Nhac Nguyen/AFP/Getty Images

Southeast Asia

President Trump seeks to use Southeast Asian nations as an economic “wall” against Chinese exports. But not all countries appear to be on board.

China

Zongyuan Zoe Liu, Maurice R. Greenberg senior fellow for China studies at the Council, sits down with James M. Lindsay to discuss China’s response to President Donald Trump’s tariff hikes and what it means for the future of U.S.-China relations.

China

Chinese exports are growing much faster in volume than in dollar terms. Europe is losing out.
AI

What the Marco Rubio AI Imposter Means for National Security

What the Marco Rubio AI Imposter Means for National Security
Climate

Nuclear Energy

As President Trump seeks to cut clean energy funding across the country, nuclear energy emerges as a rare area of bipartisan alignment and a priority for the administration. Yet inconsistent and conflicting federal policies threaten to impede efforts to promote nuclear energy production.

Climate Change

The legislation promoted by Trump and the White House will undo many of the climate and energy initiatives and tax credit programs passed during the Joe Biden administration.

 

Tariffs

United States

Ten CFR experts break down what the president’s trade agenda has accomplished since he placed a ninety-day pause on his expansive “Liberation Day” tariffs. 

RealEcon

The Trump administration initially expected to conclude multiple trade deals by the end of the 90-day pause but found that trade negotiations take time. 

United States

President Donald Trump has launched a wave of Section 232 tariffs and investigations, seeking to protect U.S. national security. These nine graphics show the scale and structure of U.S. reliance on foreign suppliers for products ranging from cars to copper.
Israeli-Palestinian Conflict

Israeli-Palestinian Conflict

Elliott Abrams, senior fellow for Middle Eastern studies at the Council, sits down with James M. Lindsay to discuss ongoing efforts to bring about a ceasefire in Gaza and the war’s ripple effects across the Middle East.

 

Israeli-Palestinian Conflict

Explore the history and important events behind the long-standing Middle East conflict between the Israelis and the Palestinians from 1947 to today. 
Iran

Iran

Tehran is stepping up its crackdown on information flow as the country faces one of its greatest challenges following U.S. strikes on its nuclear sites. Those living under the regime’s rule have been forced to get creative to obtain a fraction of the full story.  

Iran

Countries without nuclear weapons could decide nuclear nonproliferation and transparency efforts that the world has taken for granted now pose more risk than reward.

Iran

The United States joined Israel’s bombing campaign of Iran’s nuclear program. A clear picture of the damage inside Iran—and the state of its nuclear strength—is still unfolding.

Events

United States

Representative Gregory Meeks discusses the Democratic vision for the future of U.S. foreign policy. If you wish to attend virtually, log-in information and instructions on how to participate during the question and answer portion will be provided the evening before the event to those who register. Please note the audio, video, and transcript of this hybrid meeting will be posted on the CFR website.

United States

Panelists explore the shifting landscape of journalism, including the influence of political pressures, and the broader implications for press freedom and democratic values worldwide.Please note there is no virtual component to the meeting. The audio, video, and transcript of this meeting will be posted on the CFR website.

Trade

Panelists discuss the latest announcements from the Trump administration on tariffs and trade agreement negotiations, the likelihood of extended pauses on tariffs for specific countries, and how businesses and the market are navigating trade policy uncertainties. CVETKOVA: Thank you, Alexis. Welcome, everyone, to today’s on-the-record Council on Foreign Relations virtual meeting on U.S. trade policy and tariffs. My name is Dima Cvetkova. I work for Moody’s Corporation. And I have the great pleasure of moderating this session. We have an excellent panel of experts joining us today who will help us disentangle the trade signal from the noise. We have with us Jennifer Hillman from Georgetown University Law Center and the Center for Inclusive Trade and Development; Inu Manak, a CFR fellow for trade policy; and Francisco Sanchez, partner with Holland & Knight, and a former undersecretary of commerce for international trade with the Obama administration. Jennifer, I know you need to head out a little bit early, so let’s get started. So we have now reached the end of the ninety-day pause on the liberation day tariffs enacted to—which were enacted to allow for trade negotiations between the U.S. and trading partners. However, the deadline for the tariffs and the trade negotiations has moved to first of August, with only two framework trade deals put in place—one with the U.K., and one with Vietnam. So my first questions to the panelists are, what was actually achieved during the first ninety days? What should we expect on the U.S. front over the next few weeks or even next months? And does uncertainty around trade negotiations bring more concessions to the U.S.? Francisco, would you like to start? SANCHEZ: Yes. Thank you, Dima. It’s a pleasure to be with you, and with Inu and Jennifer. Thanks to the Council for inviting me. I think it would be good to start with what is the underlying goals—what are the underlying goals that President Trump and his administration are trying to achieve, and then see what he has achieved. Clearly, one objective is just as a negotiation strategy. You might describe President Trump’s strategy is one of sticks and no carrots. And so he’s trying to make it necessary, if you will, to have people come to the—countries come to the table. That’s one. Two, President Trump, long before he was ever in politics, was feeling that American business is unfairly treated by other countries in the world. So he’s seeking to find more fairness for American business. Third, he’s trying to bring back manufacturing to the United States. And, fourth, to raise revenue. And finally, fifth, he’s looking for cooperation on non-tariff barriers that a lot of countries engage in. I would say at this point the success, if you measure it against those five goals, is rather limited. As you correctly point out, there two agreements—framework agreements. The details haven’t been worked out. When he made that announcement back in April, some members of his administration said there’d be ninety deals in ninety days. I think it’s going to be difficult. One, USTR is a rather small agency. They don’t have the resources they need to do a lot of deals. That’s number one. And, number two, negotiating trade deals is hard. India, for example, started negotiations with us in February, and here it is now nearly the middle of July and we still don’t have a deal. So I think it’s going to be slow moving. There’ll probably be some deals done before the August deadline, but I don’t think there’ll be a lot. CVETKOVA: Thank you, Francisco. And I’m going to turn over to Inu. I remember reading one of the articles she published. And she was talking about the average time it takes to sign a trade deal, which has nothing to do with the ninety days we have now. So, Inu, what is your take on what we should expect by the first of August and beyond that? MANAK: Yeah. I mean negotiating trade agreements is very hard. It takes, usually, 917 days to negotiate a trade deal. So that is definitely not that ninety-day deadline that President Trump was hoping to conclude a ton of deals in. So I’m not surprised that we only have basically 1.5 deals that we know of, right? So the U.K. deal, the text is out. We’ve seen what’s in it. The Vietnam deal, we’ve heard a little bit about what might be in it, but we have seen no text. And it seems like there’s still a bit of ironing of the details going on. So what have we seen so far? If we look at the deals and the structure of what the administration seems to be negotiating, it looks to be about five different aspects that they’re trying to nail down. First is really trying to get tariff reductions where they can, because tariffs are a big part of President Trump’s trade strategy. Second is to have some sort of cooperation on non-tariff barriers. They haven’t really defined what they are, but said if you look at the national trade estimate report it’s all in there. So that’s where countries can actually take a look. The third item that they’re looking at is digital trade provisions, trying to figure out how to get countries on board to U.S. approaches to digital trade. The fourth item has been some sort of cooperation on economic security. This is kind of vaguely defined, and it varies by country, but it means a little bit more investment screening, perhaps a little bit more monitoring of supply chains to ensure there’s not transshipment of goods from China, and other aspects of economic security measures that they may want to undertake. And then the last part are commercial considerations sort of broadly defined. This includes things like encouraging investment in the United States to help boost the manufacturing base and also purchase agreements as well, like ethanol, which the U.K. actually signed up for. So if you kind of look at the U.K. agreement in particular—so that’s the one that we have. It’s five pages. So it’s a quick read. But it reads more like a term sheet than a trade agreement. So folks who are used to reading trade agreements, it’s a little puzzling to see it because you’re, like, what are you trying to do here? It’s a deal that resolves some trade irritants. It’s mostly a framework for future negotiations on a range of issues, but doesn’t really resolve all those issues right now. And, importantly, what it does is sets the stage for negotiation on future Section 232 national security tariffs that may come in place, but doesn’t guarantee that the U.K. is going to get any carveouts there. So it basically leaves open a negotiation that’s going to happen over and over again over the coming years. And it’s not clear where the landing point is going to be. And Vietnam has a very similar structure in its agreement as well. So I imagine we’re going to see more of these come through slowly in the next couple of weeks, but what we’re seeing is really rough contour of what every single country is going to be negotiating. CVETKOVA: So this is going to actually continue a lot longer, you know, after this sort of framework—basic framework is signed. Negotiations will continue for a lot longer. Jennifer, over to you. The same questions with a little bit—from a different angle. We just talked about—before we started the meeting—about the average tariff rates for the U.S., and all the reasoning behind the tariffs. Could you please comment on that? HILLMAN: Yeah. I mean, clearly, you know, one of the things that has been, if you will, achieved, is a significant raising of taxes on Americans. You know, again, so if these tariffs that the president has now announced, you know, through July 7—including, again, the Vietnam trade framework agreement, the U.K. agreement, and, you know, the announcements of these new rates on fourteen more countries. If those go into effect, we will end up with an average U.S. tariff in the United States—average tariff, again, so plenty of them that would be higher than that—of 17.6 percent, which is the highest rate that we’ve seen on our tariffs since 1934. And, again, we have to remember, at their core, you know, that tariffs are taxes, you know, on American consumers. Because it is the importer in the United States that’s paying that tax. And therefore, we have to remember that these are very regressive taxes, meaning low- and moderate-income people are the ones that bear by far the largest brunt of these taxes. Because it is low- and moderate-income people that are spending 30 or 40 percent of their income buying the kinds of goods—you know, shoes, and clothing, and all kinds of the goods that are the subjects of these tariffs. Again, they’re spending 40 percent of their income. High-income people are spending less than 10 percent of their income, you know, purchasing these goods that are subject to the tariffs. So whatever else they’re doing, they are raising taxes very substantially on Americans. Which, again, feeds into one of the goals here being, you know, to raise revenue. Again, but it is raising revenue heavily on the backs of those Americans that are being taxed. CVETKOVA: Great. Thank you for that. And it’s a great segue to my next question, which is, you know, the U.S. administration announced the trade deals as the best deals for American people and American workers. And this is back to you, Francsico. How is the trade agenda impacting American households, building on what Jennifer said, and businesses? And what could be some important positive and negative outcomes of the trade negotiations? SANCHEZ: Well, it will undoubtably impact a number of sectors more significantly than others—electronics, automotive, retail, construction materials, certain foods. We’re likely to see that go up. As Jennifer said, this is essentially a tax. And so you’re likely to see costs go up. On jobs, it’s interesting. If you take steel, for example, he’s—President Trump has increased tariffs on steel and aluminum. The steel industry has approximately 90,000 millworkers. And if you take their industry as a whole, they probably employ upwards to about 280,000 people in total. That includes office workers, salespeople, everybody. If you put tariffs on steel, then you’re likely to see more production, so their employee numbers may go up because there’ll be more demand for American steel. But compare that to automotive. The automotive industry in the United States has about four million employees. If the cost of inputs for the automotive industry goes up, there’s a chance that that sector will see a drop in sales and you could actually see a drop in the number of employees in the automotive sector that would dwarf any increase in the steel industry. Worse than that, I’d say, would be construction. We have about eleven million people that work in construction. It’s a sector that’s very dependent on steel. So you’ll see potentially a major reduction in the number of employees in the construction space that also would dwarf any increase. So while there’d be a benefit in the steel industry, you could see other sectors, like construction and the automobile manufacturing, actually go down. CVETKOVA: Inu and Jennifer, would you like to add anything to what Francsico was saying. MANAK: Go ahead, Jennifer. HILLMAN: I mean—I mean, to some degree I think you’re already seeing a little bit of this. If you look, for example, at the price of steel in the United States compared to the price of steel elsewhere in the world, you know, again—I, you know, recently looked at the numbers; the price for a hot rolled sheet of steel in the United States is over $900 a ton, whereas the world average price is $400 a ton. The average price in Europe, around $600 a ton. So if every manufacturer in the United States that needs to purchase steel to use it to make a product out of it is spending almost twice as much as any of their competitors are for that basic component, you know, the concern is what it does to long-term competitiveness. You know, and then you turn to things like construction. You know, again, in addition to the tariffs on steel and aluminum, and now these across-the-board tariffs—these so-called reciprocal tariffs on these, you know, fourteen-plus countries that are above the 10 percent that’s been added onto everybody in the world—and, again, you start to see it. And then you look at what is likely coming, which is a number of these section—so-called Section 232 national security tariffs. So, again, we have to remember that there are investigations pending right now today on semiconductors, on pharmaceuticals, on copper, on timber and lumber—again, heavily involved in construction—on critical minerals and derivative products, on medium and heavy-duty trucks and parts, and on commercial aircraft and jet engines. So if, again, we were to result in even more tariffs on all of those sectors on top of all of these others, you can see what a significant impact it could have in a number of these key sectors of our economy. CVETKOVA: So can I follow up on that actually? We were talking about we were talking about legal challenges, and there is a lot of talk about legal challenges to these tariffs. So, as a legal expert, can I ask you, do you think that legal challenges can derail the U.S. trade agenda? HILLMAN: I certainly think that there’s a very good chance that the legal challenges will at least temporarily derail the tariffs that have been imposed under the International Economic Emergency Powers Act, or IEEPA. Again, and that is all of these 10 percent across the board tariffs, and all of the tariffs that we’ve just described that are the ones under the U.K. agreement, the Vietnam agreement, and, again, the new tariffs that were announced last night against these fourteen countries—all of the so-called reciprocal tariffs. Those were all imposed under IEEPA, as were the tariffs on Canada and Mexico. Remember, we’ve got a 25 percent tariff on Canada and Mexico, and, again, 20 percent more on China as a result of IEEPA tariffs, subject to this so-called fentanyl crisis—this emergency on fentanyl. So all of those tariffs, which pretty much means everything except the existing tariffs on steel and aluminum and cars, are subject to this IEEPA challenge. And it is a big challenge. Two courts have already ruled that the president’s tariffs under IEEPA are illegal, unlawful. Why? Because, again, the Congress is given the power by the Constitution to impose tariffs. Again, Article One Section Eight of the Constitution is very clear. It is the Congress and the Congress alone that has the power to impose tariffs. So the president can only impose tariffs if the Congress has handed over authority from the Congress to the president. And so the question before the courts is, did the Congress hand over this authority in this IEEPA statute? And the courts have found, and many are arguing, that the answer to that question is no. Again, partly because, again, it has to—the words that the president is relying on is that IEEPA gives the president the power to regulate importation and exportation. And so then the question becomes, does “regulate importation or exportation” mean tariff? And the argument is, no, it does not, because in every other law in which the Congress delegates that power to impose a tariff, it uses the word “duty” or “tariff.” And it puts in procedural requirements. It puts in timing requirements. It puts in notice and comment requirements. It puts in limits on the amount of the tariffs that can be imposed. None of those exist in IEEPA. So, again, there’s a big challenge as to whether or not IEEPA provides the president with tariff authority at all. And, again, at least one court has already ruled to say, no, it doesn’t. And then the second aspect of IEEPA is you can only impose these tariffs if you have declared there to be a national emergency, which is—which, again, is defined in the law as an unusual and extraordinary event having its genesis outside of the United States. So the second big argument to all of these reciprocal tariffs is how can you say that a trade deficit is an unusual and extraordinary event when the United States has been running a trade deficit every single year for fifty consecutive years? The deficit is not particularly high compared to our GDP, you know, in this year. So how is this an unusual and extraordinary threat if it’s something that’s been happening for fifty years? And similarly, the argument on the fentanyl tariffs is, you know, what is putting a tariff on, you know, teddy bears, or T-shirts, or anything, else have to do with fentanyl? There has to be a connection between the emergency that’s been declared and the action that’s been taken, tariffs. So across all of those fronts, there are these very serious challenges pending to the tariffs. These challenges are currently pending before two different appeals courts, again, because the courts have already ruled, no, you can’t use IEEPA for tariffs. The appeals are pending. I’m assuming that by early fall we will have decisions by these appeals courts as to whether or not they believe that IEEPA provides tariffs authority or not. And then presumably, from there going, you know, again to the Supreme Court, I would assume sometime, you know, again, in the winter we will have some court—sort of a ruling from the United States Supreme Court. CVETKOVA: Thank you. I want to go back to the trade deals. I want to make sure that we talk about the U.S.—potential U.S.-China trade deal. And Inu, I want to turn to you and ask you, if there is a U.S.-China trade deal—I mean, I do remember the first Trump administration the Phase One and Phase Two agreements, and what happened with that. If reached, this U.S.-China trade deal, what shape or form do you think it is going to take? Or are we just going to see a prolonged trade conflict instead of the trade deal? MANAK: Thank you, Dima. You know, I think it’s going to be very difficult to do something very comprehensive with China, because comprehensive deals take time. And it takes a principled approach with really clear targets that you’re trying to achieve. And the administration’s trade policy has basically been erratic. It’s been erratic because they’ve been trying to get quick deals, but a quick deal with China won’t bring about the systemic change that’s needed to address some of the concerns that were brought up in the original Section 301 report on unfair trade practices with China under the first Trump administration. Now, if we look at what happened during the first Trump administration, we had the Phase One deal on January 15, 2020, signed. It included various commitments, mainly focused on purchase commitments, including agricultural products, industrial products, natural resources, and services. Now, if we look at how that did, Chad Bown from the Peterson Institute found that China actually only purchased 58 percent of the total U.S. goods and services exports over 2020-2021 that it had committed to buy. And it bought none of the additional $200 billion of U.S. exports committed under the deal. So the Phase One deal not only did not live up to the purchase commitments, but it also failed to systemically change some of the concerns he had about China in terms of unfair trade practices, including whether or not it was violating IP rights and it was using forced technology transfer. All these things were left unaddressed. Now, if we are to deal with that, one of the things we need to be doing is to work with our trading partners, who we’re now raising tariffs against, to find a way to actually work together to have common rules around how we deal with China. And at the moment, what we’re doing is actually pushing a lot of our trading partners closer to China by closing off our own market and threatening all these tariffs over and over again. So I think that at the end of the day if we actually are to have some significant reforms and a comprehensive deal, we kind of need to step back and take some time, right? We can’t have this general framework that we keep modifying every other month where it comes to no real strong commitments at the end of the day, and we have no dispute settlement mechanism that we can use to enforce it. So China Phase One deal has no dispute settlement mechanism. And if you look at the text of the U.K. deal, I don’t see one there either. And, in fact, it says it’s a nonbinding deal. So how can we actually achieve concrete results if the agreements are nonbinding? So I think there is a big question here about what we can actually achieve and huge limitations in just the structure of the negotiations themselves. CVETKOVA: That’s great. And I and it brings me to the next question, actually. It leads on to, are we actually seeing the U.S. on the way to withdrawing from leadership from the global trading system? And if the three of you can think of five years from now what the trade landscape is going to look like, how do you visit it? Francisco, would you like to start? SANCHEZ: Well, the short answer is, yes. We are retreating from being the global leader in promoting free trade, in being against protectionism, if you will. Going from being against protectionism to being the leader in protectionism, in many ways. You know, hard to predict what’ll happen in five years, but there’s no question that what’s happening here will largely—(off mic, technical difficulties)—the other countries, when they negotiate with some of their trading partners that aren’t the United States. So I do see a retreat from globalism, a retreat from free trade. And time will only tell how far we go. I’m very concerned that probably our biggest economic adversary—not probably—our biggest economic adversary is China. And yet, of the fourteen countries that were mentioned yesterday, many of them are in Asia where we should be strengthening those ties and not creating tensions. I’m talking about Japan, South Korea, Thailand, Malaysia, Indonesia, Cambodia. So it creates tension where we should be creating cooperation to go after the most challenging economic problems we have, which I believe is China. Inu mentioned intellectual property, theft, forced transfer of technology. Those are the issues we need to be focusing on. And they’re hard. So I don’t believe on critical issues we’ll see those be resolved soon. To the extent we have a deal with China before the end of the year, I believe there’ll be, perhaps at best, some short-term advantages, but not long-term. HILLMAN: For what it’s worth, I’d only add that, you know what you—a couple of things. One is, you know, there is a huge risk to the whole world if we, in essence, fragment the global trading system into two big blocs—a kind of, you know, pro-U.S. bloc and a pro-China bloc. The WTO and the IMF and the World Bank, you know, recently published a study that said if we just do that—just that fragmentation alone, with no other changes happening in the rest of the economy, we’re looking at a 7 percent reduction in global GDP, and even more of a reduction for many of the developing and least-developed countries. So, again, a huge risk of fragmentation. And the other thing to watch China doing in response—you know, again, you have to be really clear about what did China do the last time the United States engaged in this trade war, is to some degree the same thing they’re doing right now. Which is, to the extent that they raised tariffs on U.S. products they lowered them on goods from everywhere else. China is immediately sort of doubling down and going to all of its Asian neighbors and saying, you know, we are a reliable trading partner. The United States is not. You should do more of your trade, you know, in and around and with the United—with China. China is trying to become, itself, much more, again, the hub of all of this trade, you know, within Asia. So I do think we need to be really worried about it. You know, and as Francisco said, I mean, many, countries share our concerns over what China is doing on intellectual property theft, on over producing, overcapacity, flooding the rest of the world with all of this excess capacity in goods that’s driving down prices for everybody in the world. A lot of countries share that. But they cannot get on board with the United States in fighting it if the United States is going to turn around and put tariffs on them. And, again, the tariffs come on and off and on and off. So, you know, that I think is the real risk, is that we’re going to fragment the world and we’re going to put countries in this very tough position about whether or not they want to side with China or whether they want to side with the United States. They don’t want to side. They want to trade with everybody. And yet, you know, we may be pushing them to have to make a decision. SANCHEZ: And, Dima, if I may add one more thing, is that the tough approach, or the no carrots a lot of sticks approach doesn’t work well when your counterparty has its own set of tools to fight back with. One that the Chinese have used, I think very effectively, is holding back export licenses on rare earths, something that’s very important to a lot of American industries. So it isn’t as though China doesn’t hold any cards. They hold quite a few. I would also point out that China is prepared to have its population be ready for economic difficulties, rather than to just simply cave in to something that President Trump may want. So I think no matter how you look at it, the negotiation with China on issues of real importance to us are going to be very, very difficult and probably a long time in coming. CVETKOVA: Thank you, Francisco. And, Inu, before I turn to you with the same question, I just want to mention for the audience that we’ll be opening the Q&A session in just a moment. So if you do have a question, please raise your hand now to join the queue. So, Inu, over to you. MANAK: All right. Thank you. You know, just to add one big picture point to that. When I’m looking at sort of U.S. engagement and global trade leadership, I would say we haven’t been a leader in the global trading system for eight years. And we never kind of stepped back into the role of leadership once we stepped out of it in the first Trump administration. You know, when Trump first entered office, he effectively ignored the global trade rules. And then Biden came in. And he largely followed suit. Most of what Trump did in his first term was maintained in the Biden years. There was a window of opportunity early on in the Biden administration to reverse course, but the prevailing view in the administration was in support of greater protectionism. And they kept betting on protectionism and to keep it in place to avoid losing support among working-class voters, who, in the end, voted them out anyways. So I think that strategy did not work. And it showed to be something that actually was not something that folks were responding to. And here, Trump’s come back and said, well, you kept these in place, obviously they’re popular, and so let’s just ratchet them up. And so what we’re seeing today is taking that tariff policy to even greater extremes. And we don’t really have any counterweight to that anymore. And so I think there’s a bit of a scramble internally within the United States to see, like, where Democrats stand on these issues today. And there’s a lot of soul searching going on to figure out where they do stand on it. So I think we’re going to see a lot of that play out in the next couple of years, as we have members of Congress respond to the pain that their constituents are surely going to feel as some of these tariffs actually take effect. And I think what we’re starting to see, in fact, in looking forward in the next couple of years, is the fact if maintain these tariffs and, as Jennifer said, you have additional tariffs coming on 232—if you pile on tariff after tariff, the U.S. is going to become an increasingly closed market. And when 50 percent of what we import are intermediate products, that means those who are going to be hit most are going to be small and mid-sized businesses. And they are going to suffer. We’re going to have less consumption and less growth. We already have low growth projections. And we’re going to see that other countries are going to look elsewhere for arrangements in which to trade. The CPTPP, which the U.S. withdrew from, is becoming one of those frameworks, and others may try to bolster the WTO and other arrangements in order to find ways to trade on a rules-based way. The EU has said that they want to do that. So we’ll see more diversification from our trading partners, less coming here. And it’s going to make the United States a less safe bet for investments over time if we have a really unstable trade landscape. So a lot of uncertainty. It’s hard to see where it’s going to land. CVETKOVA: Thank you, Inu. And, actually, mentioning the WTO, Jennifer, I’ll turn over to you, with your experience and your background. What are the urgent—what are the urgent things we need to—the WTO needs to change in a certain way? What are the urgent changes that have to be made, when it comes to the WTO? HILLMAN: Well, obviously, you know, the big concern at the WTO is here you have, you know, arguably, the two largest trading partners in the world—China and the United States—basically engaging in, effectively, a trade war outside the bounds of the WTO, which, again, doesn’t suggest the—you know, that the WTO is playing this highly relevant role. You know, again, because every single one of these tariffs—whether they’re under 232 or under IEEPA—are a violation of the United States’ commitments under the WTO. I mean, we promised when we joined the WTO, again, and when we helped create the WTO, that we would not charge tariffs in excess of the rates that we bound our tariffs at, and that we would not charge tariffs that differentiated between this country versus that country. We would not discriminate with respect to our tariffs. And, obviously, all of these tariffs are discriminatory. So, again, most of the other countries look at the United States and basically say, it’s the United States that is the major problem at the WTO, not China. That it’s the United States that’s not playing by the rules, not China. And, again, that is not in our long-term interest. So what does the WTO need to do? I mean, to me, I think, A, the WTO has got to do everything that it can to try to urge all of the other countries in the world to maintain their tariff commitments. And if they must retaliate against the United States, or must do things on the tariff front, to try to stay within those rules of what are their bound rates, what are their MFN commitments, to try to adhere as closely as they can to the rules. The second one is obviously the dispute settlement system. The United States has, again, destroyed the dispute settlement system by blocking any appointments to the appellate body. A number of countries have come up with this alternative, what is referred to as a Multi-Party Interim Arrangement on Arbitration for Appeals, MPIA. Again, every country has the option of joining that MPIA. And, again, using the rules of the WTO to try to stay as close as possible to a rules-based system. And, obviously, the WTO has got to do a lot of changing on its own. It’s clear that over the life of the WTO it has become way too hard for the WTO to update its rule book. Again, it lives under a rule called consensus where, again, nothing gets agreed upon unless everybody agrees. And it’s become just way too easy for countries to just raise a flag and block a consensus. So the WTO has got to engage in a lot of thinking about how to make decisions better, how to end up with agreements that at least the majority of or a clear plurilateral group of countries can support, so the rest of the world can move ahead even if there are some countries that are not ready to move ahead. They’ve got to update the way in which they go about rule making. And, to me, they’ve got to keep doing and do more of what they do do well, which is to provide, you know, again, a forum for everybody to talk. And, more importantly, transparency. Again, you know, you can go—you can find out everybody’s tariff rates, sanitary measures, phytosanitary measures, technical barriers to trade. They’re all notified to the WTO. So they are—the WTO is a tremendous resource for countries. And, again, they need to do all of that, and to continue to do it well, while they are figuring out how to fix their dispute settlement system and how to fix the sort of negotiating arm of the WTO. CVETKOVA: Thank you, Jennifer. And I want to turn to Francisco with a different question. You’ve helped companies navigate this very difficult trade landscape. We laid it out there. We talked in the past a lot, and you continue to talk about supply chain resilience. So how are companies actually navigating this space? SANCHEZ: A lot of them very difficultly. When you establish supply chains it takes time. And particularly when you’re doing supply chain resiliency, you’re trying to find multiple supply chains to make sure you have backups. But this is—this isn’t something that you turn on a dime. And so it’s very disruptive. It’s something that’s on every company’s mind that relies particularly on international supply chains, and very challenging. I might add, this is not exactly on point to your question, but going back to one of the original purposes of this trade strategy is to attract manufacturing back to the United States. Japan currently is our number-one—or, number one or number two depending on what source you look at, source of foreign direct investment. And 41 percent of that foreign direct investment goes into manufacturing. This is kind of hard to understand. If that’s our goal, it seems like one of our important trading partners that we’ve just slapped—or threatened to slap 25 percent tariffs if we don’t reach a deal by August one, how that is a great motivator to somebody who seems to be doing what they want. And to answer—going back to your question, that foreign direct investment will be harder for companies to make the decision to invest here if their supply chains are harder to put together, whether it’s an American company or whether it’s this foreign direct investment that’s coming from Japan and other countries. So I’d say it’s been a big challenge. And because of the economic uncertainty that we’re seeing in the execution of this trade policy, I believe that that difficulty is going to remain for some time. CVETKOVA: Thank you, Francisco. And at this stage, I can see that we have a question from the audience. I want to turn to this question. Let me just remind the audience that this meeting is on the record. Alexis, can we have the question please? OPERATOR: (Gives queuing instructions.) We will take the first question from Mara Lee. Q: Hi. This is Mara Lee. I’m a reporter with International Trade Today. And if you will forgive me, I’m going to squeeze in two questions. One question is about this question of transshipment in the Vietnam framework. Robert Lighthizer has talked about transshipment in a way that doesn’t mean transshipment, that just means a certain amount of Chinese content in a good. And so I wanted to get y’all’s thoughts about how—what the U.S. might get other countries to agree to in terms of will it be more like a rule of origin, that if you have, you know, 60 percent of the value is Chinese it doesn’t count? My other question is sort of this game of chicken, in the sense that Japan and South Korea really don’t seem to be able to accept a world that the 25 percent auto tariffs don’t go away. And we don’t seem to be willing to have them go away. So will Trump have to back down in the end because the market will discipline him? Someone said there isn’t any more guardrails, but he did back down in April because of a huge stock market drop. You know, the market’s not going to care about 40 percent on Cambodia or 25 percent on Kazakhstan, but they may care about 25 percent on some of our very largest sources of imports. HILLMAN: So I can—I can start first with the transshipment question. Just to say, unfortunately, we don’t know. I mean, what the agreement—what little we know says that the tariffs on everything from Vietnam is 20 percent, unless it has been transshipped in which case it’s 40 percent. Now, again, normally transshipment is considered something illegal if you basically are, in essence, slapping a label on something that says “made in Vietnam” when it was, in fact, made in somewhere else. I mean, that is normally what we think of as transshipment. And so obviously if that’s what you’re doing, you know, that is illegal, and, you know, it should carry a higher tariff. But if what they really mean is that you’re simply using components from everyone else, that is not what we normally understand transshipment to be. I mean, normally we live with—again, the 20 percent tariff on Vietnam ought to be on anything that is considered made in Vietnam. How do we know if it’s made in Vietnam? It’s whether it meets the existing today rules of origin that apply to Vietnam, and many other countries. And that rule is generally wherever it—wherever that article is last substantially transformed into a new and different article of commerce, or underwent, you know, a tariff shift where it becomes a new item under the tariff schedule. If that work occurred in Vietnam, that good should be considered made in Vietnam for purposes of customs, and should be subject to the 20 percent tariffs. So we simply don’t know whether they’re going to come up with some kind of a different definition of what is meant by transshipment in this. And the only other thing I will say is those kind of negotiations, over rules of origin and changing rules of origin to require more work to be done in Vietnam in order to qualify for that 20 percent tariff, are not easy to negotiate. Because the way in which every different product is made is different, and therefore you have to really struggle to figure out how are you defining the rules of origin within any given product? I mean, you saw this really clearly in the auto rules of origin with respect to the USMCA, the U.S., Mexico, Canada agreement, where that was a large negotiation to try to just figure out how to change those rules of origin, adding in requirements on where the steel was melted and poured, and a lot of other things. So the answer is—on the transshipment—I think we really don’t know what they mean or what they’re getting at by that, and won’t until we see actual terms of an agreement. SANCHEZ: Well, I’ll take a shot at the second question. I’m not terribly good at making predictions. In fact, I’ve made predictions that have been wrong in the past. But I’m going to take a shot at it. I don’t believe that the 25 percent tariff that President Trump announced will stick with Japan and South Korea, in part precisely because of what your question implies, is the increased cost to the American consumer would be substantial. I think it is—as we mentioned at the beginning of this program, one of President Trump’s goals is to get leverage in negotiations. And I do believe that that number is more about leverage than locking into that tariff rate. CVETKOVA: Thank you very much. Do we have—do we have other questions at the moment? OPERATOR: No other questions at the moment. CVETKOVA: No further questions at the moment. So I have another question for the panelists. And I sort of want to know, when you think about the U.S. trade policy is there an aspect of it, at least one thing you can mention, that has been either overlooked or, on the flip side, anything that has been overemphasized? And why? Inu, would you like to chime in? MANAK: Yeah. No, thank you. I mean, I think the thing that’s often being overlooked is the fact that we need imports in order to do the things that we do here. You know, if you have to have a vibrant manufacturing base, we need to import components. And so I think what the administration is focusing on is really just not going to be achieved. You know, they say they want to increase manufacturing and exports. Well, you can’t do that without imports, right? And so I think this is one side of it that we need to talk a little bit more about to understand the tradeoffs of imposing tariffs in all these various sectors, right? Because, as Francisco mentioned early on, you know, if you impose a tariff, say, maybe you’re going to show some sort of increase in manufacturing output, maybe in some protected sectors, right? But you’re going to lose it elsewhere. And so we have to have a broader conversation about where is it that we think we should be investing all this trade protection? And is it worth it in the end for the job losses and the reduced output we’re going to create in other sectors? And so I think that’s a broader conversation that’s not being had right now. We’re focusing so much on manufacturing, when manufacturing has been doing quite well. We have tremendous amounts of manufacturing productivity output. We have a good amount of employment in our manufacturing industry. We could do more. We could have more automation, which we’re actually quite behind in compared to other countries. If you look at the number of robots that China has in its manufacturing facilities compared to us, we are really, really low in that number. So we need to do more here in investments. But it’s not tariffs that’s going to get us to that point. And so we have to have that question of, like, what is the goal here, and how do we actually go ahead and achieve it? And how do we do it where we’re basically strangling ourselves by limiting our options for what we can actually purchase abroad? SANCHEZ: Dima, I think another premise of President Trump’s trade policy that needs to be scrutinized is the definition of America being unfairly treated. Trade deficits have been used to define whether there’s unfair treatment between the United States and a particular country. But, as Inu pointed out, one of the reasons that we import things is to make things, right? Our supply chains are international, and we need—we need products from across the board. Another reason that we import things is because we’re the wealthiest country in the world. And so defining an unfair trade relationship just based on the deficit, it just—it doesn’t make sense. There may be unfairness going on, but to measure it based on our trade deficit seems, to me, like a poor measure. HILLMAN: I’d only add two additional ones, in terms of what are we missing? I mean, obviously, to me—and it was sort of implicit in some of what Inu was saying—is, you know, manufacturing of goods is about eight or 9 percent of the GDP of the United States, if you don’t count agriculture. So what are we missing? We’re missing the ninety percent rest of the U.S. economy, which is largely in services. And this is where the United States, again, has a trade advantage. This is where we really do have, you know, the ability to outcompete a lot of other countries. And all of this time that we’re spending talking about tariffs and talking about manufacturing, as important as that is, means that we are not focused on what do we need to do to remain highly competitive on the services side. And the second piece of it, to me, that we’re really not appreciating, I don’t think, is the cost of chaos and uncertainty. And why has that chaos and uncertainty come into our trading system? And here’s where, again, I do think it goes back to some of the basis for the legal questions, because it used to be that Congress set trade policy. And so for an act to go through Congress, whether it was a free trade agreement, or whether it was trade promotion authority, or whether it was the tariff schedules that were included within the Uruguay Round agreements—once the Congress voted on that trade policy, it stayed that way for a fairly significant amount of time. And, yes, you could add tariffs as a result of anti-dumping, countervailing duty, safeguards, you know, other actions. But fundamentally, there wasn’t these huge pendulum swings. And now that we’re deciding to make all tariff action and trade policy by the executive branch, again, you’re seeing this big swing away from where—you know, again, away from a stable trade policy, in a way that I think is really hard not just for our trading partners, but for everybody in the supply chain to deal with the fact that they literally do not know what the tariffs are. They don’t know when they’re going to be applied. And that they could change at a moment’s notice for any reason. And that they’re not—they’re not related to something that you can at least predict what’s going to happen. There’s no predicting here. And I think we’re underestimating what a drag on the U.S. economy that level of chaos is creating. CVETKOVA: I would like to end this conversation on a positive note. (Laughs.) So I’m going to ask you a final question before I conclude the meeting. Is there any positive outcome that you believe could come out of this trade policy and trade negotiations? HILLMAN: I’m going to go first, only because, I’m sorry, that I do have to leave a little bit early. So I apologize to my fellow panelists that this is—you know, I’ve got to walk out the door. For me, the positive that could really come from this is if we’re starting to have really, you know, again, helpful conversations with our trading partners about many of the things that that Inu mentioned at the beginning are part of, potentially, the U.K. negotiation. You know, again, things like cooperation on non-tariff barriers, digital trade provisions, cooperation on economic security and, again, maybe cooperation on what to do broadly about China. If these negotiations do that, and we don’t take this only attitude of we have to win and you have to lose in order for it to be a good trade negotiation, if we can focus on those other things, then, to me, particularly on the digital trade agenda where there are no international rules and we desperately need them—you know, if out of all of this chaos could come a better sense of where we’re headed on digital trade, to me, that would be—that would be a big win, and is not out of the realm of the possible. So I hope that’s leaving you, at least from my end, on a bit of a happy note. CVETKOVA: Thank you very much, Jennifer. Thank you. (Laughs.) Inu, digital trade. I hear—(laughs)—would you like to chime in? (Laughs.) MANAK: Yeah, absolutely. Now, I think there is a real opportunity, actually. So there is all this leverage that’s been created from the tariffs that have been put in place. Countries want to negotiate with the United States. So we should use that enthusiasm to actually get something done, right? You know, forget the deadline. And deadlines don’t really matter. I think that’s been pretty clear this year, that the deadlines can move. And that’s OK. Trade negotiations take a long time. And we should take the time to do it right. And on digital trade is something where the United States has long been a champion of creating global rules, but we dropped the ball on that a couple of years ago. And now is our chance to make sure that we can have global rules on digital trade that reflect U.S. interest. There have been negotiations ongoing at the World Trade Organization for several years. Last year, they got very far along, to the point where they actually have what’s called a stabilized text. That just means there’s lots of stuff that’s pretty much agreed to, and there’s a few things that aren’t agreed. I think for the United States, it would make a lot of sense to go into those negotiations and say, hey, look, maybe we need to change some things here, and expand a little bit what we’re doing, and include some provisions in there that are a little bit more stringent for China, in particular, to address some of the concerns over data localization, for instance, that have been a major sticking point in negotiation. So I think there’s a real opportunity for that. But also just generally, on the WTO reform front, we could do a lot. We can address the problem of developing country status in the WTO, which is self-declared. You are a developing country if you say you are. That’s something that’s been a major sticking point for a very long time. We could address the unfairness of subsidies and overcapacity by having a broader conversation about that. And if we don’t do it there, we can do it within a smaller grouping of countries that are actually also concerned about it. We had discussions under Robert Lighthizer between the EU, Japan, and the United States on overcapacity and subsidies reform. We should rebuild those discussions again and try to find a way to have some common ground there, because if we work together and we leverage our allies to make sure we can actually get these changes, I think there’s a real chance that we can have some positive structural reform at the end of all of this. CVETKOVA: Thank you. And Francisco. SANCHEZ: I’m probably in very strong agreement with the comments that Inu made and Jennifer made. I do believe there’s an opportunity here to focus on non-tariff barriers, which are often more problematic than the tariffs themselves. Anytime you start a conversation there’s hope. There’s hope that you can have something good happen. And I think in the non-tariff barrier space we could see some movement. And that would be a very positive thing. Jennifer mentioned more cooperation among the countries that are concerned about China as an economic threat, particularly in some of the unfair practices that they engage in. And, again, just starting the conversation with countries, even though these conversations have been testy in many cases, could lead to cooperation to something that really is going to be critical for our future. And then finally, not so much on the trade front but geopolitically, it’s possible that we begin to get closer to India, for example, which is going to be an important country for the United States to build a relationship with, not just economically, but geopolitically. And the same in the Asia region. Although we’ve had very difficult, it seems, conversations with Japan and Korea and others, geopolitically it’s in our interest to be closer and to work together. And I’m hoping, from this chaotic beginning, we can see an improved relationship that that that goes to our geopolitical interests as well. CVETKOVA: Thank you very much. With that, I would like to conclude the meeting by thanking the speakers for a very lively and engaging discussion, the audience for joining us, and the Council on Foreign Relations for organizing this event. Thank you. SANCHEZ: Thank you. MANAK: Thank you. (END)

Public Health Threats and Pandemics

Thomas J. Bollyky, the Bloomberg chair in global health, senior fellow for international economics, law, and development, and director of the global health program at CFR, discusses emerging threats to public health. Kate Wells, public health reporter at Michigan Public, speaks about her experience covering health stories in Michigan. The host of the webinar is Carla Anne Robbins, senior fellow at CFR and former deputy editorial page editor at the New York Times.  TRANSCRIPT FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Local Journalists Webinar Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. CFR is an independent and nonpartisan membership organization, think tank, publisher focused on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. This webinar is part of CFR’s Local Journalists Initiative, created to help you draw connections between the local issues you cover and national and international dynamics. Our programming puts you in touch with CFR resources and expertise on international issues and provides a forum for sharing best practices. We’re delighted to have journalists from thirty-three states and U.S. territories with us today. So thank you for being with us. This webinar is on the record. The video and transcript will be available on our website after the fact, at CFR.org/localjournalists. And we will send it out to all of you on the call, along with any resources that are mentioned. We are pleased to have Thomas Bollyky, Kate Wells, and host Carla Anne Robbins with us today. We’ve shared their bios, so I will just give you a few highlights. Thomas Bollyky is the inaugural Bloomberg chair in global health, senior fellow for international economics, law, and development, and director of the Global Health Program here at CFR. He is the founding editor of Think Global Health, an online magazine that examines the way health shapes economic, societies, and everyday lives around the world. Mr. Bollyky also directed the first two CFR-sponsored task forces devoted to global health on pandemic preparedness and noncommunicable disease in low- and middle-income countries. Kate Wells is a Peabody Award-winning journalist covering public health at Michigan Public. She was a 2023 Pulitzer Prize finalist for her coverage of a Michigan abortion clinic. Ms. Wells also received the Livingston Award for Young Journalists for her work on the podcast Believed. And Carla Anne Robbins is a senior fellow at CFR and host of the Local Journalist Webinar Series. She also serves as faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. And previously she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. So welcome, all. Thank you for being with us for this conversation on public health. And, Carla, I’m going to turn it over to you to have a conversation with Tom and Kate for twenty minutes or so, and then we’re going to go to all of you for your questions. So get ready to raise your hand or write it in the Q&A box, but we would prefer to hear your voice directly. So, Carla, over to you. ROBBINS: Irina, thank you. And thank you so much for the local journalist people who support this, because this is really on top of the news—on top of breaking news right now, because the Senate bill just passed with the tiebreaker from the vice president. And we know there’s a lot of public health implications. And we will get into that. But, first, Tom, I want to turn to you. And, Tom and Kate, thank you so much for being here. We talk about the local journalist webinars as linking the global to the local. And the United States was a major funder forever of global health initiatives. There’s been a massive cutback in that, with the destruction of AID and other programs itself, and great fear of emerging health threats developing around the world. And there is no wall that we can build that’s going to stop disease from spreading to the United States. So what are the emerging health threats globally? And are they already threatening the United States? Are we going to have to be reporting on that and worrying about it for our kids? BOLLYKY: Great. Well, thank you so much to Irina and her team for hosting us. She has heard me say it many times but it doesn’t make it any less true, I really value the national program and its networks that it operates. They’re a great opportunity for us to learn, of course, also to speak with you. But it’s really one of the strongest parts of the Council. So I’m grateful to her and her team for doing that. It is nice to be here with Carla and Kate. In terms of thinking about the global to local, you know, CFR’s role is to inform U.S. engagement in the world. And that, of course, includes on health risks. But when we think about U.S. global health engagement, it is often framed as a product of hard security interests, you know, soft power, humanitarian concerns, geopolitical calculations, and machinations, divorced from the health concerns that happen here at home. But the reality is that health in the United States, including and sometimes particularly at the state and local level, profoundly shapes the way in which our country pursues health globally. And of course, the reverse is also true. The impact of U.S. domestic health on global health starts with the problems the U.S. takes seriously. And our understanding of which problems the U.S. takes seriously, of course, is being informed, as Carla said, in real time. We have a tax cut bill that has just advanced in the Senate that might affect Medicaid coverage, insurance coverage for eleven million people. But I want to really highlight two examples of this domestic-to-global intersection, and how it bounces back. The first is on public health emergencies. The administration, Trump administration, has cut $4.6 billion in grants related to pandemic response, both for COVID and for future pandemics. There have been significant cuts at the state and local level, in particular through our epidemiology and laboratory capacity program, that had distributed tens, in some cases, hundreds of millions of dollars to state and local public health authorities. You’ve seen just in the last month or so the president released his budget request for fiscal year 2026. And you’ve seen this de-prioritization of pandemic response occur in how the U.S. engages globally on the same issues. The news is a little grim for those of you that—for those of us that are concerned about the funding of such programs. The budget would eliminate the CDC’s Global Health Center and funding for most of its bilateral programs internationally, including on immunizations, TB, HIV/AIDS, polio, and so forth. Global health programming for other U.S. agencies, like the State Department, isn’t spared. It would reduce its funding of pandemic preparedness by 77 percent. So at a moment where we remain concerned about avian flu, Cambodia has just announced two more cases just this week, part of a spike of cases of avian flu that has been going on in that country. This intersection of what we’re seeing internationally, as well as our own domestic outbreak, is a real concern. And, again, indicative of this global-to-local connection. The other one I would just point out here, the second to last one, would be on vaccination. Secretary Kennedy, as all of you, I’m sure, know, has fired all seventeen members of the panel that produces the nation’s vaccine guidelines, and replaced them. He has also as part of that announced that the U.S. will forego its pledge to the Global Vaccine Alliance, Gavi. It had been committed to spending $1.2 billion to support global vaccination through that institution. Gavi is an institution the U.S. helped create. It vaccinates seventy million children annually around the world for pediatric diseases. And that’s been cut. There is some announcement of funding and people standing up this year some additional funding through that financing round, but it seems now, quietly, we’re getting a sense that some of that $9 billion that had been pledged to Gavi this week is repurposed funds from COVID, money that already existed. So it’s probably a little closer to $6 billion. If that’s the case, this is about 60 to 50 percent of what Gavi was seeking to continue its operation. So it’s a significant loss. The U.S. has concerns around—or, rising vaccine hesitancy in the U.S. is also reflected somewhat internationally. The Lancet released a study this week that twenty-one out of thirty-six high-income countries saw a decline in coverage for at least one of the major vaccines on the routine child immunization schedule. So you see this intersection happening there, where we see surges of pediatric diseases that might be—you know, that might foretell increasing episodes like this. In particular, the U.S. is likely to set this year a thirty-year record for measles cases. And we may see more of that to come. Let me pause there, having talked a little bit about this global intersection, and really interested in your questions in this conversation. ROBBINS: So if we were to be—obviously, we weren’t expecting COVID. And so it’s hard to predict something like that. But more traditional diseases that people aren’t getting vaccinated, either by choice or because they don’t have access to the vaccines because we’re not going to be funding them internationally, are there particular diseases that we have to worry about? Is polio going to come back? Is measles going to come back in a massive way? Are we going to start seeing malaria coming back in a massive way, that could potentially either come back to the U.S. because there are travelers that are going to bring it, and because people here are not going to protect themselves against it? BOLLYKY: Yeah. I think a classic example would be—would be measles. Historically, most of the U.S.’ measles cases that we would see were from travel, travel-related measles cases. We are now seeing a sustained spread of cases domestically. The U.S. has, sadly, imported measles cases to Mexico. So we are now a source of other countries’ cases. The U.S. has had—and this is more climate related, which is, of course, its own conversation—but the U.S. has had—seen spreading of malaria cases domestically. So we did have sustained malaria transmission last year. And then, of course, we’ve been seeing in Florida some Dengue case cases year-in and year-out, over the last couple of years. So you’ll see that as well. That’s a little less tied to vaccination, but it’s part of this broader conversation of what kind of surveillance we’ll have on a state and local level, what sort of lab capacity we’ll have, and how that feeds into our ability to fight diseases at home and abroad. ROBBINS: Thanks. So, Kate, how do local reporters monitor and get ahead of the story of a health crisis? WELLS: Yeah. So, I mean, I don’t have, like, fun news for you on this. But we—I think what I would—I think what I would preface all of this with is, we are hearing a lot about this crisis right now, but we—on the on a local public health infrastructure, in terms of whether it’s something like measles, we have already been seeing even post-COVID the local public health system be unable to handle what we were already seeing, post-COVID. I think there’s a feeling among the general public that our public health system, not just in terms of, like, you know, your local health department, but even in terms of, like, your hospitals, that somehow when COVID ebbed, that things went back to normal. And that just isn’t the reality, for a number of different reasons that we don’t need to go into too deep. But everything from the sheer number of pediatric beds that you probably have in your state, to how many maternity wards you have in your state, to how many people have left health care or are just entering health care and don’t have a lot of experience behind them. We have already seen—even before we started seeing measles rise in the last several months, in the last few years, post-COVID, we have seen childhood diseases just behave differently than the way we did before. And there’s some theories about why this is. But a few years ago it was this surge of RSV that completely overwhelmed children’s hospitals. And then this past year and the year before we really saw this increase in pediatric flu. And it’s less sexy than measles, but I say it because we need to understand that the system, as it is, was strained by COVID, but never went back to normal. And so already exists in this period of real strain. What is happening now that we have these changes coming from HHS and CDC is it means that your local public health infrastructure is really going to be on their own. The way public health works in this country is that, to a large extent, the way we monitor everything from, say, avian flu in the ag world, to norovirus and walking pneumonia, that that does happen at a local level and looks very different from state to state. We are going to be depending on these systems that, as Tom has said, just got a massive cut in funding. And also many of them, when I talk to these—to my sources, they are in a state of not just like uncertainty about what the future holds, but uncertainty about their own funding. So I think—I feel worried on a level that I don’t think I have for the last few years, really since COVID, of just a real uncertainty about what kind of system we’re going to have. And I think the importance of local—I mean, I realize I’m biased—but I think the importance of really good local health reporting is going to be more important than ever. And I think your audiences are going to really need clarity and be hungry for that kind of local level understanding, because there’s just going to be a lot of uncertainty and confusion. And people are—people’s kids are going to be sick. They’re going to get sick. They’re going to show up to the emergency room, and if they haven’t been to the ER in the last few years, be really confused as to why the experience that they’re having is not what they expected. Why are they being boarded for three days? Why can’t their kid get a room? And part of what we’re going to be able to need to do is explain to people why that is, and be in really good touch with our local health officials. Which, I know, is easier said than done when you’re dealing with a million different deadlines. But it’s why I’m glad we’re talking about this. ROBBINS: So, Kate, I’d like you to talk a little bit more about stories and about how you do that what you’re talking about. You’ve talked here just on a basic sets of stories about capacity, and particularly pediatric capacity. There’s some really interesting stories that are there. There’s the post-COVID story, and what bounced back and what didn’t bounce back. There’s the story about the coming cuts and what they’re going to do about capacity, and how—and depending on whether you’re in an urban setting or a rural setting, you know, how these Medicaid cuts, all of these things, are going to happen, and how that’s going to affect hospital capacity, and particularly pediatric capacity. Which sounds—those sound like great stories. I’m really interested on the—just the basic—because I’m sort of a numbers geek—on the basic ability to monitor what’s happening in my town, my region, whatever it is that I cover. I mean, I loved it and—I mean, it was awful—but I loved just the sheer fantastic work that Johns Hopkins did with that dashboard during COVID. I mean, you could go on every single day—now, the fact that it had to be done by a university and not by the federal government—(laughs)—but you could go on every day and you could look at that map, and you could look at the mortality numbers, and you could look at the infection numbers, and it could be for the United States, and you can look globally, and you could parse it, and all of that. If I want to look at what’s going on in my county, or in my city, or in my state for measles, or if I want to have some early warning about something that’s happening, how do I do that? WELLS: I wish I could give you an answer that was going to work for everyone on this call. The reality is, sort of like what we’re talking about here, the way that local public health works, and we really saw this during the pandemic but we’re going to see it a lot more now, is it is going to look completely different—not just state by state, it is going to look different county by county. And I’m going to say this multiple times, but, like, the importance of just having the phone number of who is your local public health officer, who is in there who tracks cases, and what cases do they track, what kind of contact tracing are they doing? Like, being able to establish this when there isn’t an immediate crisis is going to be really important, because the way—we’re going to be seeing fewer and fewer of the Johns Hopkins, because a lot of the researchers who have been doing this kind of work—where I am, it’s a lot—when we were in the pandemic, it was a lot from the University of Michigan. When I talk to those epidemiologists today, their departments are in hiring freezes, right, across the University of Michigan. They are not doing some of the work that they were doing previously because of this kind of funding uncertainty. And Michigan is one of the states that have been very active in some of these lawsuits, where there have been at least temporary injunctions against some of these funding blocks. But that doesn’t mean the money is actually flowing anymore. It is going to be more incumbent on local public health reporters to be figuring out, and also then showing people the really disjointed system that we have. It’s also not going to be just whoever your local public health officer is. And I’m sorry, to, like, give people a list of homework. You’re also going to need to know who is at your children’s hospital, and be talking with them ahead of time, because they are going to be seeing spikes and things before anybody else is. And there may not be the kind of tracking data that we had during the pandemic. I am not expecting that whatever the next big thing that we go into, that we’re going to have the same kind of data that we did during the pandemic. And I think we need to be preparing for that now as local public health reporters. There should be a good answer to that question that you’re asking, Carla, because it’s so basic. And I can tell you that there isn’t. Even right now in Michigan, when we are having more measles cases than we have in years, the amount of information that I can tell you about one measles case in one county versus the next is completely different. And that is because of local public health officers are trying to do jobs that you could not pay me enough to do right now, which is try and get and communicate information from people who feel resistant about sharing that information. But what that ends up doing, as a public health reporter, is you have to be really transparent with your audience. You have to tell them, the reason we know this much about these measles cases is because that’s what local health officers are telling us. And the reason I can’t give you the same answers about the same measles cases, you know, twenty miles away, is because everybody is kind of on their own right now, in a way that we just didn’t see during the pandemic. I don’t know if that’s a good answer. I wish I had a better one for you. ROBBINS: No, it isn’t it. This is hard. This is incredibly hard. And you add the politics of it, and the local politics, and the federal politics of it, and then you add to that the cutbacks that are taking place, it’s pretty scary stuff. WELLS: Yeah. I also think a lot of this, too, though, that we have to be really careful about, is we have to be honest and understand, like, the business of health care has changed, and has been changing. And that these changes that we’re seeing at the federal level and at the research level are going to be layered on top of that. The reason we are going to have fewer pediatric beds before, the reason we’re going to have fewer maternity wards already, the reason why I think it won’t just be rural hospitals that are impacted by these Medicaid cuts, I think it would be harder to see an ER doctor in Detroit and New York City and Minneapolis after these Medicaid cuts because the private equity staffing companies that run these emergency rooms are going to want to reduce the numbers of advanced practitioners they’ve got in these ERs. Like, we’re really going to have just a lot of different factors that are going to make it harder for your average reader to be getting the kind of health care that they’re used to. ROBBINS: So I want to turn it over to the group. I’ve got a million more questions to ask, but if you could raise your hand, would be great. And waiting for people to raise their hands. And while they—we wait for them, I will also ask Tom a question, while we do that. We have a question in the Q&A already. So, nope, maybe this—so L. Beveridge, would you like to ask your question, or should I read it for you? Q: Hi. Yeah, I can ask my question. ROBBINS: OK. Can you identify yourself? I apologize I don’t have a list in front of me. Q: Yes. Yes. Not a problem. Sorry. My Zoom is acting weird today. My name is Lici Beveridge. And I’m a reporter for the Clarion-Ledger and—Gannett newspaper in Mississippi—and the Hattiesburg American, a smaller version of the newspaper. We are seeing an awful lot of pertussis cases jumping up, in addition to the measles. We’ve had that, I would say, maybe the last ten years or so that I’ve noticed. But usually it’s been one or two cases. And, you know, nothing much comes of it. But I think this year and last year we had an awful lot of pertussis cases. And I think—I’m just wondering—you know, I think most of it is because a lot of people are opting out of vaccinating their children. And they’re saying it’s for religious reasons, but I really question that. And I’m just, you know, wondering if that sort of thing is happening elsewhere, and what is the potential impact of just parents refusing to vaccinate their children, even if it is available. ROBBINS: Tom. BOLLYKY: I’ll just weigh in quickly a little bit. Absolutely it’s happening elsewhere. You know, of course, our measles outbreak is being driven primarily by—at least initially by a religious community in West Texas and New Mexico. You saw increased cases there. We did look at some states post-COVID and their rates of religious exemptions. Florida being one where you’ve seen them go up. It’s been a while since we’ve looked at that national data, but I’m going to suspect you’ll see that in more places. States have historically taken different stances on how—whether to permit religious exemptions and for what, and with what documentation. But a lot of that has been disrupted, of course, by some of the politicization of these issues after the COVID-19 pandemic. I wanted to build a little bit on the data side, though. Like I said, it’s relevant for this conversation. I would—for myself, at least, I completely agree with everything Kate said. But I think one helpful distinction to have in mind is there’s the issue of funding and resources at the state and local level, and how that information goes to the federal level, and what’s being reported for threats on which there are existing surveillance systems. So most people, colleagues of mine, still rely on the CDC’s weekly report for measles. So that has all the shortcomings that Kate just described, but it is a—it is a credible source. What I think can be difficult is surveillance on emerging threats. So we did not have any reporting on new H5N1 cases for a significant period of time. It’s hard to believe that’s because there are none, given how many farms have reported infected dairy cattle, how many farm workers are in that area, combination of are we still looking, or—and also the issue, of course, around immigration, and how that might affect the willingness of farm workers to report. So I would—I think one challenge here is there’s—how are we going to work in a more resource-constrained environment with the existing surveillance networks, but in an area where there are both political and economic interests. And how new cases are being reported for an emerging outbreak, what is that going to look like? And I think they’re distinct. Other entities to put out there that I think are useful for you all to think about, depending on what you’re reporting on, National Association of County and City Health Officials, NACCHO, I think is a very useful data source, particularly for structure, funding and workforce issues. Association the State and Territorial Health Officials, ASTHO, also a really good data source. We do a lot of work with the Institute for Health Metrics and Evaluation on retrospective analyzes of states. And we’ve done a lot of that together with them on looking at the drivers of differences at the state level and county level, for instance, in COVID-19 and other threats. So in trying to understand what’s happened in the past, they could be a good resource too. But, again, my fear is surveillance of novel threats and what that’s going to look like, as being a distinct concern from these resource-based concerns. ROBBINS: So you’re saying that we don’t know what the avian flu status is in the United States at this point? BOLLYKY: I don’t think we have a good idea of what the spread of cases—I mean, we didn’t have that great of an idea last year either. But I think we really don’t have a good idea over the last six months how cases have spread in this country, because I don’t know if our surveillance has been quite as robust as it should be. And I think there’s—of the population of individuals most likely to have been infected, I think there’s a lot of reluctance to get tested and report, given the push on immigration status. ROBBINS: Kate, are you reporting on that in Michigan? WELLS: Yes, very much so. I think Tom said it well. And, Lici, I do want to just—I want to just circle back to your question too. Yes. Tom’s absolutely right. We are seeing this across the board right now. I think one change in particular with these—the rise of vaccine-preventable diseases, especially in kids, is one thing that we’re seeing now that we didn’t, especially in your neighboring state of, like, places like Louisiana, where you are seeing the health department literally start—the state health department—literally start to back off of promoting vaccines. That kind of thing is going to—you know, we need to be asking the questions as local public health reporters of, like, what is that doing in terms of not just are they having vaccine clinics, but then how are they counting cases? What does the reporting system look like? I think there’s a lot that we can be doing in there. The thing that makes—the thing that made avian flu reporting already particularly difficult to begin with, even before we were in this period of different types of approaches to immigration enforcement, is a lot of this was happening with work between the ag departments at a state and local level, your national vet labs, and then also with how good of a cooperation system did they have with public health. Michigan, we were lucky in that, like, we have a pretty good surveillance system. Where you run into problems, even with a really good surveillance system and really good collab between your ag department and places—land-grant universities like Michigan State University, the vet labs there, those places are all dealing with funding issues now too. Places like these national vet labs. But then also, what you’ve got is there’s just a major resistance—not even among necessarily farm workers themselves, but among farms themselves. You know, these are—these are massive businesses. And this is not—if we—if you are imagining that there’s, like, good testing happening in a dairy parlor, or even the availability of PPE, or if that were some sort of, like, a practical thing to be wearing while you were working in a dairy parlor, it just isn’t. Tom’s right. We don’t—this is the—he’s absolutely right that, like, we have these major gaps around some of these emerging risks. The problem is that we already know we don’t have the health system capacity to deal with the risk that we are already tracking. ROBBINS: Ariel Hart, health policy reporter at the Atlanta Journal-Constitution. Ariel, would you like to ask your question? Q: Hey. Thank you so much for doing this. So, if I could ask you to pull back, I report in a state that—I mean, they call it purple, but it’s really very—there are a lot of rural areas that will be deeply affected by the One Big Beautiful Bill Act. And even though we did not expand Medicaid, and so our coverage losses will be somewhere between the tens of thousands to the hundreds of thousands. But when you talk to folks in those areas—so, for example, if you drill down into the research of the four rural hospitals likely to close in Georgia if the bill passes, three are in Republican voting districts. There’s a great deal of comfort in the Trump administration of trust, of relief. And I think that there’s a sense that they’re finally being heard and tended to. And there is not—I mean, the level of concern I’m hearing on this Zoom for the people who might be more likely to be impacted by it, that’s just a world away. And so I wanted to ask Mr. Bollyky specifically, you know, given your kind of broad experience, for those folks, both the voters and the representatives, the policymakers, who they just really have a sense that the speed we’re at is the speed we will always be at, and it’s only getting better, where are we as a nation right now? Is there anything that I should be explaining to them, that you could explain to them, or thoughts that you have about this moment? BOLLYKY: Yeah. So really such an important question. So thank you for it. You know, to start on the big and then move more narrow, on where we are as a nation, I mean, I think it’s fair to say the United States is failing at its fundamental mission of keeping people alive. U.S. life expectancy, long regarded a benchmark of a nation’s success, has declined over the last eleven years. U.S. life expectancy is now lower than any other high-income country, of course, worldwide. So that—we’re not making progress. I think the dynamic you describe happening in your state I think exists in a lot of rural communities, where there is a feeling like government hasn’t delivered sufficiently on health. People run on a platform of, you know, cutting through all that government red tape and delivering better outcomes. So you see further cuts and further health declines, which, of course, alienate people even more from government services because they feel that their health outcomes aren’t good. And you have this spiral. We’ve spent a lot of time specifically on COVID-19, of course, because what happened. And we did this big study in the Lancet looking at the interstate difference in COVID-19 outcomes. And, you know, even when you control for age and relevant biological factors, there was a fourfold difference in how states performed, with the best U.S. states performing akin to countries in Scandinavia and the worst performing—U.S. states performing like some of the worst-performing countries in the world. That’s not normal. On most population health issues, you do not see that extent of a divide. And the relevance I drew from that, and my colleagues that worked on this study drew from that, is that we can do—even in—we didn’t see a divide between red and blue states in this study. Our top ten were five red states, so to speak, five blue states. We can do this. The U.S. can respond to its health challenges, even health emergencies. And we know that because some do, and some have. And we really worked very hard to get this message out because I think it’s a quite hopeful one. I worry that coming out of the pandemic, in particular, people have taken the opposite lesson, that somehow our health services are underperforming, we’re doomed. And instead of looking to the examples where we’ve done this well and trying to import them in states that aren’t doing well to address our health challenges, including those driving our poor life expectancy numbers, we seem to be cutting down the system. And I think state and local journalism has a key part in making it clear that the picture is actually a lot more complicated. There are some real success stories of communities and states standing up and really performing well under these threats. And I do think it’s important to get some of those messages across, because there’s just a lot of despair on public health, or the notion that somehow what we did didn’t work, that people aren’t delivering for populations. And I really think you all play such an important function in trying to get the information out there on what the reality of that picture looks like. Q: If I can ask a follow up. So to put a point on it, are we possibly at a global turning point as a nation? ROBBINS: I’m sorry, Ariel, can you talk—can you speak up? Q: Can you hear me? ROBBINS: Yeah. Q: Yeah. All right. To put a finer point on it, are we possibly at a global turning point as a nation? BOLLYKY: I worry that we are, because most U.S. health gains, when you dig down on it, are about prevention and public health. That most of the improvements that have happened on our broader health indicators, like life expectancy, are really driven by the public health side, not advances in the new fancy drug and the best machine at the hospital. And I worry a little bit that this moment, particularly coming out of COVID-19, has been—really undermined the infrastructure on which our health system truly relies on, at a population level. And I think it’s incumbent on all of us to do what we can to try to address that. And, again, I think what’s fortunate in this case is I actually think the data supports that conclusion. It’s just not getting across to people. And, you know, that’s something you all can help teach us in terms of communicating to your readers in local and state levels of how to do that better, because we’ve clearly not gotten it through to people. People have a very different impression on what’s happened in the utility of these services. And it’s absolutely essential that we do something to address that, because otherwise we will be at that inflection point you’ve described. ROBBINS: Great. Ariel says, thank you, in the Q&A. So just I’m going to quickly sum up what Tiffany asked the same question, but—somewhat of the same question that I asked earlier, for either Tom or Kate. Are there any national dashboards right now that we can be looking at? Because she, like I, was quite dependent on Johns Hopkins and the University of Washington. Is there anything out there that’s being maintained that one could just—obviously, they should be going to Think Global Health every day, which is actually really an incredibly well-designed website, by the by the way. And I’m—(laughs)—having come from the web world originally, I admire your design there. But anybody else out there doing a national go-to. Kate anything you look at every morning before you jump out of bed? WELLS: I mean, particularly for measles? Or which—when you say dashboards— ROBBINS: Anything that’s going to alert you to a story that you got to jump on? WELLS: Yeah. I mean, I think those national dashboards are great. I think if—going back to a little bit to what Ariel is saying—I think one of the things that we can be—when it comes to, like, sources to use for ways to communicate what’s happening right now, especially with some of these cuts to people in language that they—yes, there’s a lot of good resources. One of the things that I’m using a lot right now are both whatever your state health department has been able to put together in terms of estimates about what some of these Medicaid cuts will look like, but not just Medicaid cuts. SNAP as well. There’s also, if you haven’t been able to check them out—I’m biased, because I worked for them—but KFF Health News has great— ROBBINS: Kaiser Family Foundation. OK, go on, yes. WELLS: Yes. They actually—they’re no longer called the Kaiser Family Foundation. They’re KFF now. ROBBINS: OK, sorry. WELLS: That’s OK. They do a really, really good job of—they will not only have—let’s say we’re talking about Medicaid and SNAP cuts here, or, say, like the implications of work requirements, which have just been passed. They will be able to break down for you by congressional delegation, what some of these impact estimates look like in your local area. And they will have really good experts who can talk to you about that. The Urban Institute does as well. Those are just two good go-tos who have done a lot of local resources. I would definitely talk with your state health department. They will probably have information on that as well. I think one of the things that we can be doing for people right now when we talk about some of these cuts at the local level is make sure we are talking to them in the language that they use. Most people who are on Medicaid don’t think they have Medicaid. Like, you know, in states that did do expansions, you know, most people just think that they have the—whatever their card says, you know, whether that’s Blue Cross, or Anthem, or something. So we need to be, as local health reporters, talking to people not just about Medicaid, but we need to be talking specifically about the—we need to be using the terms that people understand in their day-to-day lives, because that’s what they use. So KFF and Urban Institute won’t be able to give you those. The state health departments will. And they are a really good resource right now. ROBBINS: And I know that when I get—for me in the morning, when I get up, I know that I have my basic go-to newsletters that I read. Like, I’m addicted to Punchbowl, which is, of course, about what’s going on on the Hill. And since I’m a national security person, I have my list of national security. Are there particular public health newsletters and websites that you go to, the people who are—do more general reporting, but if they want to get into this right now, that you would recommend, beyond Think Global Health, but in addition to? WELLS: Is that for Tom or for me, Carla? ROBBINS: For both of you. WELLS: Tom, do you want to take that? I’m happy to jump in. BOLLYKY: So I will tie a little bit to the—to the global side. I want to endorse what Kate said. I think KFF on budget reporting, particularly coming out of Congress, does an amazing job. And I want to really, on the global side, highly recommend my good friend and colleague. Jen Kates’ group on the global side does really fantastic reporting. They also do good reporting on racial inequities in health care provision. There’s a lot of great resources there on budget and congressional initiatives. So that’s certainly useful. For machinations in Geneva, the Geneva Health Files does a nice work—nice job of having some local-based reporting of what’s going on, on the global side, that I think is worthwhile to highlight. You know, again, on existing health concerns rather than emerging health concerns, I do still use a lot of the weekly reporting coming out of CDC. Another good resource that I’ll recommend in addition to our own is my good friend Mike Osterholm’s group, CIDRAP, in Minnesota does—he’s also a council member—does really good weekly reporting on outbreaks that are happening out there. And they do a digest. That’s a useful site that I’d recommend to folks as well. ROBBINS: Right. And we’ll push all this out to everybody after this is over with. So if you’re scribbling or typing, probably typing, we will do this as well. Debra Krol from the Arizona Republic asked questions about: Is anybody in particular taking a look at the impact of the cuts on the Indian Health Service? BOLLYKY: We’ve done a couple of stories looking at some of the cuts, as well as the measles outbreak, and how that’s affecting. This is on Think Global Health. And I’m happy to include those links. I was also one of the senior authors on a study we did last year on the ten Americas. That actually just came out in December. That looked at us life expectancy disparities, again, in the Lancet, by race, geography, and income. And the one thing I will point out on American Indian and Alaskan Native populations in the U.S. is this is a health crisis that predates COVID. They are the one group that both pre-COVID and, of course, post-COVID had a decline in their life expectancy from twenty years ago when that study was first performed. They are the bottom side of the headline figure that came out of that study, that the divide between these Americas, these groups, by race, income, and geography, has grown to twenty years. They are, unfortunately, on the bottom end of that spectrum. And that is from twelve years when we first—when that study was first conducted in 2005. So you’ve really seen, unfortunately, a—there’s a crisis going on in those communities. And, you know, COVID was certainly one area that should have highlighted it to people, but it both extends beyond that and predates it. ROBBINS: Diego Lopez with—is it the Cibola Citizen? Q: Hi. ROBBINS: Diego, great. Thank you. Q: Hi. Diego Lopez with the Cibola Citizen newspaper here in Grants, New Mexico. I really appreciate hearing you guys talk about how this is going to affect indigenous communities. We cover seven indigenous communities. And the Albuquerque Journal recently reported that several of our rural hospitals across the state are going to be closing as a result of these cuts. Could you talk a little bit about how is this going to impact funding for our indigenous tribes? I don’t quite understand how this is going to impact their hospitals and their health services. Thank you. WELLS: So I could maybe speak a little bit to this broadly. I am not going to have great answers for you on that specific part of it. Was this an estimate that came out of the health—your local—your state hospital association? Q: Yes. Thank you. Yes, it was. WELLS: So they’re going to be able to give you the best possible answer. I, in normal times where we are not slashing Medicaid, have a lot of skepticism, and think we all should as reporters, towards what your local health and hospital association, which is an industry trade group, is telling you is going to happen. I think right now they are a very good tool. And they will, because they are so well funded, have some very good communications people who will answer—one, answer your call very quickly. Two, be able to connect you with local providers on the ground who will be able to walk you through this. And three, also be able to give you specific funding mechanisms, because it’s going to look a little bit different everywhere else. I would also—I know this is difficult right now—I would also ask them to explain how they are making those calculations. We’re going to hear a lot of fear about entire hospitals closing right now. We need to be careful how we talk to people about that. Because it’s entirely possible that the hospital won’t close, necessarily, or not each of these hospitals will close but, say, two years from now their maternity wards will close, or 30 percent of their advanced practitioners will decide to move out of the area. So I would be—I would—I think they are really good resource right now who will be able to talk to you specifically about the funding mechanisms in each of your areas. I would also then ask them to connect you to local providers about what they are seeing and hearing, because they will be able to talk to you about how this is going to impact direct community services. If it is an estimate about closures that is coming from your hospital association, I would just bear in mind that as truly, like, generational as these cuts are that we’re talking about, this is also a trade group that is trying to make a—make a sales pitch right now. And so I would just—I would take whatever they have with that grain of salt, and use their resources well. I would also then find additional sources in your area who can talk to that. Now for emergency rooms, that can be places like ACEP, your American College of Emergency Physicians. They’ll probably have a state chapter. Your state medical board will be hearing from folks. These are—definitely talk with your state health association and your hospital association right now, just understand that they’re not public health officials. They’re a trade group. I don’t know if that’s helpful. ROBBINS: And is the impact separate? I mean, as what Debra—the question that Debra asked. And, hi, Debra. Debra does quite wonderful and just great reporting. Is the impact different in hospitals based on reservations? I mean, these are—that’s a different public health system, or is it not? WELLS: I don’t know the answer to that. But your health association—your hospital association, will be able to point you in the right direction of somebody who has those answers specifically to your area. And also, I would call the tribes. I mean, this is—these are—like, you know, I would talk to that local leadership. And there’s also, at least in—certainly in our areas, like in the Upper Peninsula—a lot of them also share community health departments, right, with non-tribal organizations. And a lot of the funding that they’ve been operating off of has been shared. If there is massive funding cuts there, that’s going to impact people who are outside of those tribal reservations as well. A lot of them share maternal and infant health funding or substance abuse funding. Like, the impacts will go beyond just whether or not a specific hospital closes. ROBBINS: Diego, does that help? Q: Yes, very, very much. Thank you. Thank you. ROBBINS: Great. Diego, I have Acoma relatives, if that’s covered in your group. Q: Yeah, absolutely. Not far from here. Great. Thank you. ROBBINS: So I was just going to quickly ask Debra Krol, if she’s still on, Debra, can you give us any help about how to do reporting on this? She may not still be on. She does great reporting on this. So I was just going to turn back to Tom and Kate in the remaining time. And, you know, this one big beautiful bill is enormous. I suppose two sets of questions. One is, like all legislation, particularly health legislation, you know, it’s been—it’s so big and so—and so incredibly technical, and so—there’s so many interests that have been—and deals that have been cut at the last minute, and specific carve-out deals. And we don’t even know what’s going to happen when it goes back to the House. But, first, what are you reading and who’s doing the best deconstruction of it for you to—if you’re interested in the impact of Medicaid on rural hospitals, or if you’re interested in the impact on SNAP, or if you’re interested in the impact on local public health spending, or whatever? Who’s doing a deconstruction that you—at least to begin to understand the playbook? How are you getting your information, Kate and Tom? WELLS: Tom, I’m happy to jump in there. You want to take the first swing? BOLLYKY: No, go ahead. And then I’ll fill in. WELLS: I mean, it’s going to—it’s going to sound like a retread of what we said. I would say two things as just, like, closing thoughts here, and then also some resources of who I think is doing this well. This has passed the Senate. Our job as local reporters is not to communicate this to people as if this is a done deal. Like we should be honest to people about the fact that this is happening very rapidly. And we should be honest with people about what the intentions are for that—why this kind of thing is happening so quickly. We should be clear with people about that. We have a period of time right now in which our main job is to communicate to people about how this would impact their lives as clearly as possible, in stakes and language that is clear and not hyperbolic, but uses all the resources that we have. The two orgs that I mentioned, KFF, Urban, they’re going to be really good at being able to—you can call KFF and say, like, listen, talk to me like I am five years old and explain this to me and what I need to be talking. Tell them your area if you have a specific metro area. They may even have specific polling. They’ve done a more recent polling about the popularity of some of these measures in congressional delegations. But then your state health department has probably done its own estimates, if they’ve done a pretty good job. I would be reaching out to your state, the people who are running Medicaid and SNAP, who can talk to you about estimates of here’s how many people we think would lose coverage here, potentially. Because our job right now is not to talk to people about this in broad political terms. Our job right now as local reporters is to talk to people about what this means for their lives, even if they are not on Medicaid. If you lose a maternity ward, that is your maternity ward that’s no longer there. ROBBINS: Tom, quickly? BOLLYKY: Great, the only thing—I’m sorry, Carla, did you have a follow up? ROBBINS: No, no, no. Just quickly over to you. And because I’ve neglected to ask one final question, and I want to get to that too. BOLLYKY: I’ll be very quick then. I do think NACCHO and ASTHO are still good resources on these issues in terms of reporters that do great work, particularly on public health. Not that she needs it, but she deserves it, Helen Branswell is always terrific on understanding these issues, and is somebody I often talk to and rely on with these kinds of questions. So just to put that out there, in addition to the sources Kate mentioned. ROBBINS: Great. And last question, thank you. And Helen Branswell writes where? BOLLYKY: I’m sorry, STAT News. ROBBINS: So Rick Berke. Is Rick Berke still the editor of STAT? BOLLYKY: Yes. ROBBINS: Former colleague, yes. And former congressional reporter. So he has the Washington side of it. Rachel Schnelle. Rachel, can you ask the last question? From KRPS? Q: Yes. It’s Schnelle, actually. Yeah. ROBBINS: My apologies. Q: (Laughs.) No, it’s OK. I was wondering, I’m covering issues in Missouri and Kansas. Our station kind of covers the Four Corners. And we work with Kansas News Service. And there’s been eighty total measles cases in Kansas as of last month. I come from a rural area so I know there’s sometimes speculations around vaccines. And I was wondering, is there a correlation always—I guess, is there a correlation between rural counties having low vaccination counts and also religious exemptions? Like, are those often one and the same, where they’re in the same area? Or is there a throughline between the two? So, yeah. I’m not saying that vaccine misinformation and rule exemptions are the same thing—or, religious exemptions are the same thing. ROBBINS: Kate, you were shaking your head. WELLS: There could be an overlap, though. I think when we measure religious exemptions we’re talking usually specifically about a specific waiver. A lot of the reasons we started to see pediatric vaccinations fall off was just it was harder during the pandemic for people to be able to access some of the basic care that they were regularly getting to. If you are in an area where there’s, like, fewer pediatricians than there were before, or what things may look like after Medicaid cuts, there can be a number of reasons why it’s just harder for you to be able to get your kid in on a regular basis, as you used to. I would not—we want to—sometimes, people will—I want to be very succinct about this, because now we want to go—sometimes, depending on where people are, they may get a waiver that classifies as, like, religious or philosophical waiver because they show up to school and their kid doesn’t have their vaccination, right, have their vaccines ready. And so the school just slots them in that way. It looks different, but I would just take the time to sort of talk to whoever your local public health department is about those differences so that we’re not conflating those two incorrectly. But there’s certainly overlap. Like we’re seeing— Q: Yeah, sorry, I meant to say overlap. (Laughs.) WELLS: Yes. I think there can definitely be overlap. I would just make sure that I talked to my local health department about what the specific process is for these waivers when people are getting them. Do they have to seek them out and go through a series of, like, talking to their public health nurse to do that? Or is it like they show up to school, you know, in August and their kid didn’t have this, so they’re—the school just signs them up for one, and they just sign a form. Because it looks different, different places. ROBBINS: Tom, final word. And I’m going to ask a totally uninformed question that’s related to this. And keeping in mind that I grew up in the generation in which everybody got measles. So is eighty cases a really high number? And is it—I mean, do we get to the point in which it just shoots up? You go from eighty to 500, and suddenly you really, truly have an outbreak? I mean, when do we start—when do we have to start getting really nervous about something? Like, what numbers? BOLLYKY: Well, we’re at—I’m sad to say, we’re at 1,227 cases nationwide. So that is just fifty short of a thirty-year high. Twenty-one percent of those cases have resulted in—or, required medical treatment or hospitalization. So that’s—of children, I should say, five and under. Of the cases involving children five and under, 21 percent of those have required hospitalization. So we should be alarmed. There have, of course, been three deaths also. Those aren’t great numbers. The thing to put to what Kate said before is that vaccination—there are three sets of barriers. There’s administration, supply, and demand. This issue of religious exemption gets at the demand issue, but there are absolutely what Kate was referencing to, administration barriers. And, for instance, this issue of multidose vials is an access issue also. There are going to be a range of things like this that people should pay attention to, particularly given the cuts and some of the guidance that’s coming out. ROBBINS: Well, thank you. I want to thank Tom. I want to thank Kate. This has been a great conversation. I want to thank everyone else for great questions. And I’m going to turn it back over to Irina. FASKIANOS: Thank you, Carla. And thanks to Kate Wells and Tom Bollyky for a terrific conversation, and to all of you for your comments, questions, and the work you’re doing. We will send a link to the video and transcript. We will round up the resources that have been mentioned during this call. Also some were dropped into the Q&A chat, so we’ll gather those up as well. You can follow our speakers on X at @TomBollyky, at @KateLouiseWells, and at @RobbinsCarla. And, as always, we encourage you to visit CFR.org, ForeignAffairs.com, and the online magazine that Tom Bollyky founded and runs, called ThinkGlobalHealth.org, for the latest developments and analysis on international trends and how they’re affecting the U.S. And, of course, please do email us with suggestions for future webinars or how we can further serve as a resource to you and your reporting. You can email us at [email protected]. Or if you want to be connected to a CFR expert, such as Tom or others, we’re happy to make that connection as well. So, again, thank you all for today and for the work that you’re doing. ROBBINS: Thanks, guys.

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