 other people coming in. All right, if everybody take a seat, we're going to get started. Good afternoon, my name is Karen Meacham. I'm deputy director and fellow within the Global Health Policy Center here at CSIS. Today, I have the tremendous honor of introducing Dr. Michael Merson of Duke University, who will discuss the explosion of interest in global health on university campuses across the country. Dr. Merson, I feel, personifies what is inspired a generation of students to go into global health. With a career dedicated to service through medicine and public health, he's worked tirelessly to address disease and health disparities worldwide. A brief review of his work includes being chief epidemiologist at the Colorado Research Lab in Dhaka, Bangladesh. Researching acute diarrheal disease, including cholera. Dr. Merson has held many prominent positions within the World Health Organization as well, first being the director of diarrheal disease control program in the 80s. In 87, he was appointed director of the acute respiratory and infectious control program. And in 1990, became director of the WHO's global program on AIDS, where he was responsible for mobilizing and coordinating global health response to the HIV-AIDS pandemic. Very big at that time, and continually. In 95, Dr. Merson became the first dean of public health at the Yale University School of Medicine. And through 2006, went on to direct research on HIV-AIDS prevention at Yale, something he's done significant work on. He's led training programs to build capacity on HIV-AIDS prevention in Russia, India, China, and South Africa. Dr. Merson is widely published and also serves as an advisor to UN AIDS, to the Global Fund, Gates Foundation, and many other prestigious institutions. In his spare time, he has played a key role here at CSIS, most recently becoming a member of the Commission on Smart Global Health Policy, where he lends his voice and expertise to the policy debate here in Washington, DC. Today, Dr. Merson will talk about his most recent work as the founding director of the Duke Global Health Institute, where he uses his experience to educate and guide the tremendous population of students towards careers in global public health. He'll also discuss the consortium of universities for global health, which was recently formed to define and direct and encourage this wave of student interest. So with that, thank you, and please let's welcome Dr. Merson. So I'm on now. Thank you very much, Karen. Let me first say that it's a very kind of remarks, but really what I want to first say is that CSIS is a very special place, and thank you for inviting me to be here. I have come in many different capacities. Steve Merson couldn't be here today, but Steve and I go back to some of the early work that was done on AIDS here and the visits we made and the commission, and it was a working group, or that we had. Task Force really made a huge difference on the hill, and I have great admiration for what CSIS does. To me, it's the epitome, the example of what a Washington, quote, think tank, or Washington group that really wants to make a difference in the world should be, and I great respect for it, and I'm just delighted always to be here. I also want to acknowledge in the audience, particularly given the topic, a few people like Jim Sherry, who's the dean at the Public Health School here at GW, and Guy Thufferman, who works with a lot of the business schools, and there may be some of you else here from other academic institutions, and if I say anything that isn't right, please raise your hand and correct me, or if you feel differently, please say so. I'd like to keep this somewhat informal. I didn't expect a room like this, but I want you to feel that you can comment or ask questions as we go along, we wait till the end. I don't feel strongly one way or the other. What I want to do is do three things. I want to talk about the context of global health, and then I want to talk about the consortium that we're in, or trying to set up, and what's going on in some universities, and again I hope some of you will chip in from your own experience, and then talk a little bit about, in the end, about how I think the US government can maybe universities could partner a little more, and what universities can do in global health in general, that given this incredible enthusiasm that is going on today. I should tell you that one of the bottom lines I want to start off by saying, looking at the audience, but if I had one message that I'm going to give you, is that we owe it to students. We owe it to today's youth more than anything else. I was talking to John Donnelly this morning. You may know him. He used to work for the Boston Globe, and we were talking about what's, from the perspective of the media, what's made the big difference, and what's really caused this global health phenomenon to occur, and I think there's a universal feeling that we owe it to the students. So those of you who have recently been students or are still students, you are really behind a lot of what's happened today, and you should be proud of that. You're way ahead of the faculty and the deans and presidents of universities and your enthusiasm and understanding of the field and what it means. So for those of you here, I don't know how many students are here. Are there any students here? Oh, great. OK. I'm glad I said that then. So what is global health? I often get asked that question, what is global health? So the students who just graduated, what is global health? I mean, I don't know whether any professor ever asked you that question. So we've tried to say what global health is. And here you see an effort, study, research, and practice. It's an area, not a discipline, involving study, research, and practice. Our focus is on equity, where it emphasizes transnational health issues, determinants, and solutions. It involves many disciplines within and beyond the health sciences, promotes interdisciplinary collaboration, and is a synthesis of population-based prevention and individual-level care. That's a mouthful. So if you want to read the paper about it about a month ago now, there was a paper in the Lancet, a bunch of us in the field from developing, developing countries put out this definition. And I'll show you another slide in a minute. And we've had a lot of interesting letters to us, many people who don't like it, many people who do like it. And it was put out there to start the debate. It's not meant to be the end of the debate. It's just an effort to try to define a new field. New fields come and go in academia. Women's, 20, 30 years ago, there was this whole women's studies, environmental studies. Academia is slow. Those of you who are in academia or remember academia, things don't happen quickly in academia. But new fields do start, and this is a new field. And we're going to figure it out. A good definition is we go along. So this was not meant to lock anything in stone. And you can see, oh wait, I have to do it this way, that this is not projecting very well. But I will just say here, this is trying to compare global health, international health, and public health. Three terms that are very frequently used. So here's that definition of global health that I just went through. Trans-N's national boundaries, global cooperation, prevention and care, health equity for all nations, highly interdisciplinary and multidisciplinary, within and beyond sciences. So that's the essence of global health. Now what about the term international health? It's a term that's still used in many textbooks and around the world. And for the most part, it's talking about health issues of other countries than other than one's own. It usually involves binational cooperation and it has prevention and care. And it seeks to help people of other nations. So the term international health traditionally means when the, historically, when the UK wanted to help its colonies, when the French wanted to help its colonies. And when the US years ago felt foreign aid was helping others. We weren't really, it was nothing to our health. It was helping other people. That was the term, that's really where the term international health more or less comes from. And then you have the term public health. And of course, this gets a little grayer, the difference between public health and global health. And there there is room for more discussion perhaps. But public health, for the most part, it doesn't focus so much on issues that transcend national boundaries, but more on populations in a particular community or a nation. It's not as often involving global cooperation. It's more focused usually on prevention and care. And its health equity issues are usually more within a nation or community. And it's not, it certainly is multidisciplinary, but more within the health and social sciences. So there's a grayer area between global health and public health. I accept that and we're trying to figure out ourselves together with our colleagues, having been a public health school dean, how we're gonna work this out. I think what the international health is a very clear difference in the way we approach global problems. Really, international health was a one-way street. In global health, we do mean global health. The world is a whole. We can come back to that if you're interested. Now, one of the issues within the context of global health is the challenge. And there is a mistaken, I think, belief that global health is infectious diseases. And we really need to dispel that in terms of any of the parameters that you wanna look at of what the leading global health problems are today. Certainly infectious diseases, HIV, TB and malaria, and particularly in the poorest nations in sub-Saharan Africa in particular, we wouldn't doubt that. But chronic diseases, clearly cardiovascular disease and obesity and diabetes and hypertension and cancer are more and more becoming the leading killers in the world, everywhere. Even, I mean, those of you who travel in urban Africa, how many friends do you have in men in their 50s who've died of stroke? It's really become an epidemic. 20% of Chinese are hypertensive men. So we know that chronic diseases are really the coming problems. When I'm asked, what are the big health problems in the world? What's the big risk factors in the world? Well, certainly you'd have to say AIDS, particularly in Africa, but smoking and obesity. You have a billion people on the planet, one billion that are gonna die from the consequences of tobacco. So how can we just think that global health isn't infectious diseases? It's just not what the data shows. And then, of course, the environment. I often tell my students that my generation didn't do a very good job dealing with the AIDS pandemic and it's gonna be up to this generation, our new student generation, to figure out how much we're gonna suffer from climate change and air pollution and the environmental threats around us. And they are real. We got too much water in places. We don't have enough water, even in this country, as you know, in the western part of this country. We have a terrible drought. But seriously, the environmental consequences, the health consequences of our environmental problems are huge and they have to be in the realm of global health. Social determinants, it's not just the diseases, but the determinants. Those of, we work in global health. What I, again, emphasize, it's not just the diseases. We're not just doctors treating diseases. We have to be as concerned with why they occur. What are the social, economic determinants? Gender, poverty, education, culture, we can go on and on. And then, of course, the issue that always gets neglected, the system. As someone who's worked for many years, I have some guilt about this. As someone who worked for many years in vertical programs, we all fought back in the 90s and 80s, that if we adjusted immunization programs, or diarrhea programs, or malaria programs, or this program, we would drive the health system. And we would strengthen the health system by making our vertical programs work. Well, how wrong we were. Because here we stand now in a situation where our health systems are really in need of strengthening as health systems, not because they deliver AIDS programs or MCH programs or any other programs. But we need to focus on health manpower issues. We need to focus on the system, on the management of the system, on the policies of the system, as a system. Where our interventions we've learned we're just gonna go so far in what we're gonna be able to achieve. That's a critical component of global health. So when we think of global health in an academic sense, at least, that's just a quick picture of the kind of things. And there are others, I haven't mentioned road accidents, I mean, migration issues, we can go on on some of the other priorities. Mental health, huge issue. Unneglected for the most part right now in the field of global health. But one that's crying for attention in the field is the field of mental health. So I just wanna make, I mean, it's a critical point in understanding the field. Now that is, here is a projection of global burden of disease and it's just a bunch of arrows, I know. But what it shows here is that between 2004 and 2030, we're gonna see a shift in the global burden of disease. And what's gonna be number one on the right there is depression. So in 2030, our leading cause of disability adjusted life years is gonna be unipolar depression. And then heart disease. And then road traffic accidents. And then cerebral vascular disease. And then chronic lung disease. So that's where the world is headed. So when you have the privilege of running a global institute and you're thinking about what your research priorities are and you're thinking about the world in 20 years, those are the issues that are gonna predominate. We're still gonna have our infectious diseases, for sure, and our pandemics, no question. But the world, as we develop more and populations get richer and more middle class, where's the largest middle class in the world right now? Okay, I don't know how many of you would have guessed, but it's certainly not the United States, it's India. And China's a close second. We'll soon overtake India. That's where the global burdens are mostly in these transition countries and even as I mentioned in urban Africa. So again, thinking about the context of which we deal with global health. Now, global health though is not just disease and determinants. These are all the reasons why we need to take action on global health. Let me get some water. The first one is security. And my God, I'm in a security institute. And you've defined it. The best example are pandemics. I think, how many of you know, what's your estimate of the number of pandemics that we, new organisms, let me put it this way. New organisms that we have each year that have been discovered. Anyone wanna guess? Say about one a year, we get a new organism or a new or an organism that comes back becomes emerging that was sort of dormant, almost one per year in the last 40 years. Two thirds are viral and two thirds are zoonotic. That's a very, and that's what's leading to a lot of our pandemics. And those are, that's a good example of security threats. What if H1N1, what if H1N1 had a 50% mortality rate? Probably I wouldn't be here. But what if H1N1 had a 50% mortality rate? And just think about that. Would you think about that? What that would mean? It might eventually have that, hopefully not. But what if we have a new pathogen that comes along with that kind of virulence? That could certainly result in serious security problems for everyone. Diplomacy, sometimes global health works when other politics don't work. Where is the US most popular in the world today? Africa, why? PEPFAR, whatever you think of the previous administration, you have to give that administration great credit for PEPFAR. Whatever the reasons for starting PEPFAR, it's done a tremendous amount to promote the United States abroad. And President Obama talks about improving America's image abroad. Global health's a great way to do it. Science, most discoveries in science today are not one person who has a brilliant idea and they figure it out on their own. It's not the way science works anymore. Most of our greatest discoveries are step by step. Most Nobel Prize winners, I think two thirds get to do their discoveries before the age of 35. But they do it by working together and building on science that others have done. So global cooperation around science is huge. And that's how we make our discoveries. So global health is terribly important for science. Sustainable development. I think one thing that's really clear now is that if we're gonna have healthy populations, if we're gonna have development, we need healthy populations. And if we want healthy populations, we need development. The development, in fact, the field of development economics across US universities has really come forward again as a great specialty area. More and more young people going into economics are going into development economics. Thank goodness, because it's a field that had been dormant for a number of years. Commodities. Global health is $3.5 trillion business in the world. Drugs, vaccines, diagnostics, prosthetics. So from the standpoint of the business world, global health is big. Has a lot of great importance to the business sector. Global public goods. There are, global public health goods means that there are certain certain given rights, not rights, but certain given actions that we all benefit from, like smallpox eradication. That's another reason why we take action on global health because we want to achieve some global public goods. Another one is the convention on tobacco. That's another global public good. And then another, finally, reason why we take action on global health is because of human rights. I would say for students, certainly in the past decade, the price of antiretroviral drugs was a major factor. And the human rights issues around that were a major factor in interesting a lot of young people and bringing a lot of human rights activists into the field of AIDS. Was the fight over the price of antiretrovirals, which are now down to almost less than $200 a year when they were $15,000 a year when this whole AIDS pandemic started. And that's a considerable drop. So there's a great achievement in health and human rights. So again, the field of global health, it's not just diseases. It also is determinants, but it also involves security, diplomacy, innovative science, sustainable development, commodity, business, global public goods and human rights. It's why the field is interdisciplinary, multidisciplinary and captivating so many people around campuses. Now, of course, in the context of talking about what's going on at universities, there's the question of development assistance. And this was published in last week's Lancet. If you haven't read the paper, I urge you to read it. It's just showing you the growth in global health. 22, well, if you can see it's between 1990 and 2007. And you can see it's up to $22 billion in assistance for health now by 2007. And you can see the bottom is AIDS and there's been significant growth in AIDS and malaria. But that's substantial. Look at that growth. And then here's the growth in the United States. Almost $10 billion last year from the US government alone in global health. That's a significant, more than a doubling in five years. And then if you ask where the money has gone, and this has been a great change, of the $9.6 billion in 2008, you can see this is from Jen Kates' stuff at Kaiser. Almost half is now at state with OGAC. So, of course, the AIDS, PEPFAR has played a major role in that. NAID, of course, and then the rest with much smaller, except the NIH budget, which is about 10% of global health money, although a small percent of the total budget of NIH. So, you can see here, that's the growth in the US. So again, the context of global health has a lot more resources internationally and nationally. Now, this is a slide based on a talk that Steve Morrison gave. US policy, though, despite all this funding, does have some interesting challenges. And I'm gonna come back to this at the end. There are like 21 different agencies in the US government that are involved in global health. No offense to anyone here from an agency. It's just a fact. 21 different agencies doing global health. Most of our money is going into AIDS. We have an interesting debate going on whether global health is public health or foreign policy. And our global health policies tend to be Africa-centric. And they overwhelm, in some cases, other bilateral programs. And we have an interesting tension in our global health policy in the US between vertical and horizontal efforts. You saw that from the previous slide. All that money going into AIDS. Almost nothing going into health systems. So I think we're at a very interesting time in the US and globally. We have a lot of money. And we have some interesting policy decisions we have to make taking into account the previous slides I showed you on global burden of disease and what we even mean by global health. The last point I wanna make before I get to universities is the current economic context. Very often I get asked, why are you even talking about the rest of the world? What a mess we're in. Well, shouldn't we worry about ourselves? I mean, why are you even thinking of the rest of the world? Well, these are just some facts. The poor are the most affected by economic downturns. Most out-of-pocket, most more out-of-pocket extensions. The poor are most affected because they have to spend more out-of-pocket. There's less expenditures by government and there's less foreign assistance. So we know that in the face of an economic decline in the world, the poor are gonna suffer the most. We already have heard, it's been in the press, that up to 90 million more people are living in poverty this year alone. We anticipate there'll be an additional 400,000 deaths in children in low and middle-income countries and 45 million more children malnourished over the next 18 months. Similar impact expected on women's health. We'll talk about this at the end, but this is why it's good that the Obama administration is thinking of a maternal and child health initiative. And certainly a cut in foreign assistance would reverse the hard-won gains that we've had in the past five years in a number of areas. It would undermine global surveillance of flu and TB and other important organisms and it would hurt our image abroad. You know, the word out there on the streets, the US created this crisis. So it wouldn't be so smart politically for us to cut back our foreign aid at the same time. I mean, that is what you hear on the street. So I would argue that we've got a challenge ahead of us but this is not a time to cut back our efforts in global health. Okay, so let's turn to universities now. What I hope I've done there is I've set the context for you on what global health means in a broad sense. Definition, disease problems, the multidisciplinary nature of it, the importance beyond the health sector of all these issues I mentioned of security and commodity. And I've given you a picture of the finances right now. So let's talk about universities. This is just one slide which shows you in one of our programs at Duke, our global health certificate, which is a program for undergraduates. So in 2007, there were two students. It was a new program. And by 2011, there'll be 60. This is just undergrads at Duke, taking what we call a certificate. It's what you would maybe meant some of your students have minors in your college so this would be like a minor. And I'll talk a little bit more about Duke later, but I'm only introducing this as the example. There are many universities that can show you a slide like this in one or two or three or four or five of their programs. And the question is why? Why has this happened? Why have we seen this enormous growth on university campuses? Now I don't know the answer to it, but I'm gonna give you some ideas and maybe some of you are gonna give me ideas. So I've got a list of ideas here, but I'm gonna go right to the bottom idea first. And David Brooks wrote a column in The Times around when there was a lot of talk about why so many students were out there campaigning in the last election. And I thought his observation was very interesting as it applies to global health. And what he said was our current young generation has an unconsummated desire for sacrifice and service. I don't have any data to prove that, but I believe it. And I'd like to think I'm from the 60s generation, those of you who joined me in the 60s generation, I think we had some of that. We were reacting to a war, many of us in Vietnam, but I think the students of today, they're reacting to the things around them. I was teaching last semester when I went to meet some of the freshmen in our focus program. We have a thing called Focus, which is for freshmen and 30 students in the class. And I asked how many of you, first week of class, how many of you are just coming to college? How many of you in high school went abroad? Over half raised their hand. How many of you have been to Africa? 40%. As high school students. When I grew up, it was a big deal to go to New York and see a Yankee game. When my wife grew up, it was a big deal to get in her truck and go to Chicago to see the, go to Wrigley Field and watch a Cubs game. So that's what it was like when I grew up. But the students who grow up today, they're in a whole nother world. I don't think our faculty get it, but all of them. But the students that come today, they've got these devices, I don't know, these social networking things. I just heard about Facebook, you know? But since they've been young, they've been on the web. They've seen it all. They hear it all. They've got friends all over the world. Now they've got all these Twitter's and Twitter's and social networking and, you know, I don't get it, but they get it. And so they've got an information technology boom. They got rock stars out there, right? Everyone knows, say Bono, what do they know? Everybody knows, it's you too. I just learned that. But they know that he means something. He was able to really push for global health. The G8 is terrified of him, okay? So I think that you have movie stars, you have rock stars who really have caught on. George Clooney. I mean, we can go on, I'm learning some new names, you know? But I think that this is, you have, and then you have the social justice movement that I already mentioned touches students on the access to drugs. And then you have what I somehow find hard to quantify and that's this response to the 9-11 in Iraq war. And this desire to show we're a better nation. Okay, it's hard to quantify that. So you have all these impacts on the current generation. And then you have other factors. You have the pandemics in the news, SARS, AIDS, I have avian flu, I should put swine flu. I mean, so we have all these pandemics that make food illnesses. We have a pathogen that gets in a food from Mexico that comes here. We have these diseases that travel with food importation. And then we have, of course, the philanthropy. I've already mentioned the government's money, but look at Bill Gates. Gates Foundation, by far, by far, the biggest foundation in the world, $3 billion a year on global health. $3 billion a year. And Bill Gates himself is just, as you know, left Microsoft and is president of the foundation. And then, of course, the faculty. I think what you're finding, because global health is so interdisciplinary and multidisciplinary, you get faculty from almost all schools, at least to Duke, from all our schools, and in arts and science, from many departments that feel that they have a role. They see their place in global health academically or from the education standpoint. But I come back to the last bullet, which is that this generation really cares. For whatever the reasons this generation cares and global health and, I hope, the environment are the two things where they can really demonstrate that they care. And so I use that, again, as my final point here. Now, I'll show you, it's not just the students, not only the young people. About, when was this done? About a month ago, Karen, the Kaiser Survey in May. Anyone here from Kaiser? No, okay. March, it was done? Okay. This was a nationwide survey of what does the American public think of global health. It was published on the web. We got some PR. I'm just gonna show you a few of the slides. So the majority people, this was a nationwide survey. The majority say that developed nations are not doing enough to improve health for people in developing countries. 57% not doing enough of the people surveyed. Even in the current economic climate, this is from March. 28% doing enough, 4%, 14% didn't know, but 57% of the American public. And this is really interesting. So the question was asked, tell me why you think the U.S. should do more to improve health in developing countries? Look at the predominant answer. It surprised me. 47% because it's the right thing to do. It's what we, it comes back to what I was saying about students. This is from the American public, the national survey. And then this really surprised me. Have you personally ever donated money to an organization that works to improve health for people in developing countries or not? First, the first circle, 50% are giving, gave money last year. For something to do with health in the developing world. That's an astounding figure. Now, much of that I think it's not in the survey is through churches. And that's fine. I mean, so it's, I don't have the detail of the breakdown of who they gave money to, what organization. That's an impressive figure. So I think the student context has to be seen in the population context. And then this issue of enlightened self-interest where we have to be honest and say it's, it's students' care and the public cares. But our government interest and our political leaders' interests is also there's some enlightened self-interest. We're afraid of outbreaks and pandemics. We wanna repair US image abroad. We wanna ensure economic development and we wanna fight poverty. So I don't want it to sound like this is all just being good guys. There's also an enlightened self-interest part to the interest in global health. I don't think it's the predominant one, but I think we have to be honest and say that it's a, that our own government's interest is somewhat due to enlightened self-interest. But I do think the fundamental drive on American campuses, I wanna come back, is the students. In the context of the public interest and in enlightened context of enlightened self-interest. So we, last year, we formed the consortium, well, we had a group of 20 universities that got together and say, hey, let's talk about what's going on. And we decided, we had a meeting out in California and in September 2008, we got 20 universities together. We're gonna have a second meeting this September here in Washington. We've invited 52 universities. Now in that initial 20, this was, we said, okay, we're gonna invite initially 20 universities that have multiple parts of their university that are involved. They have some university resources that they're designated, there's a designated leader. Education and research activities are part of their portfolio and they have overseas collaborators. And so we 20 met and we decided to form this consortium, formally form this consortium. And now we've invited 53 schools. We have a board of directors now. We're incorporating ourselves as a 5013C. It's gonna be called the Consortium of Universities in Global Health. Our secretariat, we're housed for the first three years at the Global Health Science Division at UCSF and we have some initial support from Gates and Rockefeller, but we're gonna, of course, have to charge dues, like all most university groups. But what's exciting about this meeting coming up in September is we invited five university presidents. We figured, you know, we're gonna write it be a university consortium. We're not gonna be a medical school consortium, a public health school consortium, a business school consortium, because most universities are trying to approach global health across the university. So we thought we'd take a chance and make this a university consortium. So we invited five university presidents to speak. We didn't know how many would accept. We had no idea, all five accepted. So we're gonna have a meeting with five university presidents coming and talking with us about what to do with the consortium. That's not small fish. I mean, that you can get five university presidents to come to a meeting and they're pretty busy people. Of course, one new one was come and the other one says he's coming. But still, I mean, this is still an impressive, and we really hope to launch this consortium and we wanna promote university's role in multi-disciplinary capacity for tackling major global health challenges. We wanna build university collaborations to define global health competencies and set standards for training. We wanna strengthen the university's capacities to provide seamless global health experiences for students and researchers. We wanna provide a platform for exchange of knowledge and experience in global health. These are some of the initial goals we've put forward, but we'll work on this more at our meeting in September. Actually, NIH is hosting us. We're very pleased about that on the 14th and 15th of September. We did a little, no, one of the things I don't have to show you, I wish I had to show you, is data from these 53 schools. How many students are doing what? How many faculty are doing what? I don't have that data. We're still young. We're, next week, we will be starting to survey all 53 universities with a common questionnaire to try to get this data for our meeting in September, also for our event on the 16th, Karen, because we wanna have some data that we can show is going on around the United States and also five universities in Canada. This has become a big issue, big hot field in Canada as well. And we did do a quick survey of our own and we found that 41 of the 52 schools do have activities that are into school. 26 universities are actually giving hard money to their global health entity, whatever that is. 44 have education and research programs and 41 have formal partnerships or exchange of students in research. We've gotta do a lot better of documenting what's going on. Right now, what I've told you is just, from my own experience, but I think this is our goal over the next couple of months. This slide is too small, but I was going to just say one of the, the reason why I put this slide up, this is Duke, Emory, Harvard, Johns Hopkins, University of California, San Francisco, University of Washington, I put those up because each one of those universities has somebody on the initial board of directors. But the reason why I put it up is I want you to realize that each university is approaching global health in a different way. There's no magic formula. So at Duke, that I direct and privileged to direct, we have a trans university institute. I'm half owned by the provost and half owned by the chancellor of the health system and I sit under the president. That's one model. Emory also has a trans university institute, very similar model. Harvard, being Harvard, has a diverse structure for global health in various parts of the campus. Strong in the public health school, strong in the health policy, strong in arts and science in Cambridge, strong in the hospitals like the Brigham. No real unifying structure, not yet anyway. Hopkins has a institute of global health, but it only involves medicine, nursing and public health, but it only involves medicine, nursing and public health. It doesn't involve the rest of the campus. I'm not saying good or bad, I'm just giving you the different scenarios. UC San Francisco is setting up the first university school, school of global health. It's going to be a very unique situation where they're going to have a center in each of the UC campuses that exist now and then they're going to have a central core and that's being debated now where that will be. I know California has a budget crisis so I don't know how fast this is going to occur. They did get a $4 million grant from the Gates Foundation to get this started, but this is going to be the first school of global health, quite an interesting concept, making use of the entire California system. It'd be quite an experiment. And then University of Washington, they have a global health department which is made up of a combined effort by the medical school and the public health school that has a lot of support from the Gates Foundation. And I could go on, we can come up with probably 30 different scenarios. It doesn't really matter, but what I wanted to present to you is that universities are working to figure this out in a context that works best for each of them. And there's no one way to do it. But the important thing I want to show you is that this is happening across the country. Now at Duke, you allow me five minutes of promotion of my own institute just to tell you a little bit more about the way we're doing it, without much detail. But I'm doing it to emphasize a few points. What happened at Duke, just to give you an example, is that there was a committee established two years before the institute ever was created to decide what Duke should do in global health. And they decided to have an institute that would reduce health disparities in our local community and worldwide. We consider global health to be global and local. If you go east of I-95, in North Carolina, you almost enter a developing country. I mean, it's pretty sad, the kind of disease problems we have in much of the South, as you probably know, particularly in rural areas. And we are very interdisciplinary and we are focused on solving problems that's research and training the next generation. But the most important thing is that our institute spans the humanities, social sciences, engineering, environment, law, divinity, and life sciences, which are medical school and nursing school. We don't have a public health school at Duke. So I think that's, I think it's an example of how one university put it all together. And our five goals are to build the next generation of our institute, is to build the next generation of scholars that's education, encourage innovation and promote excellence in research, respond to the policy needs of decision makers, undertake research, service and service learning, and facilitate access to current information. And this slide just gives you a picture, I'm not going over this, of all the different education programs we've started, the various research initiatives we've started, that on the left is the number of service programs we've started in on the writers on policy. I just wanna tell you one thing that we did on the service side, which I hope more universities are going to do. We found that our health system has a lot of surplus supply and equipment that goes on eBay and frankly doesn't sell very well. This stuff is fine to use. It's just a little out of date. And we convinced the head of our health system to let us take those supplies and equipment and give them to our faculty who are doing research abroad so they could give it to their partner institutions as a way of giving as a part of our partnerships with the various activities we have abroad. So that's just the way in which you can get your health system rather than putting their surplus on eBay and barely probably storing it at a huge price. Instead they gave it to the faculty to give to our partners abroad for the kind of research we do. So just to give an example of how a university can do things quite uniquely when it comes to global health. And then I just, well, this is a map of the places where we're doing research around the world. I would say that probably Hopkins has the most in an, I think the last time I talked to Tom Quinney had Hopkins had projects in close to 100 countries. So I think they have the most partnerships around the world. I think we're quite modest when it comes to that. And then we are also been working with a number of partners around the world to designate what we call global health sites where we are hoping to concentrate our research and education efforts from the different schools because it gets expensive and you build up close relationships of equal close relationships with partners. And if you're doing an AIDS research in Tanzania we started off in AIDS, but we're now working in maternal and child health. Our engineering students are there working on some projects. We have an environmental group there. We're working on some projects. We have students from the various schools. What we find, and what more and more universities find, is that it's most effective in creating close bilateral partnerships by partnerships that go in both directions, rather, that it helps to concentrate your efforts. And you'll find that I think what you would find is more and more universities are doing that. We're actually having a meeting next week at Duke with six other universities between Washington and Alabama. We're having a meeting with six universities to talk about how we can share our resources and how students from one school can go to a place that another school has a site where education or research can take place so that we don't step on each other's toes, be sensitive to our partners. And then let me then now just close a few minutes about what I think is some of the issues that we face down the road. So I was thinking, what are the challenges that we face in all this enthusiasm that's out there? First, within academia, those of us in global health, we still have to convince our colleagues on the validity and sustainability of global health as an academic field. It took years for women's studies to be accepted on campuses. And I don't expect this to happen overnight. This is a new field. And we have to prove ourselves that we are serious scholars and I'm going to make a serious impact from an education or a research or a policy standpoint. Secondly, we have to be sure that there are reliable career paths for students. Students are not stupid. Students think about what's going to happen when they graduate, well, they should, most of them do. So there has to be career paths. Thirdly, we have to make it a truly global field, not just a field in the north. So I mentioned that Canada has five universities with global health institutes. England now has four. Peter Piat has just gone to an Imperial College to start a big global health institute there. I think he spoke here recently. Australia has the Georges Institute, which is a leading institute in global health. And we've been invited now to start global health diploma programs at Peking University in Peking and Mahidol University in Bangkok and then went with the Public Health Foundation of India. Because at least in Asia, we're seeing that more and more universities want to create academic programs in global health. Again, very much driven by students in those universities. So I think we're going to see this worldwide. And I know a number of my colleagues are doing similar activities in Africa. We need to determine benchmarks and ways to measure the impact and success of our programs and we need to maintain the exciting momentum for global health under the current global economic downturn. And therefore, I think we need to keep asking ourselves as universities, what can we offer to the field? What do we offer that you can't get from CSIS or you can't get from Family Health International or you can't get from the US government? What is it that universities can offer or from NIH? What is it that universities can offer? And these are just some thoughts. Obviously, we can capture the enthusiasm of students and educate and train future leaders. Our scholarship and research of our faculty can address the leading global health challenges I mentioned. We can do objective, hopefully, policy analysis and we can provide service to our local partners, to civil society, to the US government, to international organizations and to the private sector. What I mean by that is particularly is in the area of monitoring and evaluation. We've been involved in my institute in a number of projects around the world in the area of monitoring and evaluation where we've been called on by usually a funder to come in and do some serious evaluation work. Now, in terms of partnering with the US government, this is a challenge for us. There is this thought that with some validity that universities are slow and we take big overheads. Although I must tell you I've seen some others that take even bigger overheads that are not universities. But I think the question that we need to ask ourselves is how can we partner better with the US government? Traditional relationships have been mostly through HHS, of course NIH, CDC. The Department of Defense supports quite a lot of research on universities and the Department of Education, mostly through Fulbright scholars. All that could be expanded. Then we need to think about new relationships with state. As I showed you, state now is half the global health budget of the US government. There hasn't been a lot of collaboration historically between state and universities in the area of health. And that's an area I hope can be established. And then, of course, in the area of policy analysis, I'm sure we can do more to work more closely with the US government. And so I'll finish with this slide, because I want to come back to where I started, which is that what's driving us more than anything is, and I think we should all be very excited about that, is today's youth, and the fact that they want a better world. And, you know, Martin Luther King, this quote, as long as there is poverty in the world, I can never be rich, as long as disease are rampant, I can never be totally healthy. We are co-ordinated in an inescapable network of mutuality tied in a single dominant destiny, and whatever affects one directly affects all indirectly. For some strange reason, I can never be what I ought to be until you are what you ought to be. The point here being that health disparities are not something we should tolerate, and people who go into this field, I think what's at the core of why they're doing it is that they want to remove those disparities, and that's why it's an exciting field, and I hope one that'll be around for a long time to come. Thank you. Thank you so much, Dr. Merson, for that well-rounded description of the growing interest in field of study, global public health. I have lots of questions, but I do want to open it to the floor, as I think they're in the interest of time, and I already see some hands. So maybe there are microphones around the room if you would identify yourself, and I'll take two or three at the time. Great. I agree with you that you put your finger on the very strong interest that young students have in doing the right thing and social justice as part of the reason why people go into the field of global health. But I'm worried there's a yawning gap between that humanitarian ethos and what has caused global health issues to get on political agendas over the last 10 years. And if you look at the issues that are on the top of the political agenda, aside from HIV-AIDS, like the Asian flu, H1N1, international health regulations, the virus shared in the country that's used in Indonesia, they bear no resemblance to the burden of these studies of what public health conceives as the future issues of global health. And I worry here that we're doing a great service to the students who are coming in to this United States by not giving them training in international relations and foreign policy to understand what role global health will take in world affairs. So I would hope that one of the, possibly one of the goals that we're starting is to bring in schools of international relations and bring in international relations. Mike, that was a terrific speech. I just want to encourage you to give another tiny addition to it because I think if the metaphor is right, you've underplayed your trumpet or whatever, because Duke is a university which was one of the first which encouraged different schools to collaborate. And I remember the conference a couple of years ago on health workforce issues where the president of the university brought together everything from the community to the business school and you also did this pioneering survey of people at WHO, et cetera, showing a tremendous awareness of the lack of basic management skills and that's where I wanted to go. And you did mention health systems and you did mention that very little money was going towards health systems. But I wish you'd say a little bit more about these issues because unless you have people in the trenches who know how to get things done, much less will be getting done and the money won't be useful. My name is Guy Peppermann. I'm the CEO of the Global Business School Network and we're working together. One more, maybe? Could you identify yourself? Just identify yourself. I was wondering if you could further pin down the definition of health system strengthening. I've seen a lot of solicitations out of the government in recent months where they're calling for it and it's not entirely clear to me that they know what they're asking for. Sometimes it's M&E, sometimes it's evaluation, sometimes it's actual capacity building in HR and sometimes it's actual systems. Is there any kind of consensus as to what that phrase is going to mean? Yeah, so your comment is quite interesting. The school, so we have nine schools at Duke. The school that's most involved with us is the public policy school. And the students, many of the students who are involved undergraduates, they're major is public policy. I take your point about the disconnect. I tried to show one slide in that regard about how our money is being spent and what our priorities are and what the global burden of disease is. And it's why I'm hoping universities could get a little bit more involved in the analysis with U.S. government because I understand, you know the whole genesis of PEPFAR, I think it's public that PEPFAR came about not just because there was a terrible AIDS pandemic, there were issues around the African-American vote and there were issues of faith-based, the faith-based sector was losing people, literally losing people in Africa. So I think that the importance of global health in the context of international relations is huge. Certainly at Duke we are focused on that. I was asked to talk the December before last, it was the annual meeting of the schools of international relations that is held every December or something. I was asked to come and speak to them and I was impressed that there was interest in the public policy domain or international relations domain. One of the challenges they faced was not having faculty to teach courses and I reason why I say that one of our greatest challenges right now not just at Duke but in academia is not having enough faculty to meet the demand both for the education, the courses that are needed and wanted and the research that's out there and even to participate in more in the technical support role. How do you get more faculty motivated? How do you get more faculty? Well, either you try to take existing faculty and give them incentives to do their work internationally. Most faculty have their thing and they do it well and they want to do it better and then they want to get promoted. It's normal, I don't have any problem with that. But sometimes if you could just get them if they're interested in obesity in middle class people in Durham maybe you can get them interested in obesity in China. I mean maybe you send them on a trip and you give them a small pilot grant and maybe they get enthused or you try to bring in new faculty and that's why we need doctoral programs and postdoctoral programs and we need to find opportunities for young scholars to advance their interests and that's what I find in the public policy area right now or in the national relations area is getting those schools to take this on at the administrative level although at Duke, Sanford is great but I think this is a real challenge but I take your point and how to get the US government to take a more balanced view on where to put its money is complex because right now two-thirds of our money is invested in AIDS and historically that's going to be hard to change in my opinion because you've got a lot I don't know, two million people, I don't know the number but one to two million people on HIV as a result of PEPFAR it's not going to be easy to pull the plug on that and the question is how do we get sustainability of this PEPFAR effort in the long term I mean I think in the short term we've got to continue to provide resources but if we're not going to get more money or if we're only going to get a little bit more money eventually we've got to get that age treatment covered in other ways so that we can do other things with the money I think that's a real great challenge that the US government has now it's not going to happen quickly just in expanding into maternal and child health which is a good sign so that's how I'd respond to that on the management side Guy is right and I alluded to it and it's related to your question about health systems I mean think of our own country think of the mess we're in in our own health system I mean the problems are some of them are quite common you know what often happens in Africa let's say is that someone graduates from medical school and the next year they're running a clinic in a rural area they've had no training whatsoever to run that clinic none but they've got a job in the government they're going to go run a government or they're working for a faith-based organization and they're being asked to run a hospital and they never run a hospital they don't have a clue how to run a hospital so to me what we need in strengthening health systems is we need more people we're short 4 million healthcare workers in the world Africa has 25% of the disease burden and 3% of the health workforce so we have a huge need to have more health workers the nursing crisis worldwide is huge so we have that problem we need more people that's where you get this health manpower but then we need training we need to train people whoever physicians or nurses or people who get MBAs or get business training we need to train them in the basic management skills so to me strengthening health systems of course means more people it means more hardware we need more hospitals and health centers we need to get comfortable with what's called e-medicine or e-health because I think the future in reaching out to people is going to be 3.5 billion people have cell phones today so the way we're going to reach people is by text messaging in terms of reaching out on healthcare I think and PDAs as they get cheaper so I think that we need to think about people and then the hardware that goes in the system and then for those that are in the system they need to know how to better manage within the system I think we should evaluate programs usually that doesn't jump to mind when I think of health systems I'm not saying we shouldn't evaluate but it wouldn't be what I would put in the basket of health systems, program evaluation it should be done but I'm thinking something of the system itself I would refer you to WHO has some very good publications on a framework for strengthening of health systems I don't remember the exact reference where you could get I think some very good definitions of that and Guy I agree we need to understand that management needs to be taught in many different schools not just in business schools not just in medical schools not just in public health schools but the concepts of basic health management even in this country how many medical students graduate and even know what Medicare is I hate to say that to you all but it's true we have teachers right in our own country and getting our young doctors and allied health graduates to learn something about the health system they're going to enter when they finish their education so I don't know if I answered that but try it maybe and then Samuel and then maybe one more time Mike, there's an old adage about those who can't do and those who can't teach because the quintessential exception to that it's good to have you at the thank you Jim, that's Jim Sherry the how do we get the reciprocity in this the other consequence of 9-11 was such a reduction in the number of foreign students who were coming to the country when we saw how the the Green Revolution was managed so much of that was focused on building the universities and the network of institutions around the globe and those basic capacities we find the way to get our students over there what do we need to be doing collectively to get much more of the scholars from other parts of the world moving around global health is still a concept basically nobody's actually funding global health what is sustaining another bridge what is sustaining this funding for specific diseases we've had these waves before what could help sustain this in some other way are you concerned that since this is what is sustained this way specific funding for specific diseases that this may not be sustainable and it may not be enough to sustain the institution for the world I remember people started following this basically the idea my second point is that I think just as Duke has formed partnership she should do that no I'll take one more Tim Stevens from the institute on the side it's alright we're not in basketball season I'm fully aware of we have similar issues around developing programs of public health practice I think it's the U.S. government public health programs should we be looking for lower cost models so we can have better students answer my questions your question is a little bit all these questions are interestingly a little bit related around the theme of sustainability and partnership these are all very interesting questions I think Jim's point actually going from here to the Fogarty Center for a dinner with some people at the Fogarty Center to talk about this issue what we really want is for our institute partners to be able to get sufficient support around the world to be able to be our partners and not just to have a one way street I think Jim's point is extremely well taken and within NIH there is the Fogarty Center which is great for this as a budget that's probably less than CSIS is it's really small and it's very unfortunate how small it is and I just think that until we get more support for strengthening institutions abroad this is going to be a challenge the Gates Foundation has done some of this, Rockefeller used to do a lot of it, isn't doing it now we don't have the resources that we need to do what needs to be done to strengthen these institutions in developing countries a lot of the money that was made available through Fogarty in the past decade has been through AIDS research and if you look at where the best AIDS research is done in the world now and I say this without question if you look at where the best research is done in Africa, let's just take Africa it's the institutions that Fogarty Center strengthened over the past 15 years 10-15 years through its AIDS international training and research program it's unquestionable, that's true and it's the best example of what Jim is saying that where the emphasis was made on strengthening those institutions they became great partners with partners in the north and we need more of that and I wish I had an answer to Jim's question we're all trying to advocate that Gates do more of that Foundation we're trying to advocate that the Welcome Trust is doing more of that that's for sure in Africa they just gave out a substantial number of grants to seven big grants to strengthen African institutions to collaborate with UK institutes but I do think that that is a very critical area that we all need to lobby for and try to get more resources for I can only agree with you Jim on the sustainability issue I mean I've tried to make the same point that I'm also not sure we want this field to continue one reason for forming the consortium was to try to share and to give this field a decent birth so that it would be sustainable and I am aware that some fields come and go but then some fields like women's studies hang on and environmental studies for example many universities today have environmental studies which they didn't have 10-15 years ago I think that we have some good reasons to be optimistic we have the continued support from the government we have the Gates Foundation I mean the Gates Foundation took a cut instead of growing it at 17% this year it's growing at 8% I mean we'd all like to have our retirement accounts be that successful so I think that we do have some signs but I think you're absolutely right that we also need to have such consortia work with our partners abroad and at our meeting in last year and at our meeting that's coming up we've invited a number of partners from our partner institutions to come to the meeting because Gates is interested in forming a similar consortium in Africa and a similar consortium in Latin America and maybe in Asia if the demand is there so I'm hoping that what you're saying what you're warning us about doesn't happen but I think we have to work to continue to build on the enthusiasm that's out there and I think as long as our students are so committed that's probably the best hope we have of this field surviving and being strong you know I do believe that your last question was on the workforce right your question the focus was on the question of where we're going to get the workforce right I think I told you I felt some guilt about this issue as someone who was pushing vertical programs and why I think we finally have turned the corner on this and recognized that the health system the workforce and all that itself needs attention the workforce alliance out of Geneva you have the new IHP partnership which I'm hoping the U.S. will eventually join of about 14 I think 11 or 12 nations trying to focus on about 10 or 11 countries together trying to strengthen the workforce I think we need task shifting I think we need to realize that a lot of things doctors do, nurses do a lot of things nurses do paramedics can do I think we need to also think about tasks different health workers can do that doctors don't have to do everything in fact most things doctors do could be done by another healthcare worker so I think we need to think about who does what improve the management of the system and have some efforts by donors and by the World Bank who's a major player here major player in the IHP partnership is the World Bank unfortunately Gates is not a player in this the Gates Foundation is not committed itself to this it's primarily interested in product development and innovation for specific diseases which is okay if we have others that are committed to strengthening the health system and the workforce I'm hoping the PEPFAR resources and the U.S. government will be more open to seeing our resources used not just for in-service training to get more people treated but actually to strengthen the health system because I think we've probably maxed out in Africa if we don't take what you're saying seriously so I... there is much more momentum than there was the question is can it be maintained and can it be expanded and I think we have to continue to advocate because it always gets forgotten not always it often gets forgotten in discussions so I don't know if that's sufficient but it is better than it was five years ago the question is can we maintain it and grow it more people in the the fellow in the middle right please identify yourself oh wonderful another university here thank you yep yes yes oh okay Dr. Marson is a very productive person thank you very much I have three observations I would like to share with you I think one of the reasons we departed from international health to global health we emphasize the political aspect of health and it seems like health security or security issues health diplomacy I hope health will not be the victim of the politics you want to expand you want to expand on that a little bit yes I will try one of the reasons is that I believe what you said but at the same time if health is brought only for political purpose then whole concept of development will be defeated so I'd rather say we will bring health under the umbrella of the development because that is the worst security system that we have in this world today I can tell I'm in Washington the second is that I think we need to work on more between your challenges of the universities and the topics that you identify under global health for consistency then we can see our path clearly and third which is my bias because I was trained in the reproductive health in the university mission if you look at the medium development goal definitely one of the very significant maternal child reproductive health issues we were supposed to have after 2004 in 1994 in 2004 and that didn't happen so I hope 40% of the deaths happen as you know better than anybody else to the MCA reason so I hope we can bring that back what are the other issues in the core corner of the health issues particularly in the developing countries let me just say I apologize I didn't mention that one of the greatest travesties is the maternal mortality rate around the world and that for sure now it's somewhat a technical challenge as you know we don't have all the answers but we sure can be doing a lot better I just want to say I hope the U.S. government does I'm hoping when President Obama goes to Ghana we may hear something about this but I'm really hoping that we're going to get where you want to be on that one I will invent oh wonderful I want to reflect the needs of students and how they progress in their career or will they reflect the research goals of professors oh I can see you had some interesting discussions I can see you're watching watch out Jim oh wonderful nice my question is about real private sector engagement and not just big pharma development or big pharma service but also potentially or utilization of corporate supply chains and mass vaccination campaigns or even utilization of private sector human capital good question so on the first question what comment on reproductive health I appreciate I also am I deliberately in my talk showed the dollies and then showed where the money is going because I have a similar concern I mean it's sort of a trade off a little bit because the money that's gone into AIDS and malaria and has certainly galvanized much of the government toward global health I mean PEPFAR people maybe a lot of people don't know this the big thing that PEPFAR did is it transferred the responsibility for global health to the ambassador I was on the PEPFAR evaluation team I think Jim was a part of that too and one of the things that really struck me is you go to the field in PEPFAR you can sit with the ambassador and talk about global health I mean that wouldn't have been that way five years earlier that's a really contribution to PEPFAR and I don't know we'll see if all the Obama money is used that way also but even malaria, the few countries that are doing malaria it's the same thing, it's at the ambassador level so I don't I understand the disconnect and I think what we all need to do from a policy standpoint is keep reminding policymakers what the priorities are and not let politics become the dominant theme on the other hand we should capitalize on the great progress that's been made financially and politically for the field so I take your point and I think we all need to be balanced to balance these issues and for the common good I mean there are people like Lori Garrett that are very very concerned about this I'm concerned but on the other hand we should capitalize on the achievements that have been made and on the topics it's sort of related I do agree that we need to remind ourselves as I've already said what gets some agreement and that gets to your competency question there is an organization called G-HEC which actually I believe you probably know from Seattle Global Health Education Consortium they've been around 20 years developing curriculums using global health in medical schools primarily and we are trying to come up with a way to I don't know about incorporating but certainly having a close partnership between G-HEC and our consortium because one of our priorities for the next few years is to develop competencies and I don't think competency should be based on faculty members interest competency should be based on what the student needs to learn to be a successful graduate in global health we're starting this year we've just started a master of science in global health and we've spent a lot of time thinking about what our competence should be there's only one other master of science in global health in the country and that's at UCSF that's very much focused on global health governance and we've been thinking about what our competencies are going to be and most of our thinking has not been around faculty interests but very much around what we see are the priorities in global health to be learned to have a successful career I would hope all universities would follow that path in terms of the obstacles with state per se I think what we're faced with at state is that you're in homeland security I think you said but that's new and the money that's gone into OGAC at state is new for five years state never had this role before and so I think in fact we were talking today before this meeting one of the things are CSIS commission Karen mentioned this policy commission I'm on that commission we're talking right now about this question of how we can make recommendations to state about how to provide legislation and for example oversight and what role universities could play and other actors could play in working with state as I understand state traditionally even through legislation there's certain laws which limit the amount of input that state can have from the outside maybe I'm not saying it correctly but I'm hoping that there'll be more openness to the expertise in American universities to provide guidance to state certainly if you look at NIH or CDC there's a lot of involvement of universities in review panels or even in councils and various mechanisms are used and I would hope we could see some of that at state I think a lot of it is the newness and maybe not enough awareness of how to do it and I'm hoping that this will be one issue our commission now on the private sector I think corporate social responsibility has arrived I don't think it's just a gimmick I think it's for real let's face it much a farmer now has serious challenges I mean you know all the layoffs and that many much a farmer has faced which is really not good for research and development that's for sure so I think though responsibility much a bit out of the embarrassment over the age drugs has really happened at least in the farmer world and if you talk to Exxon Mobil or the gold mining companies the mining companies in southern Africa or the beer companies I think there's a genuine I mean there's always a profit motive in what their livelihood is but I think there's a genuine desire to help and to be part of this movement and to feel that they can contribute and one way they certainly can contribute is in management I don't know if Guy's interacted much with the business the business sector in terms of how they can help business schools but certainly they have a lot to offer and I hope you will I hope that that will happen I am feeling quite positive about the approach that the business community is taking toward global health and I mean there will always be exceptions and there will always be issues over patents and pricing of drugs and all that and I don't want to seem naive but I do think that the general approach of the business community is positive toward making a difference today I think it's in their corporate interest to do so I mean the other sector which you didn't mention but is the faith based sector I think one thing one very positive another but one of them is that the faith based sector really matters and we need to work closely with the faith based sector in management training that I mentioned they need but they can outreach to populations in ways that no one else can and trying to work with them in a positive way I think and making them a true partner in global health like the business sector is really important so I just finish on that Thank you Dr. Merson and thank you all for coming Thank you