 Ladies and gentlemen, good morning or good afternoon as the case may be, my name is David Donahue. On behalf of the Institute of International and European Affairs, I'd like to welcome you all to today's lecture by Peter Sands, who is the Executive Director of the Global Fund to Fight AIDS, TB and Malaria. We're delighted to be joined by Peter, who will speak to us today on the subject of enhancing global health preparedness for the future. This forms part of the Institute's Development Matters Series, which is supported by Irish Aid, the Irish Government's Development Cooperation Programme. Mr. Sands will speak to us for about 20 minutes, and we will then go to Q&A with our audience. Both his presentation and the Q&A are on the record. You can find the Q&A function on the Zoom at the bottom of your screen, and please feel free to send in questions whenever they occur to you during the event. Please also feel free to join the discussion on Twitter using the handle at IIEA. We're also live streaming today's discussion, so a very warm welcome to all of you who are joining on or via YouTube. I'd now like to give the floor to Michael Gaffey, Ireland's Ambassador to the UN in Geneva, and a former Director-General of Irish Aid. Michael will introduce our speaker, Peter Sands. Michael, over to you. Thank you very much, David, and good afternoon, everybody, from Geneva. I am really delighted to be here to introduce Peter Sands, Director of the Global Fund to Fight AIDS, TB and Malaria. It's a real honour for me, because in my current role here in Geneva and my previous role with Irish Aid, I am very familiar with Ireland's firm commitment to the Global Fund in good times and in bad, and more importantly, I suppose, the impact that the fund has had on the lives of some of the most vulnerable people on the planet. I would want to highlight Peter Sands' leadership as Executive Director of the Fund since March 2018, and I welcome the recent announcement of the approval of the extension of its term for a second four-year term from March 2022. He has brought his skills as an expert in global health and a leader in the financial sector to bear on the Global Fund, and by the way, I only realised and preparing for this, that his distinguished career began after Oxford in the FCO, which he then left for McKinsey. He led, as Executive Director, he led to great effect, the historic sixth replenishment in 2019, which generated $14 billion in pledges for the three-year funding cycle. This was a huge effort, which owes a lot to Peter himself. It was an effort of encouragement and of pressure, whatever it took, but it was very effective. So thank you to the IIA for hosting this webinar as part of the Development Matters series. As many of you will all be aware, Ireland was a founding member of the Global Fund in 2002, and we're very proud of our partnership since that time, and we're proud also to be increasing our support to the fund pledging in 2019, an increase of at least 50% to 50 million euros over the period 2021-23. Ireland plays a full and active part in the governance of the Global Fund through our membership of the 0.7 constituency, jointly the fund's fourth largest donor, and later this month Ireland will take our turn as the board member, an opportunity we are really looking forward to at a time of challenge and very real need. So it's clear to all that the world has learned the centrality of global health to global development over the past unexpected and dramatic year, and we're still learning. Since its foundation, the fund has proven itself to be one of the most effective organisations in global health. It is saving lives, preventing disease and suffering, and strengthening health systems in some of the poorest countries. The purpose of the fund, of course, is to accelerate the end of AIDS, tuberculosis and malaria, and that was never an easy task, and the COVID pandemic has made it more challenging, disrupting health systems and threatening progress. But the eradication of these epidemics remain critical goals, and there has been real success in the effort. For instance, since 2002, AIDS-related deaths have fallen by 61%, new infections down 41%. Before COVID, TB was the world's leading infectious disease, focused on poor and marginalised communities, and in countries where the Global Fund is investing, the death rate was down 20% on 2002, and malaria saw a 60% fall in death rate since 2000. So these are remarkable figures, but all of this progress has been threatened by what the fund itself has described as a perfect storm of economic health and social crises as a result of the COVID pandemic. So with the next replenishment less than two years away, the fund is at a critical juncture. But there is no argument but that we need the fund in our global health architecture. Also, however, that we need to re-evaluate that architecture in the light of the experience of the pandemic and its impact. How the fund positions itself in the years ahead is going to be critical, and that is why Ireland has been so invested in your ongoing strategy development process, helping to tease out the list of current and future priorities. So today, we will hear about enhancing global health preparedness, looking forward to the challenges that we will face in the future, and considering the actions we can take now to prevent or mitigate these. And there are few, if any, better place to speak on this than Peter Sands. Before taking up his current leadership role in the Global Fund, he chaired the International Working Group on Financing Pandemic Preparedness at the World Bank, and chaired the US Commission on a Global Health Risk Framework for the Future. His work has looked at the security dimensions of health and the importance of investing in health security. Well, it's clear the pandemic arrived, and hopefully the world is now catching up with this work. And we look forward now to an open and frank engagement on the challenges ahead. And I give the floor over to Peter. You're very welcome. Thank you. Thank you very much, Michael. And also, thank you, David, and the IIEA for inviting me to share some thoughts today. I'd also like to start with a big thank you to Ireland. As you said, Michael, Ireland has been deeply involved in the Global Fund from the start, from 2002, and has consistently stepped up your support of the Global Fund, most recently at the Sixth Replenishment, as you mentioned. We face, as you say, a perfect storm right now. And before I talk about the future, I think it's important to reflect on where we are now and why it is that the Global Fund, as an institution set up to fight HIV, AIDS, TB, and malaria, is now so deeply involved in supporting countries in their responses to COVID-19. This time last year, or actually a bit earlier, we were wrestling with how we were going to help countries that were reeling from the first impacts of the pandemic. And we, on top of, roughly speaking, four billion or so that we invest every year in the fight against HIV, TB, and malaria, we mobilized another billion dollars during the course of 2020 to help countries with three things. First was what we might call pure COVID responses, things like diagnostics, treatments, PPE, and so on, things that countries needed to respond to the pandemic. I remember this was before any vaccines were available. Second was actions to mitigate the impact on HIV, TB, and malaria, because we saw these services, vital life-saving services, being disrupted across all sorts of different countries. And then third, countries needed to do urgent fixes to their health systems, whether it's supply chains or lab networks or so on, to be able to both preserve and sustain their HIV, TB, and malaria services and to respond to the new pandemic. We moved very swiftly to deploy that money. The first tranche of $500 million was all deployed by the end of July. The second tranche of another $500 million was all deployed by the end of December. We have now launched a second phase of our COVID response mechanism, we call it C19 RM, with an initial funding of about $3.7 billion. So on top of the four billion, over four billion, we will be investing this year on HIV, TB, and malaria. We'll be investing another $3.7 billion ish to support countries in their COVID responses. Just to be clear, what we do and what we don't do, we don't do the vaccine side of the response. That is organizations like GAVI and CEPI and UNICEF through COVAX. But countries have immense needs beyond the vaccine side of it, whether it's testing, oxygen, treatments, the actual underlying health systems, the supply chains, lab networks, and so on. And perhaps the most unglamorous, but one of the more essential things is PPE. Every health system is dependent on having health workers. And if health workers aren't protected, they get ill. Tragically, the mortality rate among health workers in many low and middle income countries is roughly speaking about 10 times as high as the general population. So protecting health workers is absolutely essential. The Global Fund hasn't been doing this in isolation. We are a founder, participant, and member of the ACT Accelerator, which is a combination of global health agencies, WHO, GAVI, CEPI, UNICEF, World Bank, who came together last April. And we essentially meet the principles of the organization's meet every single week to ensure that we are working together in a coordinated and collaborative way that we can. And as part of the ACT Accelerator, we were part of the investment case, which has now been revised and developed, some $14 billion, including money to the Global Fund was raised. And now we have an outstanding gap, a funding need of about $19 billion to drive the next phase of the global COVID response. A couple of observations I'd make. First is that while it feels in many of the richer countries in the world where vaccine rollout has proceeded quite fast, that the light is at the end of the tunnel, people are talking about relaxing lockdown restrictions and so on, we looked at from a global perspective, infection rates from COVID are higher than they've ever been. We have a catastrophe happening in India. And we have extreme vulnerability from a lot of the neighboring countries whose capabilities to respond should they experience the same epidemiological trends as India are not as strong as India's. And so the Global Fund is very engaged with India and with neighboring countries or countries that are likely to, because of their trade and human contact with India likely to see the same variants communicated rapidly, we're trying to ensure that those countries in a sense get ahead of the curve in preparing for a potential next phase. So we are not through this at all. We as a world, we still have an immense challenge on our hands. Essentially, we're fighting with the virus that is evolving quite rapidly. And the pace of viral evolution is a function of global prevalence. So we have a massive shared incentive, all of us in getting global infection rates down everywhere. Because that'll slow the rate of viral evolution and mean there are less variants that are undermining the tools that are keeping protecting all of us. This means that we can't just take a vaccine strategy. Accelerated deployment of vaccines is absolutely vital. But we're not going to get vaccines out at coverage levels high enough in most of the world fast enough to reduce infections materially. If we want to reduce infections materially in the short term, we've got to help countries with public health measures with PPE, with casting, with all the things that many of us have become familiar with over the course of the last 12 months. That will then in a sense buy time until we can get vaccine coverage to greater levels in all the world. But we need that broader comprehensive strategy. The other point I'd make before looking to the future is we all see and you look on Google the infection rates and death rates around the world and it's very sobering from COVID-19. What people may not realize though is that actually in the poorest countries in the world, in the very poorest countries, it's not the direct impact of COVID-19 that will be killing people. It's the indirect impact. It's the knock on impact on other diseases such as HIV, TB, and malaria. In the very poorest countries in the world, countries like Chad, Niger, Mali, in the Sahel region of Africa, it's almost highly likely that the incremental deaths from malaria will exceed the direct death toll from COVID-19 because of the knock on impact on health system where the underlying malaria burden is very high. And although globally TB kills less people than COVID-19, in lower middle-income countries, TB kills more people than COVID-19. And the impact of we ran a survey last summer of some 500 facilities, healthcare facilities across Africa and Asia. And some of the numbers were dramatic with HIV testing down by 41%. TB referrals, i.e. the first step in diagnosis and treatment down by 59%. Malaria diagnosis down by 31%. Antinatal care visits down by 43%. You get a sense of huge pressure of the health system and massive disruption of other diseases. And so that's why we are taking an approach. Our mandate is to end the epidemics of HIV, TB, and malaria. But our view is we are not going to achieve that while COVID-19 is rampaging, killing people, disrupting health systems. So we have to help countries do both. We have to help countries fight COVID-19 and continue to sustain progress. And we capture some of the ground loss on HIV, TB, and malaria. And these really aren't separate tasks in any case because it's the same healthcare workers, it's the same laboratory networks, it's the same supply chains that you use to fight an endemic epidemic and a new pandemic. So turning now to the question of how we enhance global health preparedness for the future. In some ways my comments just now should have laid, I hope, the ground for that. Because the first point I would be making is that pandemic preparedness is not something completely separate or different from what you do to fight other major infectious diseases. Most low and middle-income countries' responses to this pandemic have been based on the infrastructure and capabilities put in place to fight HIV, TB, and malaria. And when you think about the next pandemic, a lot of the capabilities and infrastructure will be that which we have invested in for fighting COVID-19. So we need to think about the new threats, not as something totally separate or discrete but something that is linked to inextricably entwined with the way we're fighting the infectious diseases that are there now. That's true both from a practical perspective because it's the same, it's the same kit, it's the same people, it's the same infrastructure that you're using. But it's also true, I would argue, from a moral perspective because actually the world has had a rather unfortunate history of re-categorizing or somewhat losing interest in pandemics when they stopped killing people in rich countries. So the last big pandemic to hit mankind, humanity, was HIV-AIDS. And HIV-AIDS has killed over 30 million people since it appeared really in the sort of early 80s. And it still kills well over 700,000 people a year but very few of those are in the rich countries of the world. But it is a pandemic where the fight is unfinished, where we haven't actually finished the job. Roll back in history to TB, it wasn't actually that long ago where in countries like Ireland or the UK, TB was the biggest killer. If you go back to the end of the 19th century, early part of the 20th century, TB would have been the biggest killer. In places like Japan, it was until the 50s, the biggest killer. But TB has largely been eradicated as or eliminated technically as a pandemic in the richest countries of the world, but is still killing one and a half, 1.6 million people a year worldwide. Again, we've sort of taken the focus off it, maybe thought of it more as a longer term development health issue and not so much as a pandemic. I think one of the most important things we need to do right now as we think about future health preparedness is say we're not going to do the same with COVID. We can't leave the fight unfinished. We can't have a situation where people in the rich countries all get vaccinated and feel like they're coming back to normality but actually COVID-19 is still killing millions of people in the poorer parts of the world. We need to have an approach to health preparedness for the future that truly leaves no one behind, that doesn't in a sense move on to the next threat until it's finished the job with the current threats. And so my view is that our approach to pandemic preparedness should be one that in a sense encompasses the pandemics we haven't yet finished the fight against as well as the pandemics that might be around the corner. There are a lot of things we need to do collectively to make our work against and our protections against pandemics are better. We need better disease surveillance so that we understand where new pathogens are emerging and they are emerging all the time. This is not although it may feel like this is a one in sort of a hundred year event or something that actually potential pandemics are emerging really quite frequently every year. You may recall we had Zika. The peak year of deaths from HIV-AIDS was only 2005 not that long ago as two and a half million people died of HIV-AIDS in 2005. So these things are happening all the time. We need better disease surveillance both of the animal and human health because a lot of these threats are what they call zoonotic. They cross the animal human barrier and disease surveillance has to be everything from the simple reporting of what health workers are seeing through to genomic surveillance and sequencing so you can understand variants and viral evolution. We also need to ensure that some of the critical technology platforms that we've seen deliver fantastic results actually in COVID-19 are A, used for other sorts of pathogen but B, may scaled up so that they're more widely available so that we don't have a situation where so much of the world isn't able to get access to the latest tools. And the most obvious example of that would be mRNA the platform for things like Pfizer and Moderna vaccines but there are other scientific platforms where we need to do that. We need to help the poorest countries in the world build their capabilities in actually delivering such tools. It's not enough just to buy them. You've got to be able to actually deliver a test trace isolate strategy or a clinical care pathway. Just having the drug or the test isn't enough to constitute a proper response. Preparedness and financing preparedness is the best way. People talk about response financing but actually the best response financing is better preparedness financing. The final point I'll make is the critical challenge with preparedness financing and giving us a global health system that makes all of us safer is sustainability. We have a long history of having a flurry of activity after every pandemic or potential pandemic. We saw this with Ebola, we saw this with H1N1, we saw it with HIV of policy makers and the media and everybody getting very interested in this for a short while and then attention moves on to other things, the money dries up and the preparedness spending isn't sustained. And in a way it's kind of understandable because if you're investing in something where the metric of success is that nothing happens, it's kind of hard to keep people interested. It's not a great, you know, if you're a politician it's not a great achievement to say, you know, we invested all this money and nothing happened and that's a good thing, right? That's just a difficult challenge. So we need to create stronger incentives for how we sustain this spending. There are a number of ways we can do this, but just to offer a couple. One is the IMF does regular risk assessments of economies. It doesn't include health risks in those assessments. If it included health risks in those assessments in a more structured way, it would be a way of introducing what we know of very real economic risks into the conversation between the IMF and finance ministers in a way that doesn't happen. And it would be a way of, in a sense, exposing those countries that aren't actually doing what they need to do because we all have an interest in every country investing in preparedness. A second way is to improve our preparedness in ways that deliver immediate benefits. Now, I'm very interested in this because it accords with the mission of the global fund, but if you want to make, in a sense, rural Africa more prepared and more able to detect and respond to new pathogens, new viruses, new bacteria and things, the best way of doing that frankly is to step up the fight against malaria. If we had a more systematic and assertive approach to getting rid of malaria, we would be building all the systems that you need to contend with new pathogens, but you would be doing it in a way that, in a sense, saved lives along the way and delivers benefits along the way. And I think if we're smart and we essentially use the fight against COVID, HIV, TB and malaria as a mechanism to strengthen our preparedness for the next pathogens that might threaten us, then we will, in a sense, be creating ongoing benefits in terms of saved lives that will create the ongoing incentives to sustain the effort. So I think there is an opportunity to make the world much, much safer from future threats, but it's one that we have to do, we have to sort of take appreciating the synergies and the linkages with the threats we face today. And this is very real right now in the G7 and so on. There are people moving on to talk about future pandemic preparedness, which kind of risks running, which kind of risks sending the wrong message to those in India and other places who are deeply threatened by the current pandemic. We need to ensure that we both commit to helping everyone in the world to get through this current pandemic and then lift our performance against all the deadliest infectious diseases, including those around the corner. So we have a big challenge ahead of us. We have been knocked off course on HIV, TB and malaria, the three biggest infectious diseases measured in terms of deaths before COVID came along. COVID itself is still at record levels of infection and we have a huge challenge in beating that. I think we have proven that scientifically we can do things that we didn't think were possible. What we now have to do as a world is show that we can actually deliver on that promise, not just for those of us lucky enough to live in the richer parts of the world, but for everyone, because ultimately the line that no one is safe until everyone is safe, it sounds like rhetoric, but actually in the world of infectious diseases, it's an epidemiological fact. The way we make everybody safe is by making everybody safe. Thanks. I'll stop there. Peter, thank you very, very much. That was a fascinating thought-provoking presentation. You make a very compelling practical case for treating these two phenomena, as interconnected. In other words, the immediate mandate that you have in the Global Fund and then the current global threats relating to COVID-19. You demonstrate very clearly how they are interconnected and in fact inseparable from each other. It's also a moral case that you make about the saving of lives in the process as you try to build stronger health systems. I was struck by something which Samantha Power was quoted as saying at her swearing-in event yesterday, I think, to become the new head of USAID. She mentioned two or three key challenges which USAID is facing, but one of them was other vaccinations and immunizations. I thought that was important, but she had it as really one of the two or three implied top challenges for USAID. Clearly, your advocacy is working in, I'm sure, many areas. Could I just ask, Peter, how are you finding it easy to get this rather complex message across that the two phenomena are interconnected and have to be, in effect, treated as a continuum? Those are my words, but how are you finding the advocacy end of it with governments, donors, IFIs and so on? It's got its challenges. I would say I would highlight two particular challenges. One is that in the response to COVID, it's quite difficult to get donors and stakeholders to focus on anything other than vaccines. While vaccines are incredibly important, and ultimately the right answer, if you look at a situation like India right now, what's needed immediately to save lives of those with severe cases of COVID is oxygen, and what's needed to stop transmission is testing PPE and public health measures, social distancing and so on. The vaccine rollout will not be fast enough to arrest what's happening. We need a comprehensive approach. That's one challenge, is that there isn't a silver bullet in fighting a formidable virus like COVID. You need to use all the tools you've got. The second challenge, and there's a lesson to be learned for people like me from this, is that it's difficult to get people as excited or focused on problems when you don't have the data. We can all go on Google and see how many people got infected or died from COVID-19, any country in the world, any day, and the numbers may not be completely accurate, and they're not completely accurate, but you can at least get that, and it mobilizes attention, you can see the trends. India, for example, has the world's largest TB burden. I know that TB services have been massively disrupted by what's happening with COVID right now, and that will result in hundreds of thousands more deaths, but it's hard to, what we don't have is the same data capture and display that allows us to say, do you quite realize how much is happening? And I think one of the lessons we need to draw from the COVID experience is that having that data is incredibly powerful, and that the conversation we could be having about what's happening on the knock-on impact on TB would be very different if I could tell you how many people got infected, how many people died of TB yesterday, because more people will be dying of TB in India right now than COVID, I suspect, but I don't know that for a fact. So data is very powerful, and not having it is a real disadvantage from an advocacy and communication point of view. Yes, indeed, but I can echo that, and you provided a number of indications in your presentation, which are quite striking, namely how many people are, in fact, how many more are dying in certain poor countries from the likes of malaria than COVID, and you need more and more of that kind of data to underpin your message. I can see that. Could I ask, as we're in the period before COVID-19, were you finding it easy or otherwise to persuade governments, in particular, to provide funding for health, for the strengthening of health systems? So, like even before COVID came along, how was the global funds doing? You mentioned the macro figures that you've been able to attract, but I noticed that you would have a ninth, in relation to COVID, you would now have a 19 billion requirement for the next phase. What is the overall willingness on the part of governments and other donors to devote significant resources to health, if I can put it like that? Sorry, I put myself on mute. The global fund has had extraordinary support from donors, and in 2019, before COVID struck in October, we had a replenishment that was to raise money for the next three years of our operation, and we raised a record $14 billion. As was mentioned, Ireland increased its pledge very significantly to 50 million euros as part of that. So, there is undoubtedly a strong commitment from the richer countries in the world on global health, and indeed, we were seeing that implementer countries, the countries we were supporting were increasing their own commitments. That said, I think what COVID-19 has demonstrated is that we were all underestimating the downside from allowing infectious diseases to really impact our societies and economies, and that actually we need to be investing more in health, more in protecting people from these threats, because the downside is so enormous. And indeed, even before I joined the global fund when I was at Harvard for a couple of years, I wrote a couple of papers on exactly this kind of issue. Frustratingly, I think I had very little impact on persuading people, but I'm hoping that COVID-19 has proved perhaps a rather brutal lesson on the economic downsides of not investing enough in being able to detect and respond to infectious disease threats. I think part of the problem, though, is that we tend to think of this as aid, and aid has natural limits to it, and it is true that Irish aid and USAID and FCDO in the UK and others support institutions like the Global Fund, but we should also be thinking about this in terms of our own human and economic security, because that's what COVID-19 has put at risk. This is something that has affected all of us very directly. The IMF did a bit of analysis in which they showed that the difference between ending the COVID crisis quickly and ending it on a slightly slower trajectory was worth $9 trillion to the global economy. To put it another way, if investing, if closing the actual accelerators investment cap of $19 billion brought forward the resumption of global economic activity by one day, it would have paid for itself. The very high return on investment here. Peter, that last question came from Breida Gahan. I now have a question from Dennis Nocten, who is a member of our parliament and former minister. Can Peter elaborate on the need to address shortages in testing capacity and PPE and so on in the developing world? As we vaccinate our own populations, some of this will become surplus in the developed world. How can we best meet this or address this paradox? It's a very good question. In a sense, that's exactly what the global funders is doing right now, is supporting countries with the testing, PPE, oxygen, and so on. Actually, if you looked at the accelerator funding gaps, these are where the biggest gaps are. It's actually been much easier to raise money for the vaccine side of it and much harder to raise money for the other elements of the response. The only thing I would say, though, is we're not seeing rich countries do less testing or use less PPE as they roll out vaccines. In fact, what we're seeing is testing going up and use of PPE going up. I don't say that as a criticism. Actually, it makes sense to be, particularly with the emergence of variants, we want to be testing at relatively high rates so that we understand and anticipate whether any of the variants are evading the vaccines. Also, I think one of the things we've learned as a global health community is we underestimated the importance of PPE. PPE is incredibly, is arguably being the tool that has prevented most infections of any of the ones we've used so far. What's different now is this time last year, we were very constrained on manufacturing capacity for both tests and PPE and it was very difficult to get any for the developing world. Now manufacturing capacity has expanded significantly, so we're not constrained by that. We're more constrained by money, essentially. I would stress the absolute importance of PPE because one could talk about healthcare systems, but ultimately a healthcare system is based on people and on trained health workers. If you lose those trained health workers, you don't have a health care system. You can't deploy vaccines, you can't make oxygen instruments work, none of it, none of it works. PPE is absolutely vital. Thank you, Peter. A couple of questions here, which are linked to the sense. One is from Toda Crane, who is a researcher with the Institute. Could you share your thoughts, Peter, on initiatives to catalogue zoonotic diseases, such as the global viral project? How feasible is it to identify and shortlist the next disease X, as it were? And then there's a question from Bill Emmett, who's a former editor of The Economist and chair of Trinity College's Long Room Hub. Many thanks, Peter, for the important work you're doing. I wonder if you could say more about what we rich countries can do to improve surveillance systems against new pathogens. I mean, you touched on that a bit, Peter. Should one priority be a network of labs for genomic surveillance and analysis? And what political obstacles might stand in the way of that? Both great questions. I'll take them in reverse order if I may. First, Bill, on the idea of improving surveillance systems, absolutely we need to, and part of how we build greater preparedness for the future, is going to be ensuring that across every country we have better disease surveillance. But we can't just think in terms of genomic sequencing. Genomic sequencing is the apex of broader surveillance pyramid, so to speak, which starts with community health workers with a tablet noting down what frequency of what types of infection or disease they're saying and being able to upload that so you can see patterns emerging. If you simply have genomic sequencing on its own, it's really difficult to know what to do about it, because you can't link it to any information on what the actual epidemiological impact of a variant is. The UK is one of the countries with the most sophisticated and far-reaching genomic surveillance, but the Kent variant, the B1117, the UK variant, was actually first identified not by genomic sequencing. It was identified by doctors in a particular area seeing patterns of disease they didn't understand. What they then did is they got genomic sequencing to help identify what was going on. But I think it's a good example of the fact that you want to link classic epidemiological surveillance by frontline health workers through the pyramid of surveillance all the way to genomic sequencing. The other issue, a very basic issue, is genomic sequencing operates off test samples done through molecular diagnosis. I am seeing proposals now to sort of fund genomic sequencing in parts of the world where there are so little molecular diagnosis happening is there won't be any samples to be sequenced. So you have to kind of get your run before you walk before you run type thing right here. The other issue is that sequences have value. They provide input into what the vaccines should be or what the diagnostics and therapeutics are. And there is an issue about countries providing valuable information and then feeling like they don't get anything back. So if information on variants is provided by low and middle income countries, surely they have some right to having some of the products, some of the tools that are developed on the basis of that information. So I think there is a political and equity issue underlying the development of sequencing. We have already seen that in the influenza world with the pandemic influenza protocol and the Nagoya agreements which were exactly addressing this issue in the influenza world. You also mentioned malaria and I wanted to give malaria as an example in rural but in dense urban areas of low middle income countries, TB would be the kind of vehicle by which you could build stronger pandemic preparedness. On the question about, I'm just trying to remember what the question is. The global viral project. Global viral project, right. Look, there are a lot of people who know much more about zoonotic disease and zoonotic transmission than me. What I would say is I think it is simultaneously very good to have initiatives like the global viral project so we understand more the kinds of threats that could make the zoonotic transition. But we should never assume that we know where the next disease X is going to come from. We should always assume that there's going to be something that we hadn't thought of that comes from the blue. The other thing I would say though is that when you look at WHO's categorization of major disease threats, most of them are linked to things we knew already. We knew coronaviruses were a threat. I actually ran a workshop when I was at Harvard in 2016 based on a scenario around a more transmissible SARS type coronavirus emerging in China. I don't think I was being particularly insightful. It was a known risk in a similar way. Influences are, we know because of the 1918-1920 influenza, we know that influenza can be devastating. I think we need simultaneously to be making sure we understand the risks around the diseases that are all too familiar. Another example I would give would be drug-resistant TB. TB has a very high prevalence in the world. A lot more people have latent TB than actually fall ill with TB. If we saw new types of drug-resistant TB that could be pretty scary. We need to know those. We need to understand things like the global viral project, threats that can cross the animal-human barrier. We also just need to always have the humility to accept that something might turn up that we had never thought of. I don't think we can afford to place all our bets in one place. Thank you very much Peter. Obviously Africa is a key part of the world in terms of the challenge to strengthen health systems and increase resilience. What, a question from Rita Ghan, what role has the African Union been able to play so far in terms of encouraging investment in health? Actually, I think the African Union is one of the institutions that has actually had a good crisis. The African Union through Africa CDC has been very active in supporting individual African countries in responding to the COVID threat. And actually most African countries were very quick to respond. Partly, I think, leveraging their experience with infectious diseases and their capabilities, the infrastructure around testing, and so on, and the ability to mobilize communities. They also created a thing called the Africa Medical Supplies Platform, which was a new mechanism to enable African countries to, in a sense, pull purchasing capacity. And we've been working with them very supportive of that. And so the African Union, I think, has been playing a really important role in the continent's response. It's also played an important role around vaccines and is supporting the development of local manufacturing capacity around PPE diagnostics and so on. And so it's, as I say, if I was looking around and saying, what was an example of an institution that actually responded well to the crisis, I think the African Union and African CDC would be pretty high up that list. That's very easy, Peter. Could I ask a question myself about the global fund itself as a vehicle for achieving change as a funding mechanism, but in particular as a partnership? In the context of the Sustainable Development Goals, we've put a lot of weight on partnerships worldwide, stakeholder coalitions as the means of driving change. Do you think that the global fund itself is a model for a kind of combination of government, civil society, private sector? Do you think it works? It is often mentioned as an example of a partnership which can help to deliver the sustained the SDGs. What are your own reflections on that? I do think it works. I must admit, as somebody who's coming in from the private sector into the global health world, I was a bit bemused by the complexity of the governance structures of the global fund when I first arrived and it wasn't at all clear to me that it would work because we have civil society, private sector, implemented governments, donor governments, and also we work with a whole array of different technical and partners like UNAIDS or WHO or Backman Error or Stop TV. It can be complicated, but actually it is very effective. What I think we managed to demonstrate over the last year or so is we can also move very fast if need be. The global fund was, if not the fastest arguably one of the fastest multilaterals to actually put in a sense cash on the ground in a way that could help countries respond to the crisis. We've moved very swiftly. Like every organization, we have our areas we need to work on and develop and improve and all that kind of stuff. But actually I think it is a very interesting model of how different aspects of society can come together to achieve a goal. Peter, perhaps one final question if I may. There's been talk about a global health treaty to strengthen that the one health approach do you think that is viable? It's a good question and I have to confess I'm not sure I know the answer. If a health treaty is useful as a catalyst for getting the world to have a common vision around things like equitable access to vaccines, diagnostics and treatments and the equitable sharing of sequencing data and so on, then I think that's a really valuable thing. If on the other hand it ends up becoming something where all the energy goes into negotiating the treaty but we don't actually do the things that we need to do to make people safer, then that I'm not in favour of because ultimately the test of whether a treaty is going to help is not whether it's a fine bit of legalese that everybody stands in front of a bunch of flags and signs. Does it actually make a difference in the way we combat infectious diseases and that's where I would like to believe it's going to be helpful. I'm a little worried that it might just kind of absorb a lot of diplomatic energy but you and the ambassador are probably better placed to answer that question than I am. Peter thank you very very much for first of all giving us your time. Secondly a very fascinating and thoughtful sort of tour d'horizon. I think we've come to the end of our time unfortunately but you are very generous in responding to the various questions and in giving such a strong and memorable presentation. I will take away in particular your strong message about the interconnection between fighting Covid-19 perceived to be the short-term global challenge and the inseparable challenges relating to TB, malaria and HIV AIDS. We wish you every success in your ongoing advocacy on all fronts and I don't speak for Irish aid but on the other hand I would make a guess that you can count on Irish support going forward. Thank you very much Peter for giving us your time. We look forward to seeing you again at some point either physically or online and thank you for your contribution today. Thank you David and thank you to the ambassador and also to the IAEA. Thank you.