Innovations in Vaccine Development and Delivery

Imagine a tiny patch that could painlessly deliver life-saving vaccines without a trained medical professional. Or a malaria vaccine that doesn’t require refrigeration, making it easier to distribute in tropical countries where the disease is commonly transmitted. Those innovations, among others, are on the cusp of transforming vaccine development and delivery, a top priority in global health. 

This episode of the Princeton Pulse Podcast concludes a two-part series on vaccines, which protect hundreds of millions of people from preventable illnesses like smallpox, polio, and measles. The last show addressed concerning shifts in U.S. vaccine policy. This one focuses on progress and promise, even in the face of dwindling global health resources and a host of other challenges. 

Host Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, is joined by two guests: Princeton Professor Andrea Graham, an evolutionary ecologist with strong research interests in immunity, disease ecology, and disease transmission; and Janeen Madan Keller, deputy director of global health policy and policy fellow at the Center for Global Development. Together, they highlight scientific discoveries that set the stage for a new generation of vaccines that could boost immunization rates around the world while preparing us for the next pandemic. 

The panel shares exciting advances in the lab, from mRNA technology that can train the immune system to recognize, remember, and target invading pathogens, to plant-based edible vaccines. They also talk about overcoming barriers to access with solar-powered refrigerators that don’t depend on unreliable energy sources, combination vaccines that reduce the number of injections and medical visits, and other potential game changers that could ensure vaccines reach the people who need them most.

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Learn more about the Center for Global Development and its Tough Times, Tough Choices series.

Visit Andrea Graham’s website to read about her lab’s research on the immune system and disease transmission.

Listen to Alarming Trends in U.S. Vaccine Policy – And What We Can Do About It

The Princeton Pulse Podcast is a production of Princeton University's Center for Health and Wellbeing (CHW). The show is hosted by Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, produced by Aimee Bronfeld, and edited by Alex Brownstein. You can subscribe to The Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your favorite podcasts.

Transcript

 Episode #19 - Transcript

SPEAKERS

Andrea Graham, Janeen Madan Keller, Heather Howard

Heather Howard  00:00

Hi, and welcome to the Princeton Pulse Podcast. I'm Heather Howard, professor at Princeton University and former New Jersey Commissioner of Health and Senior Services. On campus and beyond, I've dedicated my career to advancing public health. That's why I'm excited to host this podcast and shine a light on the valuable connections between health research and policy.

Heather Howard  00:23

Our show will bring together scholars, policymakers and other leaders to discuss today's most pressing health policy issues, domestically and globally. We'll highlight novel research at Princeton, along with partnerships aimed at improving public health and reducing health disparities. I hope you'll listen in as we put our fingers on the pulse and examine the power and possibilities of evidence-informed health policy. 

Heather Howard  00:48

Imagine a tiny patch that could painlessly deliver life-saving vaccines without a trained medical professional, or a malaria vaccine that doesn't require refrigeration, making it easier to distribute in tropical countries where the disease is commonly transmitted. These innovations, among others, are on the cusp of transforming vaccine development and delivery, a top priority in global health.  

Heather Howard  01:13

Today's episode of the Princeton Pulse Podcast continues our conversation about vaccines, which protect hundreds of millions of people from preventable illnesses like smallpox, polio and measles. Our last show addressed concerning shifts in U.S. vaccine policy. This episode focuses on progress and promise. Even in the face of global health financial challenges, my guests and I will discuss exciting breakthroughs in science and medical technology, advances that set the stage for a new generation of vaccines that could expand access to immunizations while helping us prepare for the next pandemic. 

Heather Howard  01:50

Joining me in the studio is my colleague, Andrea Graham, a Princeton University professor and evolutionary ecologist with strong research interests in immunity, disease ecology and disease transmission. We're also privileged to welcome Janeen Madan Keller, Deputy Director of Global Health Policy and a Policy Fellow at the Center for Global Development. Based in Washington, DC., Janeen leads policy-oriented research focused on the economics of global health challenges. Andrea, Janine, welcome to the show! 

Heather Howard  02:21

Well, let's jump in. Andrea, maybe you can help us by setting the table and telling us about your research and how that connects you to these vaccine conversations?

Andrea Graham  02:32

Sure, thanks for having me here. I'm honored and delighted. I am an immunologist, but one who takes an ecological and evolutionary approach. And what that tends to mean is I'm really interested in things like dynamics and heterogeneity, which are super relevant for understanding immune responses in the real world. When I say dynamics, I mean that I think about how an induced immune response unfolds across the body, across time. This is really important for understanding vaccines, because what you're doing with a vaccine is you're basically trying to make the immune system a better predator, a more specific predator of the particular pathogen that you're trying to attack. So my work on dynamics of immune function is useful there. And then my work on heterogeneity, among individuals in how their immune systems work, is also super relevant because the capacity of a vaccine to confer protection is often dependent upon the age, nutritional plane, or even the genetics of the individual. So understanding the evolutionary causes of that heterogeneity can inform vaccine design and delivery.

Heather Howard  03:38

Thank you. Now, Janeen, what about you? Tell us about your background and the work of the Center for Global Development.

Janeen Madan Keller  03:46

Sure. Hi everyone. It's great to be here, and thanks so much for having me on the show. I'm a policy researcher with a background in development economics and global health. I work at the Center for Global Development, which is essentially a think tank that works on reducing global poverty and improving people's lives through innovative economic research. My work here at the Center focuses on global health. I focus primarily on what I like to call global health financing, thinking about the role that bilateral government donors play -- those like the U.S., the U.K., and many others -- and also the role of multilateral institutions in supporting poor countries around the world to get access to health products. That includes vaccines. And then to be able to deliver those products and health services to citizens in a way that is most impactful and most effective.

Heather Howard  04:45

Well, our listeners can already tell that we've got the two perfect people here to be talking about exciting innovations in vaccine development and how we get those out to people around the world. Let's jump in. Andrea, let's set the table. Why are vaccines so important in preventing disease, and how do they do that?

Andrea Graham  05:05

Folks like me like to emphasize that, second only to clean water, vaccines are our best public health tools.  And the way they do that is just awesome. I mean, I love the immune system. I think it's amazing, and that will come across in the way I describe this. So the immune system really excels at recognizing the fingerprint, if you will, of a particular pathogen during an infection, and then storing that fingerprint in the memory banks in our bones, so that the next time you get exposed to that variant of that particular pathogen, you are protected against it, again. So that's how the immune system has operated over evolutionary time, learning about the pathogens in our environment, remembering them, and protecting us against them if we see them again. So the thing about vaccines is that you can skip the part about getting sick. You can skip the part about actually harboring the pathogen. Instead, what vaccines do is they confer that fingerprint to the immune system to learn and remember, so that you can get protected when you're exposed to that infection later, without having to undergo the infection itself. And so an immunologist and textbook author that I really admire, Jean-Laurent Casanova, calls this aiming for maximum realism with minimum danger, where you really want to capture the signature of that pathogen realistically so that you really can recognize it if it appears in your body after you're vaccinated, but minimizing the danger, because you don't have to go through the whole course of infection to learn it.

Andrea Graham  05:49

Janeen, I love how Andrea just put it: maximum realism, minimum danger. How, from your policy research perspective, do you see the role of vaccines in public health?

Janeen Madan Keller  05:52

I think Andrea summed it up perfectly. I think vaccines really are one of the most powerful tools we have to save people's lives, and they are a very, very critical pillar of global health efforts. And maybe just to bring some numbers to our conversation, I think the data really does speak for themselves. Over the past 50 years, we now have evidence that tells us that immunization has helped to cut infant mortality by 40% around the world. If you just look at Africa, it's a 52% reduction. But I think stepping back, it's really, really important to remember -- and I think maybe this is where that connects Andrea's work and focus together with mine -- is that, you know, for these sort of scientific miracles to be effective and have the remarkable effect we know they can, they really need to reach people. So we're at a point right now where we're seeing the first ever malaria vaccines being rolled out in countries around Africa. We have a next generation TB vaccine that's currently undergoing testing. And these are the kinds of exciting scientific advances that are driving expansion in vaccine development. But really, those vaccines are only going to be able to protect people's health and save people's lives if they actually are delivered to people. There are many players, efforts, and institutions, especially at the global level, which is where my work focuses a lot, that help to bring these life-saving vaccines to the world's poorest countries. One of those players, maybe just to give you an example, is the global initiative known as GAVI. What GAVI does is help the poorest countries in the world to purchase and access vaccines against more than 20 infectious diseases. Essentially what GAVI is doing is it's trying to close the gap in access to vaccines. A child growing up here in the U.S. may receive a certain schedule of vaccines throughout their childhood years when they go to the pediatrician’s office. GAVI is trying to close the gap between the kinds of vaccines that a child growing up in a country like Uganda or Bangladesh may receive and have access to, compared to kids growing up in comparatively wealthier countries. And it truly has had remarkable impacts. Its own reporting has suggested that, since it was founded in 2000, it's helped to vaccinate over a billion children around the world -- remarkable impacts to date.

Heather Howard  09:47

Thank you for grounding us in those really compelling statistics. Janeen, let me stick with you then. So vaccines are life-saving. They're one of the greatest accomplishments in the last century of public health. But there's still so much work. Can we dig into what those challenges are? I've read that about half the cost of delivering vaccines in low-income countries is in the last mile. Is that right? These challenges you're talking about, equity of getting the vaccines where they're most needed, can you sort of tease out what those challenges are in that last mile? 

Janeen Madan Keller  10:23

Absolutely. We have seen, as I said, tremendous progress in expanding access. But in recent years, we've also been seeing somewhat of a slowdown in the pace of our progress. As you noted, there are multiple interconnected challenges and barriers at play. I think one thing I would note, especially when we think about the last mile, is that we really saw a pretty big setback in terms of vaccination coverage during the Covid-19 pandemic due to a number of different factors. In some places, there were very stringent lockdowns. People couldn't travel to health clinics. People were afraid of contracting Covid, so they didn't want to go out and seek preventative health care. You had health workers diverted for a whole host of different reasons We're really are only now starting to see some improvements in vaccination coverage, and we're still very much playing catch up from Covid. But to your point, Andrea, there are many complex steps in getting a vaccine from a manufacturing plant or a factory to the last mile. In resource-constrained settings, in rural areas, that last mile delivery is extremely complicated. It involves ensuring that data systems are in place so that vaccines at health clinics can be restocked when supplies are running low. As we know, many vaccines have to be kept at a certain temperature. So not only is that last mile delivery extremely long and complex, but it's long and complex because vaccines have to be stored at a very cold temperature, which, again, in places where there are frequent power outages, can become a significant challenge. There are also barriers that individuals, families, and communities face in reaching these health clinics. Mothers have multiple demands on their time every day. Traveling hours to the health center just may not be something they're able to do. And I think the last point I would also make is that we're also seeing a rising tide of vaccine misinformation, vaccine skepticism, that is also sometimes leading people to not seek out vaccines. And so there's really a kind of very interconnected but complex host of factors why. Even though we've made tremendous progress, our job is far from finished.

Heather Howard  13:16

That was a really important catalog of all the challenges. One that I want to lift up also is, not only do you have to ship and store and make it convenient for people to receive their vaccines, but you also need a health care provider, right? A trained health care provider to administer. So as we catalog the problems we're solving, and that hopefully new technology can help us address, there are a host of challenges. But they're not insurmountable. And so it's exciting to be able to explore how we're going to do that. But before we get to that, I do want to step back. Andrea, could you tell us about the role this new mRNA technology is playing? Because as we're taping, and when this drops, mRNA technologies are in the news. So I want to make sure we pause and talk about the role mRNA technology played in in the development of Covid vaccine and how it might play in pandemic preparedness.

Andrea Graham  14:12

Sure. I want to first take a step back, though, and say that it's actually in addition to all the challenges that Janeen so eloquently articulated in delivering vaccines, developing them to begin with, getting this crazy, complicated immune system to recognize and remember the right things for the right period of time and do the right things about it, is also a huge challenge, especially conferring that fingerprint of specificity so the immune system knows exactly what to target. So that it does become that really efficient predator against the invading pathogen we want it to attack. Historically, there have been lots and lots of really hard, crude approaches. In fact, the history of vaccination goes all the way back to variolation, where, for 1000s of years, people were sort of exposing susceptible hosts to ground up scabs from, say, cow pox. And it was discovered that that helps protect against smallpox, right? So the origins of some of our earliest vaccines are really kind of gross, crude preps of what the pathogen shows to the immune system. Grind up a scab and let the immune system work with that, right? We've come a long way from there, and the most recent, one of the most recent ways in which we've come from there is this mRNA technology. The reason that is such an important advance is that it lets us be extremely elegant and specific in conveying that information to the immune system. No more ground up scabs. Instead, we can provide the genetic code that will produce the protein that is the fingerprint we want the immune system to learn. So it's a way of very precisely engineering what we want the immune system to learn. It required lots of molecular biology advances. We can talk about that if you're interested. But it's a real technological achievement to be able to be less crude in our vaccine design. To make bespoke vaccines that target the exact protein sequence we want them to target. So when people say it's a game-changer, it really is. It's not only because of this acute specificity and elegance of design that I was just talking about, but it's also really fast. It means that we don't have to go through all the crude grinding up of various viral preps. We can, just as soon as we know what the gene sequence of a newly emergent virus, for example, start building the vaccine to target it. And that's why it has such power for all sorts of different vaccines, including ones that might help us prepare for future pandemics. But people are interested in using it to train the immune system to attack tumors as well, because the tumors also have genetic signatures. And if we could get the immune system trained to attack that, we can use mRNA vaccines, in principle, to attack cancer. So it's got a huge amount of potential to improve public health. 

Heather Howard  17:26

The news that we're reacting to is that HHS has canceled $500 million in funding for mRNA research. So you're saying that's not only tying a hand behind our back in terms of research on diseases like Covid, where mRNA technology led to the rapid development of a safe and effective vaccine that helps slow the pandemic. You're saying it goes beyond that to cancer and other [diseases]. What is your reaction to the cancelation of that research?

Andrea Graham  18:02

Absolutely a gut punch. It's horrible to read about, because just when we're harnessing this exciting new technology in so many dimensions of promoting human health, it's being kneecapped. Let's hope it's not completely destroyed, but it has at least delayed benefits of this incredibly powerful technology across all sorts of infectious as well as cancerous diseases.

Heather Howard  18:30

Janeen, what impact might it have on global health?

Janeen Madan Keller  18:36

Maybe just to underscore Andrea's point, there is tremendous potential in this technology. I think one thing that's giving me a lot of concern right now is that this could have very serious consequences in the case of a potential new pandemic. I can give you one example.The kinds of flu vaccines that we currently use are made with eggs, a little bit of an egg protein. So let's just say that we were to have a bird flu pandemic that is also infecting humans. We want to use our vaccines to vaccinate humans. But the bird flu pandemic also affects birds, and hence egg production. And so in that kind of a scenario, we're really going to be left in a situation where we don't necessarily have alternative ways to make a flu vaccine.That's just one example to give you a flavor of the very wide-ranging ripple effects that we could see as a consequence of this funding being canceled.

Heather Howard  19:49

So even in the face of this alarming setback, there are promising developments in vaccine in research and development. Let's go there. Andrea, can you tell us about what should we be excited about in vaccine technology?

Andrea Graham  20:04

Well, beyond the technologies that confer acute specificity to the vaccines, there's a whole bunch of other ones that I think you're alluding to -- ones that improve delivery in a bunch of different ways. Some of those improvements make the vaccines biologically work better, meaning if you want to protect against a respiratory infection, it turns out that a vaccine that you spray up your nose, that lands on your respiratory surfaces, actually can protect those surfaces above all. Rather than having a vaccine go and jab your arm, and having to eventually make its way to protect your respiratory tract, nasal delivery can actually deliver the vaccine right to the susceptible surface of your body to a given infection. That's one way in which some of the new delivery methods can improve the protection biologically. Another way is that they can have more extended time release, meaning having the vaccine components arrive very slowly over time instead of in one giant burst. That can give the immune system time to hone the response to the vaccine in a really productive way. So there are those things. 

Andrea Graham  21:18

But then there's also the logistical improvements, because a lot of vaccines are very susceptible to heating. For example, you have to maintain a really good cold chain all the way until you get it into somebody's body, and that's part of that last mile problem. How do you keep something cold across all the challenges of being out in the field? People are developing technologies that will stabilize the vaccine components in spite of warm temperatures. One of my favorite ones to talk about is using genetically modified plants. Bananas, for example, have been proposed for a really long time. If you can get the vaccine components into a banana that has the plant's own defense mechanisms for not rotting for some period of time, and then you get somebody to eat the banana. These edible vaccines that are delivered via foods, via plants, have a lot of potential to help with that cold chain problem. These are just a few examples of how new technologies are aiding both the biological function and the logistical success of vaccines.

Heather Howard  22:30

Janeen, can you jump in? What does this mean for the practice of global health and the work you do to ensure equitable access to vaccines?

Janeen Madan Keller  22:41

These innovations, especially those to ease delivery in low-resource settings or in rural areas where, once the rainy season hits, you really can't access. There are lots of challenges, as we talked about. I think innovations have tremendous, exciting potential to be game-changing. Maybe I can just give a couple of examples that I think are very relevant for these kinds of contexts. To add to what Andrea shared, we're also seeing solar powered fridges for vaccines that do have to stay cold, which is tremendous. Because then you don't need a fridge that depends on a very unreliable electricity source in certain places to keep the temperature of the vaccines cold enough, to keep them safe and avoid spoiling. Those [solar powered fridges] could be game-changing in many settings. We're also seeing other innovations, like microneedle patches. This is a kind of "needle-free" way of administering vaccines. Not only does it remove the need to have the vaccines be refrigerated, but you may not necessarily need a trained health care worker to administer them. So again, it offers tremendous benefits, especially in remote areas, resource-constrained areas. And then there's also a lot of research going on in what are called combination vaccines. Essentially, you're combining multiple vaccines into a single shot. This means you don't have to bring your child back multiple times to the health center. It's reducing the number of injections people have to get, which, again, could have tremendous impacts -- not just in the low-resource settings, but all around the world. It could be quite game-changing in terms of advancing global immunization efforts. These are just some of the examples of things that I'm optimistic about and excited about. But I think it's also important to remember that making use of these innovations takes resources. That's something that we have to be realistic about, especially in cases where countries are resource-constrained and financing is a big barrier.

Heather Howard  25:07

Well, as a parent, I love hearing about the potential for needle-free vaccines, and I'm sure around the world that's the case. But, you know, Andrea, Janeen raises all these really interesting logistical questions. How do they inform that biological research? So you're not just in the lab thinking about pathogens. Are you thinking about these delivery questions?

Andrea Graham  25:31

Yeah, it's a wonderful point, and I think increasingly people are embracing the need to think about the practical matters. It's all very well and good to develop something gorgeous in your lab. But if it can never reach the people who need it, then what's the point? And I just want to circle back in that vein to the micro-needle patch example that Janeen raised. Yes, it minimizes the number of big needles that somebody needs to experience. It minimizes the need for a trained health professional to use those big needles. But it also, because of delivering the vaccine to the top layer of the skin, and also because it's there for a while and dissolves, it actually brings both the biology and the logistical benefits. There is some evidence that those skin deliveries can induce really potent local immune responses that, depending what the target antigens are, can protect that site especially well, much better than the big needle delivery would. So it's sort of exciting when there's a synergy between what makes the vaccine work better biologically and what makes it arrive more easily in logistics.

Heather Howard  26:47

So Janeen, if we're shifting from shots in arms to all these different delivery mechanisms, what does that mean for the workforce? You mentioned that you might not need the traditional medical professional. How do you envision that playing out in terms of the workforce delivering this, especially in resource constrained areas? 

Janeen Madan Keller  27:07

In many cases, one of the barriers and challenges to delivering health services, whether that's immunization or other kinds of treatment services, shortages of trained health workers is a huge challenge. So being able to bring an innovation like this to market, that eases the sort of pressure on the need for a trained health care worker, can be really, really useful with positive benefits across the broader health system. And in many cases, what this also means is that you could rely on voluntary community health workers who may not have the same health care training, but play a really important role in outreach and helping communities understand the importance of vaccines, answering questions that people may have about any kind of reaction their child may have to receiving a vaccine. Again, you're able to reduce a bottleneck in the system where a trained health care worker is a bottleneck to delivering services. I think that makes it really important and could be extremely beneficial.

Andrea Graham  28:30

Janeen, if I may, what's the role of trust in there? Do you think that there's an element of improved trust if trained health care workers are less relied upon for vaccine delivery, like these community workers? Do you think trust is an element of the human side of this?

Janeen Madan Keller  28:49

Great question. And, you know, I do think trust is extremely important. I think, as I mentioned earlier, we are seeing a rising tide of misinformation and skepticism around vaccines. And I think having members of the community, whether that could be a health care worker who's trained or somebody who doesn't have the same training, I think having those very trusted members of the community who are focused on outreach, meeting people where they are at, sometimes even in religious places of worship, to sort of bring community members together, allow for open conversation questions. I think that is really, really important. And I think we can focus on a lot of other factors, everything from scientific discovery to logistics challenges. But Andrea, you're exactly right in pointing out that trust and building community trust to counter the misinformation and vaccine hesitancy. I think that is really important, and I think it's going to continue to be really important going forward.

Heather Howard  30:09

Yet another way in which these innovations could be real game changers. Janeen, you've gestured to the profound financing challenges, so let's go there before we wrap your conversation. Janeen has been writing a series, called "Tough Times, Tough Choices," on how to allocate resources strategically and effectively in an era of aid austerity. Given cuts to global health and the U.S. retrenchment from this space, how are you thinking about how countries, especially low-income, countries, can shift finance? How can they maintain progress and maybe even harness the potential of these new developments, given these strains?

Janeen Madan Keller  30:54

Yes, exactly. I think we're really at an inflection point, where we're seeing many large donors who have long championed global immunization efforts, global health efforts more broadly, pull back support. Since the beginning of the year, we've seen dramatic changes in the U.S., in terms of scaling back support for global health, scaling back support for development more broadly. But we're not just seeing this in the U.S. We're seeing this across a range of major donors. The U.K., France, several other G7 donors are cutting their development budgets. And I think it's also important to remember that it's not just the development budgets that are being squeezed, but low- and middle-income countries are facing a whole host of macroeconomic problems, not to say the least, sort of mounting levels of debt. And this is making it really hard to identify adequate resources, not just for immunization, but again, for the health sector more broadly. And so one of the ramifications of all of these shifts is that we're seeing many of these international organizations and multilateral initiatives that I mentioned, including Gavi, but also other institutions and organizations like the World Health Organization and UNICEF. They all play a very critical role, especially in global immunization efforts. They're all facing budget crises across the board. And this is at a time when, as we've been talking about, there are new technologies available. There's a new malaria vaccine. There's going to be, hopefully, a game-changing TB vaccine come to market down the line. These institutions have mounting demands on the role and support they provide, while at the same time they're going to have to do that with fewer resources. And so that's what we're kind of calling "tough times, tough choices." They're going to have to make some tough choices about where to cut back. And so my colleagues and I have been doing some analysis and writing to offer some advice on how the leadership and various donors to these institutions can navigate these tough decisions about what to cut, what should be protected, and how they can adapt in these really tough times. And I would say that alongside managing the short-term budget cuts, everyone in the global health community is really laser-focused on making pretty significant changes and reforms to how we do business. Really thinking about how we reduce the kind of dependency of countries on these external sources of financing, how we make sure that they are hardwiring resources for immunization, for nutrition services, for TB and malaria, and non-communicable disease management into their own budgets. And that you have donors and other multilateral initiatives playing a supportive role, helping to drive real ownership and decision-making authority by and from these governments themselves.

Heather Howard  34:22

Andrea, we talked earlier about the shocking news about the retrenchment on the mRNA research, but more broadly, Janeen addressing the retrenchment in global health. What are you seeing in the U.S. in terms of cuts to scientific research, and what that means for these exciting developments? 

Andrea Graham  34:43

I'm not very cheerful, I'm sorry to report. Partly because on the very day that federal funding for mRNA vaccine technologies was cut, two independent scientific papers showed incredible promise of mRNA technologies for generating a vaccine against HIV, which has been one of the hardest things to develop a vaccine against, for a bunch of reasons. We can go into that, if you like. But it was just gut wrenching to see on that very day, that on one of the hardest things we need to vaccinate people against, headway is made, and then poof, the federal funding support is gone. Speaking of need for resources and figuring out a way forward where, even if the federal government is dropping out, how are we going to continue to fund the kind of research and development that will lead to really important new vaccines, where we've never succeeded in making a vaccine before?

Heather Howard  35:45

Well, I'll say, as we wrap, that what gives me hope is people like you and the work you're doing. So I'll give you one last chance to talk about what you see going ahead, and maybe what gives you hope. Andrea, I'll start with you. 

Andrea Graham  35:59

What gives me hope is that there are a lot of scientists, but also non-scientists, who get it and who are trying to mobilize both to reverse the funding cuts, but also to reverse the broader cultural moment. I think education, really making sure people understand how vaccines work, [is important]. The more educated the public, the less likely conspiracy theories can take root and disinformation can take root. But also, we need to try to rebuild public trust in institutions, especially institutions of public health. I think it's probably a long road, but education, outreach, trust building, community building, I think is going to be just as important as restoring the funding. And I just think that there are a lot of us. We just need to get our acts together somehow.

Heather Howard  36:59

Janeen?

Janeen Madan Keller  36:59

I think this conversation especially has made me hopeful and optimistic about so many potentially game-changing innovations and new vaccine technologies that are out there, that could really help accelerate the fight against infectious diseases. But I think that we need to be realistic. One of the things we're going to need to prioritize for health systems, for pandemic preparedness, around the world is going to be adequate resources. History shows us, both from our experience with Covid and also with many other previous outbreaks, that we repeatedly fall into what's sometimes called the panic and neglect cycle. What this means is that we have a crisis, there's a lot of funding, there's a lot of political will to help address that crisis. But once that crisis subsides, all of the attention fades and the resources and the investments dry up. This cycle leaves communities, countries, the world, unprepared when the next threat emerges. And so I think breaking this pattern - and I'm not going to profess to have an answer on how to do that -- but I think breaking this pattern is going to be critical to ensure that we build strong health systems in the future.

Heather Howard  37:00

Andrea, Janeen, thank you so much for joining the Princeton Pulse for this important and rich discussion. 

Andrea Graham  37:00

Thank you.  

Janeen Madan Keller  37:00

Thank you. Thanks for having us. 

Heather Howard  37:35

Thank you for listening to the Princeton Pulse Podcast, a production of Princeton University's Center for Health and Wellbeing. The show was hosted by me, Professor Heather Howard, produced by Aimee Bronfeld, and edited by Alex Brownstein. We invite you to subscribe to the Princeton Pulse Podcast on Apple podcasts, Spotify, or wherever you enjoy your podcasts.