was because we're sharing vaccines, we're providing these Pfizer vaccines, they're doing vaccines, AVAT is doing vaccines, how do we make all of that work so the countries know what they're getting and when they're going to get it? So it's a close working relationship.

Quinn Emmett:                                          So I think it's, if we can start to identify some of the... It seems like, I don't want to say failure points, but where there has been, I think a lack of...

Gayle Smith:                                           Yeah. There's several of them.

Quinn Emmett:                                          Right. And I think that's the way any complex system works or it doesn't work. Again, expectations seem to be everything. But also just, again, coming back to this very tangible and clear, I don't think it's misleading, it's not to say, hey, listen, it should be this easy. But it's very easy to look at these sort of I've become a big fan of Mariana Mazzucato's mission-oriented approaches to doing these things, right. If you've got this enormous complex system to do this thing, you got to define the thing in reverse engineer from there. So it was put a man on the moon and bring him home safely. That's pretty black and white, right? You can measure that pretty clearly and you can design every system, every contractor, every team, every test, every piece of machinery you develop along the way to go. Is that going to help us do this in a more efficient, affordable, and also measurable way? Are they going to land and are they going to come home?
                                                       And you can apply that as well to something like decarbonize everything by 2050, right. The complexities behind that are enormous and not to shy away from those, but it is pretty measurable and it is something we need to do. And if you look at a pandemic that is born from a coronavirus, which we have a lot of familiarity with, but one that was novel in this sense and affected everyone and then keeps changing. If the answer to save as many lives as possible, obviously, and make fewer people sick and you're measuring that in the billions. And of course the second order effects of that are not crash economies, not crash health systems, not reduce childhood vaccinations for everything else here and everywhere else, but also just stop new variants as much as we can, arrest them as much as we can.
                                                       The answer is, vaccinate everyone as quickly as we can with at least one shot. Whenever I come to these things, and this feels like this is going to be my theme this year is thinking about incentives, right? This country, and look at what's going on with Ukraine, right? We pick and choose and that's the job. What we apply are enormous wealth and resources or military to whether that on a military front Syria or Ukraine or Yemen, and we can't do everything and we should not. But there are moments in issues that obviously are so clear so that's I think why it becomes disheartening 15 months after we have these things to see a project like this one start to fail in a lot of ways and again, it has a lot of fails.

Gayle Smith:                                           I agree with everything you said. I think there were a couple of things that got this off on the wrong footing because you're right that at some level a response like this in doing the right thing, it's one part engineering, right? You can figure out where vaccines need to go, at what rate, who can absorb, what production needs to be, all of that's almost mathematical. It is also political because to make that work, you got to make some changes, because the system is built for business as usual and business as usual means that those who can afford to buy the vaccines are those who buy the vaccines.

Quinn Emmett:                                          Sure. It's our entire healthcare system. Yeah.

Gayle Smith:                                           Exactly. It's a total reflection of that. So you've got a layer that is, okay you're going to have to make some changes. And there's a third, quite frankly, I would say it's a moral level or a common humanity or universal value level, which is you got to believe that everybody in the world should have access to a vaccine. So what happened here? First, it gets politicized from day one, it was started but it was just politicized. And then I think second, the question wasn't until much later in the game, your question, which is how do you stop new variants? How do you save as many lives as possible? The question was by the nature of the threat, how do I protect my country, my people, my borders? So every country in the world was turned inward. Arguably, you can say, it's not completely unjustified, right? They're like, holy shit.

Quinn Emmett:                                          No. And I don't fault that, but you can't operate in a vacuum.

Gayle Smith:                                           Exactly. But what that meant is that the natural default muscle in global crises of collaboration and cooperation took a long time to build, right? So you watch Ukraine now.

Quinn Emmett:                                          Sure.

Gayle Smith:                                           That's happening in one place, it's in somebody's neighborhood. The speed with which the international community...

Quinn Emmett:                                          It's wild.

Gayle Smith:                                           Government, citizens, private sector have organized, coordinated, collaborated is breathtaking and it's right. That didn't happen in the pandemic.

Quinn Emmett:                                          No, it's something that we're practiced at, right. For instance, we've been shipping arms abroad to a huge variety of countries for a very long time in massive amounts. We've been moving troops around NATO for decades, this and that. We know how to do these things. Right. I started thinking a lot after my conversation with Dr. Pai about all the pros and cons of PEPFAR. Right. And for folks that aren't familiar, that was take this for what it's worth and like you were just using the word compassionate, born out of George Bush...

Gayle Smith:                                           Compassion and conservatism.

Quinn Emmett:                                          Compassion and conservatism. Right. And those are two powerful words. And again, if you're not familiar, it was his frankly huge and truthfully incredibly impactful effort to tackle HIV and AIDS in Africa and still going on. Right. But it's imperfect. Because again, those two words, like any of these things are any of these huge efforts are going to be right. Ukraine, how many people are saying, don't just send fighter jets, send pilots and close the skies. And it's like, okay, but let's ask the bigger questions of what does that mean? Right. So PEPFAR for instance, the imperfections are still... and please correct me if I'm wrong, there's still thresholds around abstinence and prostitution requirements and I believe there's no needle exchange stuff involved. So that's going to reflect a little more on the conservatism part of compassion and conservatism. But I was just also been thinking about it because again, in the sense of like we know how to do things, right?
                                                       We know how to ship arms. I mean, PEPFAR is an enormous thing where we have, it's focused on a relatively singular issue. We've sent huge amounts of aid which have represented everything from money to goods to building. And this is where it's a little more timely with what a lot of the African groups have been saying. It's not just about for instance shipping shots, it's about supporting onsite distribution complexities, right? So for instance, one of the criticisms has been, yes, we haven't sent enough shots, but of the ones we've sent, a lot of them are expiring and the people on the ground there don't know what the expiration dates are when they get there. And they still don't have the distribution mechanisms to again, vaccinate every person in their country on their continent. Right.
                                                       But I also think because PEPFAR has over the past couple decades built indoors outcome based approaches, right. We want to have, I think was it 90%? It was 90% by 90% something like that. But they're quantifiable however much we might have succeeded and failed around them. And I just think about in the past year, in your time there and then going forward, are they are things we can still learn and apply from PEPFAR in supporting COVAX and GAVI and riding this ship. Because it seems like the further we get away and the less we talk about this, people are going, has my booster expired and realizing like we are still so far from again, reducing the chance that new variants come that affect everyone. Right. That's just how it works.

Gayle Smith:                                           The other thing about PEPFAR that's been interesting is it's also iterative. I mean, PEPFAR when it was launched is a lot different than PEPFAR today.

Quinn Emmett:                                          Sure. And it should be.

Gayle Smith:                                           It should be because the scale of it's possible to look at what worked, what didn't, there's new data all the time and there's new scientific discovery all the time. So it's changed and morphed a lot. It's building more capacity than it was at the beginning. It started as an emergency program, it is still that in the sense of urgency. But I think everybody who works in global health, whether it's on HIV and AIDS, malaria, TB, Ebola, anything else, it's coming down to a couple things, health systems. We invest a great deal of money as do governments in low and low middle income countries in their health systems. They need to be strong. That is half, three quarters of the battle, from the get go, right? So how do we make those investments so that if you're providing therapeutics, vaccines, whatever it may be, you've got a foundation to work on.
                                                       So I think that's one piece that gets to, for example, why we worked so closely with the African Union, they are building the capacity. That is the local capacity we wanted to be hand in hand with them. So we are doing this together and not hi, we want to very generous, here you go, good luck. I do want to address one thing you said on delivery, which is it's accurate, but I think there's another piece to it. Because we've all read stories now of a country that gets vaccines, but they expire. Couple things going on there. One is that we still don't have a fully transparent system for what's being produced by everybody, all the vaccine producers, where is it being allocated, who is signing the contracts, when will become available. So you still got to go put all those pieces together.
                                                       That's a fixable problem and something we are pushing on. We pushed on when I was in government, we're pushing on it now and one, we need a supply schedule. So we need total transparency there. But the other problem for some of these governments, they may get doses, there have been some cases where some countries, not the US, have shipped vaccines that had short expiration dates, inexcusable, not acceptable. There's an effort to tamp down on them. Countries also don't know when they're going to get them. And if they don't know that they have a regular supply, then why in the world would you put on some big, huge national campaign if you're only going to be able to vaccinate a million people and then say, well, oops, we don't know when we're getting anymore. Here in the US, if you look at what was put on by the US Government and governors and mayors to get people vaccinated, we laid on all sorts of things, extras, contractors, bells, whistles, but we knew we were going to have a steady supply.
                                                       These countries don't know where they have a steady supply. So what do you want to, you want to create the expectation? So again, that's why we've got to ramp up building the delivery capacity and providing that support. But this only works if you kind of look at the full spectrum of things, right? From the, as you rightly said, extraordinary invention of these vaccines to getting shots and arms, they're various sticking points along the way. So I think the lesson from PEPFAR, one of the things it's been able to do over the years is break down some of those sticking points so that you've got a more engineered systemic system rather than what we've got now, which is still a bit too fragmented.

Quinn Emmett:                                          I would never want to denigrate public health here in the transfer of assets and people and resources to the people on the ground there, wherever it might be, whatever crisis. I mean, I feel like we could title this conversation, various sticking points and it'd be the greatest understatement that anyone has ever said of all time.

Gayle Smith:                                           99 and counting.

Quinn Emmett:                                          Yeah. I mean, it's just like, it's preposterous and that's the way these things flow.

Gayle Smith:                                           But it's solvable.

Quinn Emmett:                                          This is what matters to me and it's that idea, right? Which is true and one of our partners is a gift directly, it's this idea poverty is a policy choice in a lot of places. And because it's so easy to oversimplify things that doesn't mean someone voted for something and we decided on poverty, right? It's a huge international thing. It's a huge domestic thing. There's racism built in there, there's all this other stuff. I think about one of my first public health conversations on this show was with a woman Karen Haster, who was on the ground nurse in the Congo working on Ebola. And that conversation was mostly about just misinformation fears on the ground of why don't people take shots that are available to them. I was a liberal arts religion major, it's complicated. The things you have to overcome there, are the shots expired on a truck.
                                                       So this obviously again goes all the way from Dr. Katalin Karikó solving the inflammation problem of mRNA shots, to TRIP waivers, to religious and sociological beliefs of what the vaccines do to someone, right? So it is enormously complicated, but we do have to do this thing because it's going to keep going and it's going to keep changing economies and societies. And you don't have to read the partner in health blogger, UNF or whatever it is to see that here and elsewhere, childhood vaccinations are dropping all over the place. For everything else that we have basically solved, right? Because of vaccines and because of these systems working as well as they can.
                                                       So if we can talk for a second about what maybe you would have done differently in your time there knowing what we know about how complex it is and how it's going to go. And again, these infrastructure that needed to be built everywhere, but also looking forward both for the next, for example, 12 months of this thing, however unpredictable it may be. It's the whole sense of what you can control and what you can't, but also because it's going to happen again and we're going to have to deal with antibiotics and things like this. What practically are the big moves that we could have done differently that we need to do differently going forward in the sense of what we can control?

Gayle Smith:                                           A couple of things. I mean, I agree with you that this is a huge hairy complex problem, but also there's another side of me that this isn't rocket science, right? This is a crisis where a lot of what we're dealing with is quantifiable, there's a lot we can figure out. And I think in the same way that when you said poverty is a policy choice, vaccine and equity is a policy choice at the end of the day, because the engineering pieces we can fix, that's not hard. So I'd say a couple things that can be done or I would've done differently. And quite frankly, I would've done some things differently before I went back into government. I went back into government over a year after the pandemic started. For example, if you look at the creation of COVAX, right? So some countries and philanthropies and others got together, the US was not one of them. This was during the Trump Administration, we did not participate and said, we need to create this thing called COVAX to make sure vaccines get to low income countries.
                                                       What we didn't do was say, and to make sure that happens, we're going to guarantee that X percentage of supply needs to go into that pipeline. An advance agreement at the beginning, donors can come up with the capital countries themselves may want to buy even though they got limited resources, but we want to secure a share of the market for low income countries. That didn't happen and so we all know what happened, a limited supply of vaccines came on the market. They were all snatched up. You and I were very fortunate to get vaccinated because our country was able to buy them and others weren't.
                                                       So that's one, is build in from the ground floor some ways to cover those countries that may be less or unable to cover themselves. I think the second and it's something we got started on. I would have liked to have done more on it and gotten us further up to now though, I think the US will continue on this, which is looking at diversifying production of vaccines and therapeutics geographically. You can't afford a single point of failure when India stopped exporting vaccines, that shut down a whole lot of global vaccine distribution. But also...

Quinn Emmett:                                          Well, they have the world largest vaccine producer in-house.

Gayle Smith:                                           Exactly. And there's a move now it's been around for some time, but I think it's recently been articulated very crisply on the part of Africa, for example, where their focus at the political level is yes, still on getting vaccines, but more on building the capacity on that of continent to produce vaccines, therapeutics, other medical supplies so there's less dependence on other countries. Because that's kind of the way this has worked, if you could cover your own country, great. If not, you were kind of dependent on the largest of others and that's backwards to me. And things like securing an amount of the supply for low income countries, that's building it in advance. So we've got to do those things in advance in the future and assume that if we don't, we're going to have the uneven distribution that we do now. And as you rightly say, we're just risking more variants, it's foolishness.

Quinn Emmett:                                          Sure. And not to expand this conversation another three hours, because you have an enormous amount of lives to impact here besides talking to me. But it's just coming back to the alignment problem. This is just indicative of how we are already reacting to the climate crisis, right? And oh, I'm sorry that low income countries are already feeling enormous amount of heat and Indian farmers are committing suicide because they're substance farmers and they can't afford to and migration at the Southern Porter because the land is parts and we're just going, that's great. But when does my booster expire? And like why isn't there any EV that's sexy and you're going guys, I don't think you understand how interconnected this all is. I want to be crystal clear. I usually on this show spent, tried to and I ask on plenty of folks who I fundamentally disagree with. Come on, any do not, that's not this.
                                                       My point is, when I try to help folks understand, so for instance, we had on a show with Representative Lauren Underwood before they passed her elements of the Momnibus Act to talk about black maternal health. And how black women who give birth in the year after die three to four times, as likely as white women in our home state of Illinois, six times as likely. People go, that's terrible, how do we fix it? And I always try to say, we have to fix ourselves, that exists because for the vast majority of our country's history, we either had slavery or legal segregation and we're nowhere near fixing that. This is just the tip of the spear, right? And that is not to empathize with that system, that's just, we have to paint the building blocks. And that's when I say, oh, go on about how complex this is, that's not to empathize with it, those are the table stakes.

Gayle Smith:                                           The roots of this are deep.

Quinn Emmett:                                          Sure. But like you said, there's a whole lot of shit that's fixable and frankly it's incredibly inexcusable that it hasn't. And so I want to focus on action, but again, it also just terrifies me looking at this with climate and looking at this going, what is the next year, two years, three years, five years of this look like as I talk to folks who are working on wastewater and things like that or whatever it might be. Let me ask you this, everything's going to be iterative, PEPFAR is going to be a lot of lessons from that Ebola, whatever it might be.
                                                       Now you've got a lot of African countries at least this month, right? They're saying, hold on the donations, distribution isn't working. We have to build these up but also we need more help. What are outside the box alternative things that institutions can be doing, whether it's one or otherwise, governments down to people to improve vaccine equity? What else can be done? Because again, I want to be crystal clear, the point of this conversation is none of this is cutting it. And enormous amounts of people are suffering and it's going to come back to bite us because that's how this works. So what the hell else can we be doing on a practical day to day level?

Gayle Smith:                                           So I think on a very practical level, there are a few things coming up that are going to be vital. On the point you just mentioned on delivery for example, Congress is negotiating a budget, which it always seems to be negotiating. There is funding in there that is for support to delivery, right? Giving countries the assistance they need to have the delivery systems ready. That's something the US needs to do and Congress needs to do. And significantly in global public health, including HIV and AIDS and the pandemic up to now, there's actually been bipartisan support. So it might be nice to protect that one little tiny area where there's actually agreement on something. Financing the delivery is number one. Number two, President Biden had a summit in September, he's going to have another one, it'll likely be in April that brings the world together. That's going to be vitally important and it gets to what citizens can do.
                                                       And let me just say that when I left government for the third time, I came out more convinced perhaps than I've ever been that citizen's voices really matter. And I know that at times like this, you look at vaccine inequity, you look at many things happening in the US. You look at where we are and importantly are not on climate change. It's easy to feel like what's wrong with these people and I can't do anything. But I tell you, they listen and they hear and they listen all the more when they hear from unexpected quarters. So I think weighing in both on the front end to say, we expect President Biden at that summit that A, B and C will happen. There will be more funding. There will be an agreement on a plan going forward. There will be you'll put pressure on the vaccine companies for this transparency so we know coming.
                                                       All those kinds of things, but also credit on the other end. The common wisdom I think in political circles today is that Americans don't really care about this. Our polling suggests that actually, roughly I think it's over 75% of those polled, think we should be doing more to make sure that vaccine equity is achieved either because it's the right thing to do or it's the smart thing to do or both. So I think weighing in matters on these things. I live in DC, I don't have a voting member of Congress for those of you who do.

Quinn Emmett:                                          An entire other conversation.

Gayle Smith:                                           Exactly. But let them know that you expect that budget to pass. You can certainly join us at an anytime. We've got a lot of simple actions people can take that, send a message and we're going to be pushing hard on three things. One is the ongoing pandemic response. It's not where it needs to be. So we've got multiple ways we're pushing on that. Vaccines at the center, but not vaccines exclusively. The second is the economic devastation. And if we thought we had inequity with respect to vaccine coverage, we've certainly got inequity with respect to the economic pandemic that has come on top of the virus itself. Where low income countries have been hit just massively and don't have the ability to do the kind of surplus. And then the third gets back to something you said earlier about poverty being a policy. Inequity is a policy and I could be a cynic right now, but I'm actually an optimist because I think we're seeing more and more signs that more important people are recognizing that inequities is a policy, it's a choice and it's not a smart one, so we got to do better.

Quinn Emmett:                                          Well, I mean, that all seems to make sense for me, one of my favorite organizations, if you're not familiar with it, can't recommend enough run by woman named Amanda Litman, it's called Run for Something. And they exclusively work with progressive young people under 40 to run from every office from school board.

Gayle Smith:                                           It makes so much difference.

Quinn Emmett:                                          And that is truly like one of those places where people go besides calling, besides emailing, besides these things and I'm sure you're not super familiar, but one of the things we do in each newsletter is point people towards very measurable things. Going like, no, this is the most useful and impactful way for you to spend your time to do one of these things, whatever it might be. And honestly, the thing is and of course there's an enormous amount of people that cannot do this for a variety of reasons, but one of my answers is well...

Gayle Smith:                                           Run for something.

Quinn Emmett:                                          Run for something, because I know you don't think that matters enough, but every time you get frustrated with that, Joe Manchin won't pass X for power electrification. Look at what states are doing. Look at what cities are doing and go take part, go run for your city council, because that matters. And you think it won't matter as much, but for instance, like you said, it's so typically American, but also so incredibly frustrating as we go forward to look at and say, well, everyone's got vaccines, good luck. It's like, we have done so little to fix our public health issues at home.
                                                       But how many of those are about community health workers, right? Or about passing, taking the federal money for Medicaid, that's your state. And you can go get a part-time legislative job in a state and you can start to literally save lives to do that. And you might not be able to affect any one of these African countries that are struggling with distribution, but every one of these matters and frankly, and one of Amanda's biggest points is those are the future leaders that end up in the house of representatives, that end up inside. That do make those measurable differences internationally.

Gayle Smith:                                           You're 1000% right. And I couldn't agree more whether it's school board or whatever it may be. You don't have to be at the center of the universe making all the big decisions, because it all builds up and it gives us a foundation. And I would just know something happened to me in serving in government, you have this profound moment where you realize, oh man, our government is basically us. Right. There's not a group of people somewhere over there that is, oh the school board, that's other people or the mayor, they come from some other genetic line or something. It's us, this is it. This is what we got. And so I think the more people that can run for something and the more people who can serve in government because I was a political appointee. You've got certain juice if you do that, the career men and women that serve in the US Government have enormous influence and capabilities. So I'd look at both of those avenues. Public service makes a huge difference, because it all comes down like it's us

Quinn Emmett:                                          It is us and that can be very scary. It's like when you realize your parents are just people, right. And you're just going, oh, I mean, they're the most wonderful and I worship my parents. I love them to death. I'm sure they're listening to this. But you just realize we all have hopes and dreams and faults and the system is complicated and this and this. But that doesn't mean, and this is this little phrase that I always come back to, which is do better, better feel like couldn't be more applicable to global public health things, which is like you said, it is complex. And it comes down to so many different factors, but there are concrete things we can do and we need to do and we're late to do. And that also will benefit us in the future as we confront frankly, world, that's going to be just vastly more volatile and complicated than it's ever been.

Gayle Smith:                                           It is.

Quinn Emmett:                                          And we have to start doing these things to show ourselves, to do them and to show ourselves that we know how to do them and then to build on them. Because if we don't, if you think this is gnarly and complicated, like oh my God, what's coming is crazy.

Gayle Smith:                                           It is and I think I can sometimes get a little, I don't know, romantic or something, but I mean, this can, should be a national project, right. Everybody is affected by this pandemic, everybody is affected by climate change, whatever it may be. And I think in the same spirit is run for something or public service, it's the community activism. That's the only... I don't know, those are the tools we've got because I have to believe, even though there are a lot of naysayers and oh, we shouldn't do this or it's their fault they don't have vaccines or there is no climate change, whatever it may be. I think if we organize the vast majority of people I think understand that there are problems, but that collectively we can actually solve them. And I think they're tired of excuses for not solving them.

Quinn Emmett:                                          Yeah. I agree. I mean, it's very easy posthaste to romanticize the state of Georgia electing on the same day a young white Jewish man and a black pastor. But at the same time, that doesn't happen without literally two decades of incredible organizing from people who have at the best been marginalized for that same amount of time. And before that even worse and yet they kept doing it and you think it doesn't matter on a day to day. And then all of a sudden those two votes are all we got and it does have to start from there.

Gayle Smith:                                           I think you're right. And I would just flag one of the things that I think pertains it's similar in the global health space, which is back when George Bush announced PEPFAR and people were like, what? This is coming from George Bush? It was billions of dollars. It was bold. It had bipartisan support from the get go. A lot of people who have campaigned acted for full funding for PEPFAR, for money to do Ebola and now for the pandemic, invested a lot of time in nurturing that bipartisan agreement. And making sure that there was still agreement on these Democrats and Republicans that the United States should be in the lead in ending the AIDS epidemic. That's paid off big time. I worked back in the State Department, we had $11 billion in pandemic funding from the hill that came out of that activism over the many years. So you're absolutely right, we are building foundations with what we do now that can be used in the future. So it's really worth it and I think we all know what happens if we don't.

Quinn Emmett:                                          Yeah, we do. And again, this is where when someone reads a headline about the jet stream slowing down and they call me, what can I do? And I'm like, you can't really do shit about that. But what you can do is focus on whether you're a titan of industry or a community organizer or a teacher or whatever it might be, investor, is climate change is really the heat you feel, the air you breathe, the water you drink, the food you eat, the rivers outside your door, your insurance, it's all of these things. And those are much more A to B reachable and applicable and they're tangible and something you can do about. And they do, and this is where we focus, make you feel better and help on the personal side. But also they do measurably, we know this, contribute to greater systemic change.

Gayle Smith:                                           Yeah. It all adds up.

Quinn Emmett:                                          So to tie it all up, I could not be more frustrated and angry with the state of vaccine equity. I feel like I just had this conversation with Dr. Pai a month and a half ago and it seems like a whole lot has not changed. We're in this lull between variants. Hopefully it's more than that, but as every virologist has taught me, there's no rule that says there is where the next one's going to be easier or whatever it might be. We have to do everything we can and doing it from the ground up matters. So it sounds like this summit that's coming up will find the information for that when it's announced.

Gayle Smith:                                           Yeah. Should be in April.

Quinn Emmett:                                          Find ways for folks to interact, but also the more we can do on that level with organizing and groups like Run for Something or supporting disaster relief, supporting partners and health and doctors without borders and UNICEF and all these things, it does matter.

Gayle Smith:                                           It adds up big time, hugely.

Quinn Emmett:                                          I appreciate that perspective. So I just have a couple little questions we ask everybody and then I'm going to get you out of here, Gayle, you got enough to do.

Gayle Smith:                                           Okay. I'm ready.

Quinn Emmett:                                          Gayle, when was the first time in your life when you realized you had the power of change or the power to do something meaningful yourself, part of a group, government, private, whatever it might be that made you go, oh, I can actually affect something. That's interesting. I want to do more of that.

Gayle Smith:                                           It was in my 20s. I had been a very young reporter and I was in the middle of the famine in Ethiopia in 84, 85. So the middle of a war, one side was being fed the other wasn't. And I managed to get myself into a meeting at the United Nations. I basically infiltrated the meeting I guess and rather disrupted it, but basically contradicted what was being presented and said, I've just come from here and none of these people are being fed. And I did know a lot of people were pissed off at me, but it triggered it discussion that otherwise hadn't been going on. And it was like damn, huh? I guess you can be a bit of an upstart and get something done.
                                                       And that was one where you want to talk about an equity, watch people starve to death and then you fly to a city where everybody thinks life's normal? That's when you learn to fight for fair. But then realizing that if you speak up... And then there were a lot of other things. But I think it's just learning that if you speak up and put the facts and the truth on the table, that's when you realize damn, maybe I can do something.

Quinn Emmett:                                          I love that. We just have this whole community of people who are, as we say, working on the front lines of the future and a whole lot of folks who want to and recognizing those moments I think is super helpful for them to go, that's how this person got started doing this. That's incredible. Who is someone in your life that has positively impacted your work in the past six months? If you want to pay it back, pay it forward.

Gayle Smith:                                           A guy named Strive Masiyiwa. Strive is a friend, I've met him for a long time. He's a very successful Zimbabwean businessman and philanthropist, but he's also been the lead on the African Union's work to acquire its own vaccines, right, actually buying them, delivering them. And working with him on a day to day basis, seeing the determination, the fighting for what's right in a fierce way where it's appropriate in a more collegial way where that's more appropriate, it's a total inspiration. And it feels like solving the immediate problem while also getting to the root of it.

Quinn Emmett:                                          I love that. I mean, someone who's in a position of, they have to do this, this isn't some sure to get a booster type of thing, this has to happen. Gayle, everything has been crazy the past couple years, what is your self care? What is your walk in the woods, ice cream, Netflix?

Gayle Smith:                                           Well, I've tried to shift from it being ice cream because the problem with the pandemic when you've got a lot of ice cream and a lot of Netflix, that may be a temporary, oh, I feel much better, but it's not a long term solution. Walking, listening to a lot of really good music and dancing in my downstairs guest room, like a fool. But it's very fun. It's extremely satisfying.

Quinn Emmett:                                          Is there a track or album, old or new that's really doing it for you right now?

Gayle Smith:                                           No, I've got a ton of them from all over the world and I just turn it on and have a good time. I mean, it's kind of ridiculous, but it's great exercise too.

Quinn Emmett:                                          Yeah. It's all my kids do.

Gayle Smith:                                           Removes things out of your system.

Quinn Emmett:                                          I can't recommend the Encanto soundtrack enough, it is a delight, it will move you.

Gayle Smith:                                           Got it.

Quinn Emmett:                                          Last one Gayle. What's a book you've read in the past year or so that's opened your mind to a topic you hadn't considered before, or has actually changed your thinking in some way? We got a whole list on bookshelf that we put in the show notes and people love to shop on.

Gayle Smith:                                           I hate when people ask me these questions.

Quinn Emmett:                                          You're welcome. You can let me know later. Of course, I'm happy to just through.

Gayle Smith:                                           I'll let you know, just because part of the problem though, is that being in this field, I tend to read a lot of books that are about the stuff I work on probably too much. And those might open the mind, but they open the mind not in ways you're suggesting. So I'll come up with something for you on the show notes.

Quinn Emmett:                                          Deal. That sounds great. That sounds perfect. I fully get it. I'm the person who, again, I read so much because of all this and otherwise, and I could not tell you the last three books I read, but I can tell you thematically what I got out of them, but recall is not so great.

Gayle Smith:                                           Yes. See, my thing is I tend to, I'm I'm working on this, you ask about self-care, I work all the time. Work finishes and then I'm reading more things about work.

Quinn Emmett:                                          Maybe working. It's a tough one.

Gayle Smith:                                           Got to work on that.

Quinn Emmett:                                          Yeah. Good times. As my therapist says, it's always the should with me. It's oh, should do this, should do that. He's like, and then you're dead. It can't be that all the time.

Gayle Smith:                                           Right. But the cool thing is to take a should, I decided I should walk more. So I've been walking more and it just makes me happier than a pig and shit. So what you got to do is take a should and just do it, one at a time.

Quinn Emmett:                                          I love that. You're a hero. Gayle, are you online anywhere? Is there anywhere folks can follow you or should they just hook up with the One Campaign? What mechanism...

Gayle Smith:                                           No, hook up with the One Campaign. I am also on Twitter now that I'm back and hope to be expanding that and we'll expand somewhere, but check us out of the One Campaign.

Quinn Emmett:                                          Can you give me the one line description of what you're working on at the One Campaign now that you're back.

Gayle Smith:                                           I or one?

Quinn Emmett:                                          Whatever pleases you.

Gayle Smith:                                           I mean, one is campaigning on the pandemic and the health response and the economic response. I'm working on shaping the debate.

Quinn Emmett:                                          Okay. I like that.

Gayle Smith:                                           We got to reframe the debate and keep going.

Quinn Emmett:                                          I love it. Well, we'll follow up on that, I'm excited. Gayle, thank you so much for your time and clearly for all that you do. It's a complicated beast that doesn't kind of excuse where we are, but I appreciate folks like yourself who've dedicated themselves and their work to trying to, like you said, iteratively make it as good as we can as impactful as we can.

Gayle Smith:                                           We can get there.

Quinn Emmett:                                          We'll get there. Thanks to our incredible guest today. And thanks to all of you for tuning in. We hope this episode has made your commute or awesome workout or dishwashing or a fucking dog walking late at night, that much more pleasant. As a reminder, please subscribe to our free email newsletter at It is all the news most vital to our survival as a species. And you can follow us all over the internet. You can find us on Twitter @Importantnotimp. Just it's so weird. Also, on Facebook and Instagram @importantnotimportant. Pinterest and Tumblr, the same thing. So check us out, follow us, share us, like us, you know the deal. And please subscribe to our show wherever you listen to things like this. And if you're really fuckin awesome, rate us on Apple Podcast, keep the lights on. Thanks. Please, and you can find the show notes from today right in your little podcast player and at our website Thanks to the very awesome Tim Blane for our jam and music, to all of you for listening and finally, most importantly to our moms for making us. Have a great day. Thanks guys.