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Interview With New York-Based Center For Human Rights In Iran Executive Director Hadi Ghaemi; Interview With Former Iranian Diplomat And Princeton University, Professor Of Middle East Security And Nuclear Power Seyed Hossein Mousavian; Interview With "Turn Every Page" Director Lizzie Gottlieb; Interview With Emergency Physician And Senior Physician Policy Researcher At The RAND Corporation Dr. Mahshid Abir. Aired 1-2p ET

Aired December 12, 2022 - 13:00:00   ET



CHRISTIANE AMANPOUR, CNN CHIEF INTERNATIONAL ANCHOR: Hello, everyone, and welcome to AMANPOUR. Here's what's coming up.

Arrested and executed, outrage as Iran hangs a second protester, three months since Mahsa Amini was detained, where does the movement go from here

and what next for the country?

Then --


ROBERT CARO, AUTHOR, "THE PASSAGE OF POWER: THE YEARS OF LYNDON JOHNSON": We've had some real fights about sections that he's wanted to cut out.

ROBERT GOTTLIEB, WRITER AND EDITOR: It's not that I was trying to tear his bleeding heart out of his chest.


AMANPOUR: -- "Turn Every Page. Director Lizzy Gottlieb on her new film exploring the remarkable 50-year relationship between two literary giants,

her father, Robert Gottlieb, and the LBJ biographer, Robert Caro.

Plus --


UNIDENTIFIED FEMALE: Put patients first. Because at the end of the day, it maybe their family member or their loved ones who are in a stretcher and in

a hospital or E.R. somewhere needing that medicine that is not available.


AMANPOUR: Drug shortages in America. Can hospitals cope? Hari Sreenivasan speaks to emergency doctor Mahshid Abir.

Welcome to the program, everyone. I'm Christiane Amanpour in London.

Iran has executed a second protester related to the antigovernment demonstrations that are gripping the nation. The, man named as Majidreza

Rahnavard was accused of killing two members of the security forces according to the government. He was publicly hanged in the religious City

of Mashhad earlier this morning. It is a second known execution relating to this uprising. On Thursday, Mohsen Shekari was hanged.

These protests have been going on for three months now ever since Mahsa Amini died in the custody of Iran's Morality Police. She had been

apprehended for allegedly not wearing her hijab properly. But even in the face of brutal punishments and possibly even a death sentence, the protests

have continued. The regime vows to continue its crackdown.

My first guest tonight says, executions are a tactic of repression from an outdated playbook. Hadi Ghaemi is the executive director of the Center for

Human Rights in Iran, and he's joining us now from New York where the center is based.

Hadi Ghaemi, welcome to the program. Can we start by asking you just to lay out what you know, what the human rights community knows, about the two

individuals who we know have been hanged? What about Rahnavard who was hanged today? They say it was public. Was it?

HADI GHAEMI, EXECUTIVE DIRECTOR, NEW YORK-BASED CENTER FOR HUMAN RIGHTS IN IRAN: Hello, Christiane, and thank you for having me. They claim it was a

public hanging, but from what we know, the only people present were security agents and people from the judiciary and security for, even the

parents of him were not aware that he is being hanged and we're not there. So, it was very surreal news and very tragic news to wake up to.

AMANPOUR: What do you know about what he was accused of? And also, what Mr. Mohsen Shekari was accused of? And explain the process. Obviously, you

and others in the human rights community are calling these sham trials and practically no judicial process at all.

GHAEMI: Indeed. I mean, look, the only information we have is from what the regime itself is putting out, more or less. But there is a pattern,

there is a long-standing pattern of how these prosecutions or so-called judicial processes happen. Individuals are detained, they are held

incommunicado, they are tortured. They don't have access to independent counsel, they really can't defend themselves. And then, the entire process

is very expedited, like you see in the latest case, it only took 21 days to do an investigation, to prosecute in lower court, to go through appeals

court and even go through Supreme Court.


So, I want to emphasize, these are not judicial processes or anything that resembles a sense of justice as we understand it. These are really lynching

committees. We have seen over and over that the judiciary decides that a political opponent or protester has to be executed, it doesn't matter who,

and they really lynch. They bring them they through this super expedited process, give them very strange charges such as enmity against God or

spreading corruption on earth and without any legal counsel, any due process, they even trample all over their own law.

And let me emphasize, the only evidence ever produced, the family in both cases of recent, is confessions by the defendant that has been taken under

torture. Now, torture is illegal in Iranian law and the judges are supposed to throw away any self-incriminating evidence obtained under torture. But

completely the opposite of that happens and there is never any other evidence to prove these charges.

AMANPOUR: You know, the human rights community says that more than 400 or so protesters have been killed. And the Iranian government claims that a

couple dozen of its own Basij and other police forces have been killed. Rahnavard was accused of killing two of those Basij policemen, the security

forces, who have been deployed to crack down against the protesters.

Does that sound like -- I mean, even if that was the case, do you think his lawyer -- did he have any lawyer who could at least put up a defense?

GHAEMI: No, he did not have a lawyer. Only a court appointed lawyer. And we know from other death penalty cases right now that this court appointed

lawyers don't even communicate with the families, don't even meet with the defendant, don't even have access to the case and evidence.

And in this case, the allegation was the murder of two Basijs. But again, the only evidence was the defendant being videotaped and making a

confession while it is visibly tortured and ill-treated. So, these confessions even under Iranian law would be thrown out of the court, and

this is just a political, cold blooded murder in a lynching assembly or committee that they're calling a court of law.

AMANPOUR: So, you called this process, essentially, you know, the kind of tactics taken from a tired old playbook. And what you're describing sounds

very much like, at the beginning of the revolution, when there were, again, these summary executions by ad hoc courts. How -- yes. Tell me how you put

this in context.

GHAEMI: This is really the regime's last gasp in terms of asserting control and it's going back to its playbook of the 1980s, where exactly you

had this committees roaming in all neighborhoods and cities and literally assassinating people in the name of justice. And then, it got incorporated

to their judicial system to the point when they repeated it in 1988, committing crimes against humanity by executing over 5,000 political

prisoners in a matter of three to four weeks.

So, the idea of lynchings and killings in times of crisis is very much in the playbooks of this regime and the 1980s was the height of it. The

problem is, today is not the 1980s by any measure or standard. So, I think the reaction they will get domestically and internationally will be very


AMANPOUR: I just want to quickly make a point about that number, 5,000, you just mentioned. Is that the instance in which the current president,

Ebrahim Raisi, has been implicated and censured in some parts of the world for alleged crimes against humanity?

GHAEMI: Indeed. That's why we should be concerned. Everybody from head of the judiciary to the president, Raisi, to high-level judges and other

members of the judiciary are the very same people who carried out that crimes against humanity. So, they are quite capable of it and we should be

quite concerned.

AMANPOUR: The -- one of the top judicial officials there, the head of the parliamentary Judiciary Committee, has signaled that more executions might

come. He said, the judiciary took the first step in bringing the recent rioters to justice, it had become more prominent in the coming days. And

the same time, we've seen people like Iran's only Nobel laureate, Shirin Ebadi, and others in the human rights and legal space sign a letter, an

open letter to the U.N. secretary general urging international effort immediately to stop these kinds of extrajudicial executions.

So, A, do you expect more to come? And B, what can the International Community really do?


GHAEMI: Yes. Look, they certainly want to go ahead and continue executing people, but it all depends on, first and foremost, domestic reaction, where

outrage continues to be generated in many quarters, including religious seminaries and former politicians and judicial officials within the regime.

The people, of course, are very enraged and they believe this will only inflame the protests. But we do need a very strong international reaction,


And we should all be calling for an immediate moratorium on executions in Iran and countries that have ambassadors and embassies and Tehran should

immediately pull out their ambassadors in protest, in munition (ph), especially U.K. and the E.U., Japan, Australia, New Zealand, these

countries should be downgrading their ambassadorial level. I'm not calling for closure of embassies or cutting off diplomatic ties, but I'm calling

for immediate removal of their ambassadors and protesting.

And this has to be really taken up to the Security Council too, from several angles. One is the very extensive violence against women and girls

being committed. We are starting to get a flood of reports about rape and sexual assault against women and girls inside the prisons. And that Iran is

also engaged with Russia in killing civilians by selling drones and causing damage. So, there's a lot of reasons that this should be taken up by the

Security Council immediately.

AMANPOUR: And we will explore that further. Hadi Ghaemi, thank you so much, indeed, for joining us.

Let's get more now on how the Iranian government is in fact reacting. It's the biggest challenge to his rule since the revolution. Seyed Hossein

Mousavian is a former Iranian diplomat and chief nuclear negotiator. He is now a professor of Middle East Security and Nuclear Policy at Princeton

University, and he's joining me now.

I guess from there, in any event, from the United States. Welcome back to the program. It's a long time since we've spoken. And I just want to ask

you to react to what is happening inside Iran right now. You had been working for, as they say, the first reformist president there, Mohammad

Khatami. And I just want to know whether you think this government can -- is this a sustainable way for this government to react to people's

legitimate demands?


much, Christiane. Thank you for having me. I believe we are facing two different narratives on the current situation, domestic situation of Iran.

One narrative is practically undermining the depth and the importance of the issue. The other narrative is exaggerating the dimension of the issue.

The opposition -- some western countries, some western media, they believe it is not just a protest, it is about a revolution and the system is at the

verge of collapse. I don't believe this is the case. I believe this is a misinterpretation, misunderstanding and miscalculation.

However, the Iranian government narrative is that the reason unrest is the plot designed by the U.S., Israel and adversaries to destabilize Iran and

to disintegrate Iran. That's why they believe they should react very powerfully in order to protect the security and integrity and the

instability of the country.

I believe it is clear that the U.S. and Israel, they will do whatever they can to bring a regime change in Iran. But the other very important reality

is that the majority of Iranians are unsatisfied and angry with the current situation, specifically about the economic situation in the country, which

is extremely bad. We have inflation, 40 percent. We have corruption. We have unemployment. The value of Iranian national currency has dropped 30

percent just in a year, last year, during past year.

And the country has been faced with double-digit inflation for most of the years after the revelation. And I believe the Iranians, they want more

social freedom. I believe majority of Iranians, they want an end to tensions in foreign relations of Iran with other regional and international

powers. That's why the way of -- if you ask me, Christiane, is the Iranian establishments, they need to bring a major change in the country, in the

policies, economic, social affairs, foreign relations, in order to satisfy the nation.


AMANPOUR: OK. So, you absolutely accept, as a former government official, that there's a huge amount of legitimate dissatisfaction. But you're saying

that the idea that the regime will be toppled is an exaggeration. Why do you think that? These are the biggest protests since 1978, '79 and people

have basically said that, you know, sometimes these autocratic regimes do fall when people stand up and challenge them, as you can see is happening

on the streets every day.

MOUSAVIAN: Christiane, you remember, we had these demonstrations some years ago, about three or four years ago, we had the same demonstrations

during President Khatami, if you remember. We had during President Ahmadinejad. 3 million people, they were in the streets of Tehran, and the

Western media and the Western interpretation was that the regime is at the verge of collapse, but it never happened. I believe this is not a

sustainable situation, I clearly say. That's why I believe that the establishment needs to bring major changes to satisfy the people.

The official polls, Christiane, says -- even the representative of the supreme leader's publicly said 80 percent of people, they are not

satisfied. They are unsatisfied with the economic and the current situation. That's why with such a high level of unsatisfaction, it cannot

be sustainable. But the security establishment, the military establishment, they are extremely powerful. I believe they are at the top of the situation

and they can manage it, but they need to resolve the problem.

AMANPOUR: Let me ask you this then, because many Iranians actually wanted this nuclear deal. Not because of any other major reason other than to get

some kind of economic freedom after these decades of sanctions. They -- many, many people there said, at least, we'd be able to survive

economically, which now, as you admit, they're finding it incredibly hard to do.

I want to play this soundbite for an interview I had with former U.S. Secretary of State Hillary Clinton about the likelihood of such a deal

being re-engaged. Here's what she told me a week or so ago.


HILLARY CLINTON, FORMER U.S. SECRETARY OF STATE: I would not be negotiating with Iran on anything right now, including the nuclear

agreement. I think that, frankly, the horse is out of the barn. When Trump pulled us out, we lost the eyes that we had on what they were doing inside

Iran. And I believe that they started those centrifuges spinning again and I think it's unlikely that any agreement would be agreed to and I don't

think we should look like we are seeking an agreement at a time when the people of Iran are standing up to their oppressors.


AMANPOUR: So, you heard that from the former secretary of state. IN addition, the IAEA says that it believes Iran is now upping its enrichment

of uranium to something like 60 percent. So, from your perspective, as a former nuclear negotiator, what happens to the security of the world if

there is no deal and this country, Iran, continues to enrich uranium?

MOUSAVIAN: See, Christiane, I really disagree with Hillary Clinton because Iranian -- since the revolution a 1979, there has been major differences

between Iran and the West on human rights, on terrorism, on weapons of mass destruction and on Israelian peace process. Nevertheless, for the first

time, during President Obama, the U.S. decided to have direct negotiations with Iran on the most important issue, which was the Iranian nuclear


They agreed after long negotiations. They even assigned the most comprehensive agreement during the history of nonproliferation. And for

three years, Iran was in full compliance with zero failure and it was President Trump who withdrew and kicked the D. Therefore, I believe

negotiation engagement with Iran practically could bring a good result. Otherwise, what could be the other alternative?


First of all, the U.S. and the other world powers, regional countries such as Saudi Arabia and Israel, they all do not want a nuclear Iran, it's

clear. The second reality is that the U.S. International Community, the world powers, they do not want another war in the region. The war with

Iran, which the consequences could be far more disastrous that the war on Iraq and Afghanistan.

While we don't want a war, while we don't want a nuclear Iran, there is no other option rather than reviving the nuclear deal, which perfectly was

working perfectly for three years.


MOUSAVIAN: And already they have agreed and they can revive it. And then, I believe, Christiane, it cannot be single issue. Iran and the world

powers, they need to have serious engagement on other issues, otherwise --

AMANPOUR: Like human rights, yes. Which they never have done, you're right. They have -- the rest of the world has always put security issues

ahead of human rights. And now, Iranians want human rights to be part of that kind of engagement as well. Hossein Mousavian, thank you so much,

indeed, for joining us.

We turn now to a remarkable collaboration that spans decades between two literary powerhouses, Robert Caro, one of America's most widely read

political biographers, and his editor, Robert Gottlieb. At 86, Caro is racing to finish the fifth and final volume of his epic biography of Lyndon

B. Johnson. While the 91-year-old Gottlieb waits patiently to edit it.

And now, a new film reveals their extraordinary 50-year relationship. "Turn Every Page" is directed by Gottlieb's daughter, Lizzie. Here's a clip from

the trailer.


UNIDENTIFIED MALE: So, about how many books have you edited?



UNIDENTIFIED FEMALE: Two guys, the best in their field. Bob Caro, the greatest political writer of our time. Bob Gottlieb, the greatest editor of

his time.

UNIDENTIFIED MALE: Robert Caro is in his 80s and everybody wants the story to be finished. He's running out of time.

R. GOTTLIEB: He's industrious.

CARO: He would hate to think he was like me.

R. GOTTLIEB: He does the work. I do the cleanup. And then, we fight.


AMANPOUR: Daughter and director, Lizzie Gottlieb, joins me now from New York. Welcome to the program.

It is truly a wonderful film. And for any journalist, frankly, anybody, it's a real boost of hopefulness. It's really great. So, tell me, Lizzie,

what goes into the relationship between editor and writer, or at least this particular relationship?

LIZZIE GOTTLIEB, DIRECTOR, "TURN EVERY PAGE": I think most relationships between editors and writers are different. But I think it's something that

we readers don't really know, how a book comes to be, how two people work together to make the best book possible.

And this particular relationship, between my father and Robert Caro, has been going on for 50 years and they both describe it as very contentious.

So, they have this wildly productive, very contentious relationship for 50 years and they are still at it and trying to finish their life's work in a

sort of race against time. And I think one of the reasons I wanted to make the film is I realized that I was in a unique position to open a window and

show people in a world that is vanishing, the world of book editing that we -- that sort of spanned the last century, and see the sort of alchemy of

what goes on between these two titanic book men.

AMANPOUR: And did you get any sense of this race against time, whether it will be completed? I mean, it's a hard question to ask, because we are

obviously looking at mortality here, and particularly the mortality of your father and his great collaborator. Was it kind of in that way almost sad

also to be doing this, because you knew you also were racing against time, all three of you are?

L. GOTTLIEB: It's true. I think one of the reasons I wanted to make the film now is because there is so much at stake for everybody, for the two of

them, in this race against time to finish their work, and for the readers who care so much about these books, hoping to have the story be finished.

And for me, personally, and that my father is 91. And every minute I get to spend with him feels like a gift.

So, I think we're all aware of these issues of mortality and their issues of legacy. But I really do believe they're going to finish. Bob Caro is

very determined and working unbelievably hard, and I think they're going to get there.


AMANPOUR: Well, I mean, for all his legions and legions of fans, that's going to be great, because the fifth and final episode, so to speak, volume

of the LBJ papers and biography is going to be eagerly awaited. But let me just -- I want to play a clip from the film, which really does explain the

nitty-gritty that they went down to, right now to a fight over where a semicolon should be placed. Here it is.


R. GOTTLIEB: Great thing about Bob is also the maddening thing about him. Everything is of total importance. The first chapter of the book and the

semicolon. They are of equal importance. And he can be equally firm, strong, emotional, irrational about any of it. Now, I'm like that too. So,

it takes one to know one, because I too think that a semicolon is worth fighting a civil war about.

CARO: A semicolon has a particular function. A semicolon is not as much of a stop as a period, that's a full stop, but it's more of a stop than a

comma, which is just something you slow, a little stop. So, it has a particular function.

UNIDENTIFIED FEMALE: He says you have a very different idea about semicolons than he does.

R. GOTTLIEB: Because I'm an editor. He's just a writer.


AMANPOUR: He's just a writer, that is hilarious. But seriously, a semicolon war maybe explains why it take seven years or so for Robert Caro

to actually even finish a volume.

L. GOTTLIEB: You know, I think that for both of these men, the thing they have in common is that, you know, these books are about very urgent things,

they're about how power works in America and the effective power on the powerless and things that we all really need to learn. And Bob Caro feels,

and I think my father agrees, that unless the sentences are as compelling and riveting as possible, no one will reach the books and no one will care.

So, for them, as he says, everything is important, every single detail. And they are very opinionated and they are very strong willed and they each

think that the right. And so, they really get into it, sort of in the nitty-gritty and on the big picture issues as well.

AMANPOUR: And of course, the big picture --

L. GOTTLIEB: Which I found sort of --

AMANPOUR: Yes. Sorry to interrupt you. The big picture issue in this particular case is, as you say, the exploration of power and how Robert

Caro goes about it. And one of the most powerful presidents was Lyndon Johnson. He also did one of the most powerful New Yorkers ever, Robert

Moses. Describe what power meant to Caro and how he tried to get to the heart of it.

L. GOTTLIEB: I think that Caro feels that, you know, we are living in the world created by these men. So, as New Yorkers, we're living in a world

created by Robert Moses, still to this day. His great visions for the city and also, the racism and classicism that is built into the infrastructure

of our city, still, we are living in that.

And similarly, with Lyndon Johnson, we -- what Lyndon Johnson did great things and did terrible things, and we are still living with the effects of

the way he yielded -- wielded, his power. So, I think that Caro is trying to, really, help us in our democracy understand how power has been used and

abused and how people who don't have power are affected by those decisions, by those men that he writes about. And his hope is that if we learn from

these things, we will vote better and we will have a better democracy. So, that's what he says animates his writing.

AMANPOUR: And all the while, they're incredibly readable and accessible because they are stories about people. He's not just writing, you know, a

very turgid history, it's really about the feelings and the -- everything that shapes these people's lives who he writes about.

So, I wonder what it was like for you, when you finally managed to get into a session where the two Roberts, your father, Gottlieb the editor, and Caro

the writer, they let you in but with no microphones, just the camera. What did you get from that session? We can't hear it. But what was it like?

L. GOTTLIEB: You know, when they agreed to do this film, which they were reluctant to do, and they sort of slowly opened up more and more over the

course of the seven years that it took me to make this film, they initially said, we refused to be interviewed in the same room as each other because

it might get contentious, which seemed hilarious to me and sort of endearing and sort of irresistible as a filmmaker to try to get into that



And eventually, I did. And what I felt was that what we are really seeing, and what I hope I capture in that scene is the incredible joy they feel in

their work. These are two men who are so committed and devoted to their craft, individually and together. So, I wanted to capture that joy that

they have in doing their work, which I find so deeply inspiring for people who also commit themselves to craft and do any sort of work together, and


AMANPOUR: And what did you -- I mean, look, you know, you are the daughter of Robert Gottlieb who, beyond this editorial, this job of editing Robert

Caro, is a legendary editor in his own right. You have people like President Clinton and others talk about what he meant to them as mentors

and editors and teachers, and it is very profound. And you spent several years going through your father's work and papers. What did you learn about

him personally?

L. GOTTLIEB: You know, people have asked me this question, and the true answer is that my father and I are very, very close, I grew up in a house

that was filled with his writers. People were always coming for dinner, staying the night, coming to stay with us. And so, in this -- my father I

talk on the phone almost every day.

And there is -- I don't feel that there were any secrets between us or anything left unsaid. But I do feel that this relationship with Bob Caro

was one that I did not know anything about, and I think that is part of what drew me to it. There is something different. There's something charged

and dynamic between them that they are both quite secretive about.

And when I asked them if I could film them, they both said no. And it took some convincing. And so, really, I learned so much about the power dynamics

between these two quite extraordinary men.

AMANPOUR: Yes. Well, it's really remarkable. It's a great film. Lizzie Gottlieb, thank you so much indeed. And the film, "Turn Every Page," is

released in theaters on December 30th.

Now, we turn to the man himself. I've spoken with Robert Caro over the years a few times about writing his monumental Lyndon Johnson project. And

when he published the fourth volume, called "The Passage of Power," also about the philosophy that's driven his work across 50 years, five books and

4,880 pages. Here is part of those conversations.


CARO: In 1965, blacks still vote in very low percentages in the United States. And Lyndon Johnson decides to pass a Voting Rights Act. And really,

Martin Luther King is down in Selma voting for it. And Lyndon Johnson goes before Congress and he says, we shall overcome. He adopts the anthem of the

civil rights movement as his own.

You know what happened that night? Martin Luther King is in Selma, he's in the living room of one of his aides. He is watching the speech and, when

Lyndon Johnson says, we shall overcome, Martin Luther King starts to cry. The assistant said, it's the first time they ever saw Dr. King cry. It's

like he realized, at last, they had a champion in Washington.

You know, that story does not -- in the Lyndon Johnson story is so complicated because at the end, Martin Luther King is saying, Vietnam is

destroying civil rights legislation and the war on poverty. So, the Lyndon Johnson story, we've been talking about one side of it today, it's a lot

more complicated than that. But his moments when he fought for civil rights, when he picked up the heroism of these people in the south, and

it's amazing to look at it.

You know, that's -- 64 is the summer of Birmingham. You turned on television and you see the fire houses rolling. You know, I mean, I

remember television commentators saying, look at the little girl. There was a little black girl. The fire hoses are rolling her down the street with

the force of the water. You remember all that and you say, that's a great moral uprising. But then, you also say, it needed someone in Washington who

could turn this moral force into law.

So, if you looked in my notebooks, you would see a lot of, I write, S.U., that means shut up. That means, if you don't say anything, maybe this guy

you're interviewing will feel the need to fill the silence and tell you something he didn't really want to tell you.

AMANPOUR: So, you're saying S.U. to yourself, that was your memo to self all the time?

CARO: Yes, yes.

AMANPOUR: See, that's pretty extraordinary because I'm sure I'm guilty and many, many -- certainly TV interviewers, are guilty of talking too much.

CARO: Well, not you.

AMANPOUR: He says. But is it difficult to S.U.? I mean, did you have to control yourself?


CARO: Yes. That's why I write it down. Because I have the urge to talk. You ask your question, maybe it's a tough question, the guy is not --

doesn't want to answer it. There's a silence. You want to break it, because you're human. I write, instead of breaking it, I write S.U., that reminds

me to shut up. And you'd be amazed. I mean, you're great interviewer, you'd be amazed at how many times after a while he tells you what you want to


AMANPOUR: What would you say, remembering the cub reporter, Robert Caro, that you were in the '50s, what would you tell that person and any of us

about what you have learned about power, political power and how it is wielded and the power who wield it?

CARO: Well, I don't know. I tell you something, I rather approach this saying, what have I learned about writing about power? I learned that

there's not enough to write about the powerful men who wield it. You have to write also about the powerless. What is the effect on the people without

power who are affected by government, either their lives have changed for the better or for the worse, either Robert Moses or Lyndon Johnson brought

them something, or, if they stood in their way, ruined them?

And I feel that you have to show, as I said, not just the powerful but the powerless. Otherwise, books about power are somewhat incomplete.


AMANPOUR: And that is a memo from the maestro.

Next, almost three years after the COVID pandemic began, the U.S. health care system is still struggling with shortages of medicine and supplies.

Dr. Mahshid Abir is an emergency physician and senior policy researcher at the Rand Corporation. And she tells Hari Sreenivasan what's behind these

crises and how to solve it.


HARI SREENIVASAN, CNN INTERNATIONAL CORRESPONDENT: Christiane, thanks. Dr. Mahshid Abir, thanks for joining us.

Over the past few weeks, we've seen lots of headlines of different types of medications and drugs that are in short supply. And I want to ask, as an

E.R. doc, are you seeing the same thing on the ground or what are you seeing?


critical issue that is not new for hospitals and health systems. Over the course of the years, even before the pandemic, we experienced various

shortages, including in IV fluids and also, cancer medications.

The reason why, currently, the issue is highlighted of the way it is and brought a lot of attention to is that it involves children, and some of the

medications that are important for the care of children, including amoxicillin, which treats various infections and also, albuterol for the

treatment of asthma. And this is happening all at the same time as having spikes in RSV infections and COVID and influenza. So, it's a particularly

sensitive time to be experiencing these shortages.

SREENIVASAN: Help me understand the direct impact on patience if albuterol or Adderall or amoxicillin is not available, what is the health concern


DR. ABIR: Yes, absolutely. So, you know, starting with albuterol. So, as you all know, there is a spike in RSV cases, influenza and COVID, and both

in children and adults. Albuterol is a medicine for asthma. And any asthmaticus who is infected with any of these viruses may experience an

exacerbation of their asthma, and they will really need their albuterol. And if not treated appropriately, asthma can be life-threatening. So,

that's one problem.

Amoxicillin is an antibiotic that's used for the treatment of bacterial infections in both children and adults. And particularly if, in addition to

these viruses that are now going around, someone has a bacterial infection and needs amoxicillin, because it is so effective against so many types of

bacterial infections, it can potentially cause issues as far as patient's inability, because it's relatively inexpensive. Patients may not be able to

get a substitute antibiotic because they can't afford it or their insurance is not paying for it, or that the treatment of their, you know, bacterial

infection may get delayed.

SREENIVASAN: So, give me an example of something that might be happening at your hospital right now or other hospitals about what type of a patient

is coming in and what is happening to them.

DR. ABIR: You know, I will speak to a couple of -- actually, the issues that we faced, you know, recently, actually. So, a shortage of morphine,

which is an important IV administered drug that it is important for pain control. And particularly in the pediatric population or pregnancy, it's

one of the to go medicines for acute illness and pain that we administer to patients.


And if we're not able to give that medicine or the times when we've had IV fluid shortages, you know, you don't want to be in an acute care setting

like an emergency department and have to think twice about ordering IV fluids for patients who need it.

So, these have real-life consequences for people, whether it is pain management or ensuring that you can give IV fluids to a patient to his own

septic shock, you know, these potentially can affect patient outcomes and how well they do from their illness.

SREENIVASAN: So, why are these shortages happening, especially if we're talking about antibiotics that, you know, some of which are completely off

patent now and there are generic versions, they should be available pretty far and wide in the United States?

DR. ABIR: It's usually a function of two issues. So, either decreased supply or increased demand. So, I think that we're at a juncture right now

where we are experiencing both. So, given the increase in respiratory illnesses, both in children and in adults, amoxicillin is being used

particularly if there is a bacterial infection in addition to a viral infection like RSV and influenza.

And also, if there's any kind of disruption in getting the medication to these hospitals and health systems. So, that last mile. And getting these

medications to the pharmacy, that also will impact folks getting the medications they need.

SREENIVASAN: So, what's the -- where is the kind of kink in the supply chain here?

DR. ABIR: So, the supply chain is really could be either the production of the medicine. So, if there is an issue with the facility, if they have

shortages in the components of what goes into the medication, for example, amoxicillin, or that if the actual company or the location where the

medication is made, if there is issues of staffing or labor shortages or any other issues that slows down production at the site, then you can

experience it as is a user or patient.

SREENIVASAN: You know, you are on a very special committee, The National Academy of Science, Engineering and Medicine, and you issued a report

earlier this year on the security of Americas product and supply chain. I just want to quote a paragraph here. Over the past several decades, medical

product supply chain disruptions and shortages have plagued the U.S. health care system, putting the lives of Americans that risk, costing medical

facilities millions of dollars per year and threatening the clinical research enterprise.

I mean, this is not something new, as you've said, we've had these sort of decades long problems. Why aren't these problems being fixed? Who is sort

of responsible for getting that fixed?

DR. ABIR: So, a lot of the issues that we are facing right now, and have historically faced, is due to lack of transparency. So, the companies that

make these medications are not obligated to report who -- where they get the ingredients from, who is the primary supplier and where they are even


So, the setting of this lack of transparency and not really holding these companies accountable, then it's hard to predict when there's going to be a

shortage in any of these medications. So, a lack of ability to know that there is a potential shortage is going to make it very difficult to come up

with strategies to mitigate and come up with solutions. And that is why one of the most important policy changes that we can make in the U.S. is


And this incentivizing manufacturers of medicines and medical equipment to share more information about their ingredients and where things are made

and where their products are made and that that kind of transparency, ultimately, can lend itself to surveillance of supply chain issues so that

you can mitigate in advance and implement strategies.

SREENIVASAN: I think when people read in the newspapers that there are shortages of critical medicines, they are doubly shocked that it's

happening in the United States where not only do we have such wide range of access to medications and medical facilities and doctors, but also the

amount of money that we all spend on health care. So, is there a structural fix that is necessary?

DR. ABIR: I think multiple fixes that are necessary. You know, yes, I think that the average and user of any of these medications would be

shocked to know that we have any shortages here. But part of the issue is that a lot of these medications are made abroad and imported. So, China is

a big producer, India, there's others. So, that's one part of the problem.

And so -- and also, the fact that, again, we rely on foreign producers. If there's any kind of bottleneck in the production of these medicines,

overseas, and also medical equipment, so, it's not just medicines, then that's going to cause problems and issues and delays in getting the

medications that we need and shortages. And ultimately, sometimes, doctors and health systems have had to resort to using alternates. And sometimes

the alternates are not as effective or they can have, you know, unforeseen consequences for patients who use them.


SREENIVASAN: Is this something, given that some of the ingredients for these medications that are in short supply today are coming from overseas,

how long would it take for the United States to bring the manufacturing back for some of, at least, the incredibly important ones that were short


DR. ABIR: Yes, I think you're referring to onshoring. So, you know, production of medicines here in the United States, which certainly is part

of the toolkit of strategies that we need to think about, thinking forward -- moving forward. However, you know, it is not really kind of the ultimate

solution because you have to think about, you know, the degree of demand and the time sensitivity of getting these medicines to the end user.

So, you know, as part of, again, a toolkit of various strategies, including diversifying manufacturers abroad and ensuring that we have options of

bringing in medicines that we need. Also, yes, I think onshoring is part of the solution but not the entire solution.

SREENIVASAN: Do you think that we start with medicines that are kind of the most -- I guess, lack of that medicine would be the most life-

threatening and then, kind of work our way down the chain? I mean, how do you prioritize where to start trying to make some of these changes?

DR. ABIR: Yes. I think it's a challenging issue. Because, just as you point out, there are certain products like IV fluids that are critical to

the care of many sick patients, similar with antibiotics or albuterol, which, you know, is important for asthma and many other very common lung

diseases. So, I think it makes sense to start with medicines that are used more commonly and for -- apply to a wider population, or the whole

population when they get sick.

But at the end of the day, we also can't ignore those medicines that really are pertinent to a smaller, you know, proportion of the population or for

rare conditions. But I can think starting off with the more common medicines and equipment that are critical in many conditions certainly make


SREENIVASAN: You know, I wonder, the past couple years brought to sharp relief all the different types of things that we are dependent on we

learned the hard way that it doesn't hurt to save a little bit for a rainy day. And I wonder, have you seen any big changes like that?

DR. ABIR: So, these are all excellent questions. Typically, health systems in the U.S. don't plan that far ahead. Because the return in investment for

them is low. So, imagine that they have to prepare for an incident where the next public health emergency that may never arrive. So, I mean, the

perfect example is on a day-to-day basis, many health systems, even for staffing, they don't plan ahead of time. They really kind of determine on a

day-to-day basis or maybe even 72-hour basis at best, how much nursing staff they need.

So, it really goes against the paradigm of health systems to think that far ahead and plan. But you really raise an important point. I mean, so, we've

had stockpiles for medicines and supplies in the U.S. and some of that came to good use during the pandemic. But otherwise, you know, outside of

ensuring that our stockpiles are ready and available and they're designed for the modern issues that we're facing today, we also need to share


So, for example, during the pandemic, not all cities and hospitals were hit hard at the same time, and some had lax -- they have more resources than

others. And having, you know, strategies in place and agreements in place to share those resources in addition to thinking about how we can do a

better job of stockpiling is going to be really important.

SREENIVASAN: You know, I understand, say, for example, if profit is a central motive here, that you want to be as efficient as you can and you

want to sort of maximize shareholder return or however you want to call it. But at the same time, I also wonder whether -- you know, isn't there a

financial incentive to kind of plan for a rainy day? Meaning, is it still profitable for you medical institutions not to plan ahead further?

DR. ABIR: So, you know, in the case of this once in 100-year pandemic, Hari, absolutely, that had they planned in advance, as far as having more

equipment for a rainy day or PPE, or many other things that were needed at the end of the day, it would've come in handy. And this ended up being an

extremely expensive public health emergency for health systems.

However, again, I think that the thought process is more behind, you know, the unlikeliness of an event occurring. And, you know, every time that

there's a disaster of public health emergency, it energizes both health systems and policymakers to do something so that we can do better the next

time around. And I think some of the important incentives are, what is the patients and communities that we serve that will ultimately suffer in the

setting of not planning and also, the health system workforce?


So, that as you know, and I'm sure the viewers have heard and seen, that the workforce, there's major attrition and people are leaving the health

system in throws. And part of the better planning that the system is to protect our health system. Because they are truly a national -- not just a

national treasure, but also part of the national health security that the country needs to invest in and do a better job of protecting.

SREENIVASAN: Did we learn anything from the pandemic? I mean, I remember those horrible stories, essentially the State of California competing with

the State of New York for the same finite number of whatever it was, masks and so forth. But here we are in this scenario, how -- is there a greater

amount of collaboration on the ground when you see these drug shortages where if a clinic is running short in a rural area, a major metro hospital

that might have more, is working hand in -- hand and say, OK, look, you can borrow 50,000 of these today. We know you'll be good for it in a couple


DR. ABIR: You know, we saw some of that. So, you know, various states, including in Michigan, where I am right now, some of the hospitals that

were not as busy and overwhelmed by COVID patients did accept patients and transfers from other hospitals in the state that were really overwhelmed

and overcapacity. So, that is one way of sharing resources.

Also, for example, assuring some capacity around critical care through tell a critical care where doctors kind of advice physicians in community or

remote hospitals around the care of COVID patients. So, we saw some of that. But we certainly need policies in place and more defined strategies

to disseminate the importance of collaboration and cooperation during public health emergencies, you know, more routinely.

So, although -- for example, the United States are good examples of that. It's not something that was done, you know, on a routine or regular basis

or enough.

SREENIVASAN: Recently, a lot of people were made aware of how acute some of these supply chain shortages can be in the context of baby formula. If

you had an infant, this was an enormous source of stress for several months. And the administration had to step in. And I wonder if, is there

something similar to a Defense Production Act sort of impetus that an administration can do or members of Congress can do to try to say, here's

the 15 or 25 things we can never be short of in the U.S.?

DR. ABIR: Yes. Certainly. I mean, I think that, you know, the Defense Production Act, outside of a public health emergency like COVID will be

more difficult to trigger. However, you're absolutely right. I mean, having a list of critical medicines and supplies and equipment that are important

to sustaining the work of hospitals and health systems would be really important. So that we start by addressing the supply chain issues in the

context of those priority items. And then, overtime, once we find the effective strategies and implement them, kind of expand those strategies to

other items.

SREENIVASAN: So, I'm giving you a magic wand here. If you could set a prescription for how to fix this, where would you start and what would you

tell policymakers?

DR. ABIR: Demand transparency from manufacturers and put patients first. Because, at the end of the day, it maybe their family member or their loved

ones who are in a stretcher or in a hospital or E.R. somewhere, needing that medicine that is not available.

So, I think that, in order to create that transparency, we need to identify clear incentives and disincentives to ensure that the manufacturers follow-

through. So, that we have more transparency in drug manufacturing and ultimately, have the ability to predict bottlenecks and shortages in order

to be able to mitigate them ahead of time.

SREENIVASAN: Dr. Mahshid Abir, thanks so much for joining us.

DR. ABIR: Thanks for having me.


AMANPOUR: And finally, tonight, on International Mountain Day, the heavens opened up and dustings of snow fell over parts of this world, that was last

night. And here's what people woke up to this morning. In London, snow blanketing Buckingham Palace and Victoria Park. The bookies are already

taking bets on whether it will be a white Christmas in the U.K. this year.

And look at this, all the way over on America's warm coast, California, where the first snows created the perfect seasonal postcard scene.


On that white note, that's it for now. Remember, you can always catch us online and on our podcast. Thank you for watching, and goodbye from London.