 all of you, and a very hearty welcome. This is, my name is John Hamery. I'm the president of the Center for Strategic and International Studies, CSIS, and we've had the privilege of working on this project for the last year, and I'm going to let Steve Morrison say more about the project. I want to take the opportunity to just say a few preliminary words and to say how pleased I am that all of you are here today, and how pleased I am that we're here at the Women's Memorial. I have a very soft spot in my heart for the Women's Memorial. Wilma, congratulations again, this powerful lady. Wilma Vaught was in many ways the driving force that made the Women's Memorial possible. Now it wasn't just because she's a powerful lady in her own right and a demanding intellect. She grabbed people's attentions, but she mobilized the very best of the best generation that made this memorial possible. I'll never forget the grand opening, and we had the ceremony for it over at the National Guard Armory, and it, that place was rockin'. I mean, it, there were 5,000 women, largely of the World War II and Korean War generation that had decided that they were going to commemorate their service to the country by making this memorial possible. Well, but it was a remarkable evening, and it's my time in government, and I spent about eight years in the Department of Defense. It was clearly the highlight of my experience, and I just have to say again to you, Wilma, thank you for what you've given to America by giving this memorial, and thank you what you've given to the women who served in the armed services for making this presence felt in Washington. You also brought my dear aunt, Anna, to Washington the only time she ever came to visit me. She was a, she was an Army nurse in World War II, and she only wanted to see two things. She wanted to see this memorial, and she wanted to go to see the two million notes. It's that generation that made this such a wonderful country. I get a little emotional about it. So anyway, I want to thank you all for coming. This is, we're going to discuss this afternoon the work of a series of laboratories that frankly are largely invisible in the policy landscape of America. Frankly, they're often and dangerously invisible within the Defense Department. I remember my days when I was the evil comptroller and we were having budget battles and I thought, well, what the heck are these things? You know, I mean, what do they do for us? And I had to learn the hard way by confronting a series of angry doctors who said that I was, I didn't deserve to be comptroller being as stupid as I was. And fortunately, they were prepared to educate me and I learned a great deal in the process. And of course, institutions like this are vulnerable in tight budget environments because the contribution they make, you know, it's an important contribution in the Department of Defense, but it's an even larger contribution in the landscape of public health and health in general in America and frankly in the world. Their partners are institutions that frankly need them to be successful places like the Center for Disease Control or the NIH or the Department's own health affairs program. I mean, these are big organizations that need these laboratories, but they don't really feel it's their obligation to defend them. So when budgets get tight and kind of we're in one of those areas, these institutions become vulnerable and we thought we needed to shine some light on it. What do they do? What do they do for us? Not us wearing uniforms, us wearing civilian attire as well because I think before we let things happen without knowing the consequences, we ought to study it. And that's the purpose of this effort. I want to thank Steve Morrison for leading the effort and Michelle Ledgerwood for being such a key driver on it. And I would especially today because I'm gonna let Steve introduce all the other key people that have been instrumental in this effort, but I would especially want to thank the women that have been involved in this project as leading professionals because after all, we're here at the museum and we should honor that. I don't know if Donna Hul is here, but Donna has been carrying all the work for Wilma and I just want to say thank you to Donna. Captain Robin Wilkenning who is the commanding officer at Namro in Cairo, she was absolutely instrumental in opening up and helping us understand and a couple of times, especially the last couple of months, she's had to really be both a statesman and a diplomat to carry us through some tough days. And she's done very well. Colonel Bonnie Smoke was the commander at the US Army Medical Research Unit in Kenya and she was absolutely instrumental in helping us with the project. Captain Eileen Frank Willisante who's the executive officer at the Navy Medical Research Center was a key advisor early on as was Captain Gale Hathaway. And I think I saw Colonel Bonnie Lynch who is with the Military Infectious Disease Program and these women were exceptionally important for the quality of the product that you see before you. And I want to say thank you to them. Steve can thank all the men. I want to thank the women for this today. Just to say that, and I will get out of the way I want Steve to take over. You know when you do a study in a think tank, I meet with all my young professionals. I said, what are we trying to do when we do a project? Well, we're publishing a book or a monograph. I said, no, we're trying to change policy. We're trying to inform a broader and better debate. If we have to write a book to do it okay, if we can do it with a good briefing, that's better. Our goal here is to put impetus behind the policy recommendations in this report. And frankly, we need all of you for that. I mean, the purpose of this afternoon, I said this last night to Admiral Bill Fallon who was a great friend Navy pilot, I said the purpose of this is to get the carrier deck pointed into the wind and get enough wind over the deck so we can take off, right? I mean, that's what this conference is about. This conference is about getting lift so that these ideas have traction outside of this constituency. Frankly, we're counting on you. We're counting on you to be the agents that take these ideas to a broader venue and give them life. And so I really sincerely wanna say thank you all for coming. Thank you for Wilma for letting us use this fabulous venue to highlight it. And Steve, let me ask you to come up and get the conference going for real. Thank you all for coming. Good afternoon. Thank you, John. Last night we had a chance for many of us to come together and celebrate the report and most importantly to thank those in the Army and the Navy who lead the lab's work and who have been so generous and forthcoming and gracious to all of us over the last year as we visited the labs and as we consulted closely and carefully with those here in Washington around their value, their achievements, the challenges they face and the question of what their future might look like and what sort of measures would strengthen their future. I wanna particularly single out Colonel Kent Kester, Lieutenant Colonel Jamie Blow of Rare, Captain Richard Haberberger and Dr. Stephen Walts at the NRMC. They have been particularly generous and kind to us. Let me say a few words about why I feel it's so important that CSIS be engaged in this area. We came at this work at CSIS, convinced of the critical importance of health and its intersection with security. We began with an assumption that health is critical to U.S. readiness and to our broad security interests and the United States cannot be secure without able, healthy forces and to get there the United States has to go where the infectious diseases are and work hard to be ahead of the emerging challenges through new vaccines, diagnostic tools and therapies. We also began with a strong assumption that investment in health to benefit the American soldier also helps the world. Progress by the DOD labs as our report lays out brings broad benefits to the world. These gains are shared, they're disseminated, they promote the stability of communities and improve their development future. And we're convinced and we put a special spotlight today on the importance of the dynamic partnerships across our government and with the foundation and industry worlds to generate the new discoveries that can change the world. We are in an age of vaccines. Excitement is very high about the technological innovations and the cost factors and the ability to bring vaccines to the world's poor and to generate new discoveries that benefit our soldiers. So just witness the gathering in London just two weeks ago that resulted in $4.3 billion in new pledges to the Gavi Alliance. The labs are part of this age of vaccines and this excitement. DOD's made exceptional contributions in vaccines for decades, has to be there at the table today and as part of this promising historic moment. And we believe that CSIS is an important catalytic role to play as we've done in this project in convening the different parties with an interest in the lab's work in asking hard questions about their value, their challenges, their future and in trying to forge a pragmatic consensus looking forward. We will hear in a moment from a close friend, Lieutenant General James Peake who led this yearlong effort, CSIS effort, he made a tremendous commitment to this work and was absolutely indispensable to our success and unstinting and sharing with us at any point his wisdom around the different issues that were on the table and how to proceed. Jim will outline the project's genesis, how it went about its work, its core findings and recommendations and how this all matters in the bigger context. General Peake served for 38 years in US military, retiring in 2004 as the US Army Surgeon General. He subsequently served as Executive Vice President of Project Hope and in the second term of the Bush administration served as Secretary of Veterans Affairs, 2007 to 2009. Jim, thank you so much for all the work you've done. The project would never have gotten where it did without your passion and your contributions. After Jim has spoken, we will hear. He will engage with Richard Haberberger and Kester around to hear their views. After that, we will move to a roundtable discussion of some of the key partners, Dr. Kevin DeCock, Director of the Center for Global Health at CDC. Dr. Daniel Gordon, Vice President for Scientific and Medical Affairs at Sinovi Pasteur. Dr. Clifford Lane, Deputy Director National Institute of Allergy and Infectious Diseases at NIH. And Dr. Regina Rabinovich, Director of Infectious Diseases in the Global Health Program at the Bill and Melinda Gates Foundation. Ambassador Michael Ranenberger, former US Ambassador to Kenya, a distinguished career diplomat who served until very recently for a five-year period during critical period in Kenya. Our colleague, Michelle Ledgerwood, who very expertly helped spearhead this project will moderate that discussion. Our closing segment is the keynote address by Dr. Jonathan Woodson, the Assistant Secretary of Defense for Health Affairs. Dr. Woodson, thank you so much for being with us today. Jim, could you please come forward and share with us the results of this year-long effort? Thank you all so much. Steve, thank you very much. And first, I want to thank Dr. Hamry and CSIS for all of the support and sponsorship of this effort. The report in your hands really is a result of a project that was launched back in April of 2010 to take a close look at the labs as Steve has laid out for you. Now, though these labs are really not widely known outside maybe this room and a few people with a real interest in this, they really sit at the intersection of health and security. And that's a topic that's obviously of interest to most folks in this room, but particularly with CSIS and the work that they've done on smart power, Steve's commission that really looked at the smart global health policy. These laboratories have made sustained contributions in this area of global health and really US national security interests on a relatively small budget so that when you start looking at that, they're particularly intriguing as one of the best buys in the time of what we all know is fiscal austerity. We look not only to catalog the strengths, but also to identify what challenges they might have and look to the future and try to make some recommendations that might help us move them in that direction. Our approach was we hosted three meetings of relevant experts here in D.C. I would thank particularly as already has been mentioned, Kent Kester and his able staff member, Jamie Blow at Walter Reed Army Institute of Research and Rich Haberberger's team with Steve Waltz at the Naval Medical Research Center. But we also brought together the whole of government experience and we have representatives from DOD and joint staff, DOD and health affairs, CDC, USAID, NIAID. The non-governmental organizations were in attendance as well as academia. So realizing that this really is more than just a narrow look at a military asset as we see them, they are assets for our nation. We had the opportunity to travel to the Army Laboratories in Kenya and Thailand, the Navy Laboratories in Egypt and Peru and the research detachment in Cambodia of the Navy. Seeing the opportunity, the opportunity to see the laboratories in action and to meet their people and their leaders was really invaluable in helping us to put this complete picture together and trying to help us understand the complex relationships in which they deal, the resilience that they have and the challenges that will confront them as they move forward. I'm going to talk about five, three and five. Five strengths, three areas of challenge and then we're going to make about five recommendations. Strengths, first and fundamentally, the strength is that they support the readiness of our United States military from a medical perspective. To meet the national security needs, we need to be able to put our soldiers, sailors, airmen, marines in harm's way wherever that might be around the world. We ain't always good in predicting where that might be and so we have an obligation to them to make sure that we understand the, not just the kinetic problems that they may face but the health problems that they may face. And so lacking immunity to the kinds of diseases in foreign lands, it makes them vulnerable and so the focus on developing products such as anti-malarial drugs that keep you as soldiers safe, the diagnostics that go with it, the vaccines that will protect them, well that's part of force health protection. Second, they do good science and that's what these labs are based on and the scientific breakthroughs that save and improve the lives of soldiers also save and improve the lives of people globally, notably in these developing countries when research resulted in vaccine for Japanese encephalitis, for example, it was good news not only for our military but for all of East Asia as well. The laboratory drugs and vaccines often target the neglected diseases, a great public health importance issue today. The detection of diseases globally is an important issue for us all and they have served as a platform for being a part of that detection, things like avian influenza, pandemic influenza, H1N1, other emerging and re-emerging diseases. Third, they are responsive to the volatility of global disease and over the years as some of these diseases have been contained and have fallen off the radar, others have evolved and these laboratories have been there over a sustained period of time to be able to address them. I think I'm gonna ask Kent to talk a little bit more about that perhaps later on. Fourth, they are great examples of partnership. You know, the best medical research is no longer the one brilliant science in his back room. It's the people that can put together the teams and that are gonna make the breakthroughs in this world of ours. And the laboratories that we visited were clearly examples of people who, and organizations that have cultivated those teams and innovative partnerships around the world that have been able to actually impact their limited budgets in terms of really an economy of force kind of effort. The laboratory works that we were able to see had partnerships across the US government agencies, foreign governments, international organizations, non-governmental organizations, scientific research institutes, universities, private businesses, foundations, community organizations, and all the way down to the local schools and clinics within the host nation countries. They extended not only in the countries, but really throughout the region. And I think that's an important consideration as well. Fifth strength would be the resilience that they have. These labs have been around for a while. Thailand since 1959, Kenya since 1969, Egypt since 1946, Peru since 1983. And you ask, well, what has enabled their longevity? And I think one of the answers is that they have become locally relevant and locally valued while at the same time they have produced benefits for our soldier, sailor, jammer, and Marines. They deal with diseases that have a profound local impact. And so they are seen locally as organizations that are legitimate and useful institutions. Well, so I was gonna talk about threes. There are some of the challenges that their face, the first would be, especially as we talked about already, this issue of funding. And to make sure that they do have to have the funds if they're gonna continue to make the kinds of contributions that they have made in the past. Second, I would talk about the notion of the fact that they are military entities and US government entities. And in a politically volatile world, that can sometimes be looked at as a vulnerability. We found many instances where their links to the military were a profound strength. Their ability to integrate with the local countries and bring US values with them were profound strengths. But we gotta continually be vigilant about maintaining those kinds of relationships locally to be able to keep that trust, which has been one of the things that has allowed them to sustain in this resilience that we talked about before. Third, I would say that they have a marketing problem at home. We've already addressed the fact that this maybe ain't the audience that we have that problem with. But when you start looking at all the competing priorities across our government today, across our military today, it is really important we think that their story be known and be told. And despite their tremendous contributions, they're just too few champions, both in the executive branch within DOD and in the executive branch largely, and in Congress. Their remote locations, their relatively small budgets, a relatively small number of people contribute to that, but that also is in some ways part of their strength. Well, with all this in mind, let me get to the five recommendations. First, the issue of funding, they need predictable and sustainable funding for their core research mission. That's not to say that we open the spicket and that's all that, and there's no competition. We think it has been important and valuable, the entrepreneurial spirit that we've found in every one of these labs that allowed them to compete on a scientific basis with their peers and to earn that scientific respect as well as the resources. But what we think is important is to get a core level of funding that will allow them to be even better. Second, we think they need to have a stronger visibility in the government and on Capitol Hill and things like an annual forum where DOD medical research could be highlighted convening the laboratories, Army Navy Medicine, the Joint Staff, the Office of the Secretary of Defense, combatant commanders, they're key stakeholders for them and National Security Council. To discuss the laboratory's achievements would go a long way in helping that and to help shape perhaps the future plans as they look forward. Working also with DOD legislative liaison folks, it is quite clear that I think senior military medical leaders could highlight their activities to Congress and the importance of their work and they could host members of Congress at these labs in adjacencies to other codels that go on. Third, I would say they always, while we would compliment the level of effort that has already gone on to try to coordinate activities among these labs between two services and among labs that are thousands of miles away, we believe that that would be worth a continued emphasis and think that there are ways that collaboration and consistency could be better achieved as they move forward and that communication is a key part of that. Fourth, I would say the recommendation is to recognize the quality of the people but also recognize the challenge of making sure that we have those kinds of people for the future and that some of the things that we heard made us concerned about the ability to sustain that level with perhaps it's the whole issue of challenging resources and so forth but to have a career path for medical researchers in the military we think is critically important realizing that researcher in a laboratory might be a researcher that's sitting on a battlefield at another time and there are clearly instances of that. So a dedicated career track in medical research would help these laboratories attract those top scientists and to keep them moving forward in a career. Fifth and finally, we see these overseas labs as strategic assets and that means that they ought to be considered that way as planning goes on and as resourcing decisions are made and we also understand that and would comment that these assets and I see Kent and Rich sitting together but the opportunity to continue that kind of relationship and plan together in a strategic way, whether you're deciding where a lab were to go or what area of research it ought to be focusing on, we would support that as a very important recommendation to move forward. Ultimately, these Army and Navy labs serve our service members and as we care about our service members we are obligated to care about these labs as well. In serving the military, this research also produces drugs and vaccines that serve a role, that serve really the health of all people around the world and particularly it targets the world's poor and so that plays a role in our overall global health interests as a nation and it is the importance of all these things coming together that really I think underscores the importance of and our interest in pursuing this study of our overseas labs and with that I'd like to invite Kent and Rich to come forward and just give them a chance to talk about a couple of things and whatever's on their mind but also then to perhaps have a little dialogue here, Rich. One of the things that we talked about a little bit the other day was the issue of capacity building and the roles of the labs and that and I'm curious if you'd be interested in talking about that a little bit, Force. Sure, one of the values of our labs has been that we investigate infectious diseases endemic diseases that are of importance to the host country but also that are a threat to our troops and so it's a balance where we take young scientists overseas and students and medical professionals and train them alongside us because the United States for the longest time has been one of the leaders in science and technology so we've shared that with these countries and they've grown, to use a naval analogy we floated their boats along with us and so they've risen to the occasion some of them have went on and taken great jobs in American industry and so they've benefited the country as a whole has benefited so our efforts over there as a force protection measure to protect our troops has also benefited the host country and we do a lot of public health surveillance now and that surveillance involves bringing in the host country social workers and epidemiologists and others and they get trained according to our standards and so they go out and they improve their host country infrastructure. Can you just comment a little bit about the order of magnitude of difference in terms of U.S. staff versus the local staff? I think that's something I didn't mention but it's in our report but I think it's worth talking about that. Well it depends on what country and area of the world you're talking about. In Cambodia the quality is pretty poor based on the events that occurred in the early century. But in Lima for example the texts are very good and the scientists are really good and some of them are world leaders in their fields. The proportion of locals to a U.S. personnel is really quite high. Right, in fact we employ, I mean there's probably 65 or so American, that's G.S. and U.S. and the Navy overseas in the three labs, roughly 65 personnel and they're augmented by hundreds in some places of local citizens, local staff and again they love us, they hate to see us leave when we leave and such that happened in Indonesia not too long ago. I mean we were there for 40 years so I don't know how you define success but 40 years seems to be a pretty good track record and we're celebrating our 65th anniversary in Cairo in October and you know what's going on in Egypt so we're a little concerned but hopefully optimistic to the future. Yeah, 65 years is a long time. I'm a little older than that but. And I see some guys out here from Abrams, they just celebrated their 50th. Yes. So it's a, it really is an issue of, and I think one of the reasons is, Kent I'm gonna ask you talk about is the adaptation and responsiveness of the labs. Well first, let me say it's a privilege to be able to represent the army researchers around the world. Those from the rare know that this is one of my passions is to support overseas labs and so any time that I can talk about our international work is a good day. As you mentioned in the outset, our force health protection mission is an important one. In fact it's one of our key drivers, our medical research and development programs in support of our force health protection requirements is paramount and that requires key subject matter expertise in place in these countries around the world. That coupled with our emerging and developing disease detection mission really puts us in a unique opportunity to be able to be responsive and adaptive to new and emerging disease threats. Some good examples over time are out there such as responses and research programs related to cholera, leishmaniasis, tropanosomiasis, more recently Rift Valley fever, drug resistant malaria and influenza around the world. These are all very key programs that over time have morphed in response to new and emerging threats and I think the impact is threefold. Number one, we get actionable data that comes back to the DOD. It informs our medical decision makers having to do with formulating threat matrices, having to do with disease threats for deployments. In addition, this information is also provided back to our host nation public health agencies. It's an incredible resource for them. Number two, data of this type also feeds into the larger global public health enterprise, if you will, whether it's WHO and others. And so it's a much bigger impact. And number three, this very data, this responsiveness, this adaptiveness to new threats, new diseases that have been identified feeds back to our research programs in general, helps optimize them, it helps change them over time. And in some cases may develop new programs responsive to newly identified military medical threats. So in the end, everyone wins. The military wins. It meets our force health protection mission. The host nation wins. The global health effort wins. And so it's very good for all concerned. Richard, is there anything else you want to chat about? I think one of the challenges is for us, especially in countries that may not have a pro-western bent, is that we need to offer them something that is of value. And one of the things we think the Navy is to offer them the cutting edge type of studies that we can do with the latest in genomics, for example. And so our hope is that we can afford to place some of the latest instrumentation in the labs, train up their scientists and show them that we're still on the cutting edge and that we can contribute something to them because otherwise they may think they don't need us. Yeah, it is true that the world moves on even in these other countries and where they were is a better place than they were before. And so the equation changes a little bit. I was struck actually when we visited in Egypt talking to the WHO people there and how much they counted on the lab. Even though there were other assets available, how they knew that they could turn to them and that they would find receptivity to helping and working with them. And I think it's that spirit of collaboration that I think is really a very useful one when a variety of stakeholders that are responsible for health in these regions and in these countries and in the regions recognize the value. So I appreciate that. Kent, any last words? I think I would just echo what Rich said. It is very much a shared mission, our work overseas. It's not what some would characterize as safari science. We're there for the long haul, as you noted. And so there's very much a partnership, shared mission with our host nation partners, capacity building, training. And I think it really is a nice mix. I appreciate that and I appreciate both of you, the leadership that you all have given, not just to this report, but to your respective organizations over a long period of time. So thanks, I appreciate that. I would also just reiterate this issue of partnerships and stakeholders, and that leads to our next panel. And I would ask Michelle to come up. You've already had it presaged, but Michelle, you wanna invite your panel up and we'll move on with the program. Thank you all very much. Well, thank you very much. Can everyone hear me? So my name is Michelle Ledgerwood and as Steve Morrison mentioned, I've had the immense pleasure this past year of helping to direct some of the research for this project. And there are a lot of familiar faces in the room. I wanna thank all of you who helped contribute to the research as we went along. And also thank the rest of you who came today. It's great to see an interest in both in our report and in military infectious disease research at large. As Jim Peek mentioned, we traveled to five of the overseas military infectious disease research labs, the ones in Peru, Egypt, Kenya, Thailand, and Cambodia. And in the course of that travel, we were struck not only by the breadth of the scientific research that was taking place at each of these labs and the diversity of diseases that were being studied, but also by the parallel diversity of partnerships that stretch not only locally, but also regionally and in fact reached back into the United States to stakeholders and partners here in government, in the military, and at some of the premier research universities as well as within NGOs, foundations, and a number of other organizations. General Peek listed the wide variety of organizations that these labs collaborate with in their individual nations. So I won't repeat that, but it is a significant network. And it's very clear that the quality and the longevity of these relationships that each of these laboratories has is critical to its ability to carry out its incredible body of scientific research to maintain its presence for literally decades in these different countries and regions, particularly during and through times of turmoil, which they've done very successfully in most places. And Indonesia was quite clearly an exception to that rule. And it's vital to their productivity. It also, these networks of partners they've developed around the world have a secondary benefit, which is they become incredibly useful in the event of any kind of outbreak, of pandemic, a natural disaster, or even in the case of a terrorist attack. Dr. Hamry alluded briefly to Colonel Bonnie Smoke. She was the acting commander at USAMRU-K in Kenya during the attack on our embassy in Nairobi. And her staff were some of the first responders at the scene and were able to use their scientific and medical knowledge to serve our nation in other ways. So these networks and the abilities of the laboratories are quite tremendous. If you look at our report, you will notice that the bibliography at the end is very brief. This is partly because not very much has been written about these laboratories in the past in any comprehensive fashion. It's also because our research was based almost entirely on primary source interviews, some of which we conducted here in the United States with the partners here, many of which we conducted in our trips to the five different countries with, again, these in-country partners both at the headquarters and in the field sites that we were able to travel to. And the views and the perspectives that we heard from all this vast group of people really were the driving force behind the recommendations that we put forth in this report. So it was very important to us at this event today to have a discussion with some of these partners that the labs have collaborated with for so long and in so many different ways. And I am very pleased to have such a distinguished group sitting around me here today. You heard their names before, but I will reintroduce them. You have their biographies in your handouts so I will give their names and organizations. Dr. Clifford Lane from the National Institutes of Health, National Institute of Allergy and Infectious Disease Research. We have Ambassador Michael Randenberger who just returned from being our US Ambassador to Kenya. So just returned recently from Nairobi. Gina Rabinovic with the Bill and Melinda Gates Foundation. Dr. Dan Gordon with Sonofi Pesta, one of the industry collaborators of the labs. And last but certainly not least, Dr. Kevin Dacock from the Centers of Disease Control and Prevention. So I wanted to open our discussion. We're just gonna throw out a couple questions and have each of our group here respond in turn and engage in a conversation. I wanted to start by asking about the unique value that these labs have. Why are these partnerships important to your organizations and why have they continued to be relevant to your organizations over the years? Many of you have longstanding partnerships and how do you structure and manage these relationships as time goes by, as new projects arise? What makes you decide to partner with one of the US military overseas research laboratories? And I think we'll begin with you, Dr. Dacock. Well, thank you very much, Michel. And let me start just by congratulating CSIS on this very good report. And thanking you for putting this event on in this iconic environment. I think the history of these labs does need to be highlighted. They have made a tremendous contribution and there's some elements that I think we so easily take for granted, which is what's going on. They're very longstanding. They go back a very long time. They are very far flung. They cover all parts of the globe almost. And they focus on important subjects that otherwise probably would not get focused on. They provide a core infrastructure that is there through thick and thin upon which things can be built as events change and priorities change around the world. And this kind of infrastructure is very difficult to develop, but you can knock it down overnight. They have made very important contributions to subjects that are a threat to US troops but are a threat to populations as well. And one of the reasons that CDC has been pleased to collaborate in Kenya, in Thailand and particularly in Cairo is that we have different missions but missions that touch each other. So each partner brings something unique to the different partnerships. And of course close relations with the host country are absolutely essential because it is their country after all. So we've seen tremendous advantages to these partnerships. The military side often focusing on product development, CDC on the health of populations but bringing these things together. And I would just finish really by just highlighting some of the risks if we let this go. There are subject areas in important medical problems such as tropanosomiasis, leishmaniasis. Leishmaniasis is an important example actually because that actually did emerge as a rather unexpected problem for troops in Iraq. The global expertise in these diseases is very thin. Entomology, the study of insect vectors. The military has had a traditionally strong role in this and actually as a supplier of this expertise to other parts of government, to academia and so on. So I just want to highlight those few points and comment later as the discussion goes on. Well what I want to do is focus on two of the value features that the medical research units bring to a collaboration not only with us but to the host countries. The other feature is their excellent relationship with the host country. This is a relationship that's been built out of mutual trust and respect over many decades. When you put these two ingredients together, you can see how the collaboration between those two units helps build an infrastructure that would allow for the enrichment of the scientific, medical and clinical research capabilities of the host country and the region. The MRUs basically help provide a resource for coordinating and conducting critical phase two, phase three clinical trials that provide the data to help license vaccines and drugs that are of importance not only to the health of the people in the host country but also to our soldiers, sailors, airmen and Marines. Conducting initial clinical trials in countries where the disease is not endemic, Europe, United States, provides very important information on the safety and the immunogenicity of a vaccine for example. But it's sometimes hard to predict whether the immune responses, the results we're getting out of the laboratory, the test tube, actually correlates with the ability of that vaccine to protect people against the disease in a natural setting. Working with the medical research units and the host countries, we find it very important to work with these units because of the expertise they have in actually conducting clinical research studies that meet the regulatory requirements for the United States, for Europe, for multiple countries around the world. How do we, you're asking how do we coordinate these? How do we manage these types of collaborations? They're typically managed under a cooperative research and development agreement. Not only with the medical research unit but with the host country. Our goal is to try and get a mutually beneficial relationship moving. These agreements are set up to try and look out after the best interests of everybody. The military, the host country, their population as well as striving to get these products licensed so that people can actually use them. Thanks. As was mentioned, I'm one of the deputy directors of the National Institute of Allergy and Infectious Diseases. My specific title is deputy director for clinical research and special projects. So among our special projects, I would say there are none more special than our relationship with the Department of Defense and as part of that, our relationship with the laboratories, given the nature of our organization, being a research organization. We actually carry the bulk of our partnerships with the Department of Defense and the overseas labs through two specific agreements. One of these is an interagency agreement between ourselves and the medical research and material command up at Fort Detrick. This is a pretty broad agreement and we put annexes into that agreement to cover different specific activities. So one example is the biodefense campus up at Fort Detrick. Another example is the support we provide in the area of HIV AIDS to the laboratories, both here domestically as well as overseas and Kenya and Thailand. This relationship with the MRMC and Rare and the overseas labs has been incredibly valuable in allowing us to do things that we would not ordinarily be able to do. I mean, as has been said many times, it is the presence of that stable infrastructure within what to us is a very foreign environment that allows us to go in and be able to build on the relationships that have already been established and importantly, the interpersonal relationships between the investigators and from the US, whether they be civilian or military at the military labs and the population within the country, both the academic population, the military population, the non-military government and importantly the civilian population because to carry out research, you have to have trust within the community you're working in and I think has been clearly pointed out these labs have been incredibly effective in building that type of trust in many, many instances. I would have to say that often some of our projects that were involved in with the DOD do come about at the urging of the government at times from the ambassadors in the country and I think we're in the middle of a controlled experiment because halfway through developing a program in Indonesia, the closure of Namrood 2 took us, I wouldn't say by surprise because we knew what was happening but it certainly is gonna make our life to build a program in that country much, much more difficult without that sustainable infrastructure. The other part, the other agreement that we have and the other relationship we have that has been incredibly productive from our perspective and involves the overseas labs is another interagency agreement that we have this time not with the medical research and material command but actually with the uniform services of the health sciences or USIS. With that agreement, we've established an infectious diseases clinical research program and I'm happy to see Dr. Mark Cordo-Peter here who is currently leading that program. Through that program, we've been able to both domestically and internationally do something in clinical infectious diseases research that we've not been able to do within the NIH environment thus far, namely build a sustainable set of sites being able to look at both resident and emerging infectious diseases, both domestically and abroad that has been said many times, put us one step ahead of the game if something were to emerge somewhere around the world, we'd be able to work on that, work on it quickly with state-of-the-art technology, state-of-the-art research and hopefully be able to figure out what we need to do to deal with individuals at risk for that disease, wherever it occurs or initiated and also to be able to be prepared for dealing with that disease or work to get to the United States. So again, as I say, among our special projects is really none more special than this relationship we have with the Department of Defense and in particular with their overseas labs. Compared to the other organizations here on the podium, where the young kids on the block, we've only existed for about 10 years, maybe 11, this is 2011, 11 years and the Global Health Program is somewhat different, maybe more akin to what you're focused in now specifically in CDC, in that we're focused in diseases that largely occur outside of the United States or create greater burdens outside of the United States, particularly in endemic populations and particularly for children and from others. So the first is that we're focusing on the diseases that are of relevance and while we don't have a mandate to go in and partner specifically with DOD, whenever you have a problem that needs to be solved and you go to the countries in which there are capacities, people that are working in the area, laboratories, where do you end up? You end up in Thailand, you're out in Kenya, you go to Peru, I've been to these laboratories and places where collaborations are ongoing. For the Gates Foundation, partnership is critical because we realize that none of the various sectors that we're engaged with, whether it be academia, government, industry or foundations and I'm sure there are others, have the resources or the technical knowledge or the capacities to do it alone or we don't have the patience to build it. So we have to partner and to partner effectively, I think you have to draw upon the expertise of each of the partners and set up supporting structures to make it happen. And there are studies that have been completed including testing of a malaria vaccine in Kenya but collaborations which are ongoing right now which are probably unique, including a multi, you may not know about, a multi-center prospective cohort study of diarrhea in infants to really identify not only what causes the diarrhea in terms of infectious pathogen but how that interacts with microbiome as well as understanding the nutritional risk factors that enter into the decline into mortality. And somewhere between surveillance, understanding epidemiology and the ability to test drugs and vaccines has been created a rich network of partnerships that include not just the Gates Foundation but often time our grantees who seek out those center of excellence to collaborate with. Ambassador Reneberger. Well I looked at this panel and I realized that was the only one without either DOD connections or medical credentials. So I'm gonna give you my perspective as a sort of operational perspective from the US ambassador's point of view. Of course, I understood the importance of the labs in terms of US health interests globally, what we were doing in Kenya as well as of course the nexus between that and some of the security issues that we faced. So I took a very strong direct interest in the program from early on. And why I think it's important to talk about the global aspects and diseases, I think it's important to highlight in each case if possible but I think Kenya is sort of a case that makes it very conducive to do that, the positive benefits in that particular country and for our relationship with that country as well as globally. Obviously in Kenya, fighting disease, promoting health is one of the five key pillars of our relationship. We've got a high $560 million PEPFAR program, the lab contribution that Walter Reed makes, even CDC can get lost in that mix, if you will. But it is a very important part of President Obama's new global health initiative. And you know, people don't realize it but when you look at the US relationship with Kenya, that's a pretty staggering figure. It's about $3 billion in terms of resource flows from the US to Kenya annually. And it's important to take each piece of that. In the broader scheme of things, what we spend on that lab is almost minuscule in that context but not to the Kenyans and not to the Kenyan government. So it's important to take each piece of that and give it its due and highlight it. I think there are aspects we haven't talked about in terms of the impact of the program, certainly as I saw it from the perspective of an ambassador, the impact it has on the economy and the infrastructure. I mean, we have built world-class facilities there. We've put world-class equipment into those facilities. We have made Kenya, it is part of Kenya's regional leadership as a result of what we've done just on this program, not to mention the broader relationship, over 800 technicians trained from the region, from Sub-Saharan Africa in general. And that's appreciated, I think, by the Kenyans. An institution building. We look at a climate in Kenya where clearly there's a culture of impunity, it's not an overstatement. And within that, to have an institution which is populated primarily by Kenyans with a small degree of US leadership, promoting the values, institutional transparency and accountability, that's a very important dimension of the program, although not strictly related to the medical. In terms of the way it was managed in Kenya, I'm pleased to say that before it became fashionable, I hope Kevin will testify to this, we actually had a whole of government approach. I mean, we were working together as strange as that might seem, in terms of the US government. We had NYU and CDC and Peace Corps and State and Aid, PEPFAR all working in a collaborative way. And so when the Global Health Initiative came, we were actually well-prepared for that. And we've been cited, I think, by CSIS and others as a model for that. And the labs are an important dimension of that program. But one thing that I found interesting and sort of a little bit strange at the time, and I'd asked my people about it, drilled them a bit, is that the DOD component, Department of Defense component, which is quite large in Kenya, literally hundreds of people on different elements of DOD, led by a senior defense representative who is absolutely superb. But yet within that DOD world in Kenya, if you will, I always found that the labs were sort of taken for granted. I think because they function so well, they're flying under the radar, if you will. But I felt it was important to give them more prominence within that overall DOD program. And I also think it's important, as you talk about management of the program, that we fully factor in this element because the program is important in terms of not only health but security, into the mission strategic planning process, which is an annual process, which lays out and affect the policy and budget framework for the coming five years. So I think it's important to do that. We did try to do that. To be frank, I don't think we did such a great job at it, but I think that needs to be a part of the process. Thank you very much to all of you for that. Very diverse commentary. Dr. Rabinovich referred to this rich ecosystem of partnerships that exist within the broader global health realm and certainly within infectious disease research. And it is interesting to see organizations with very different missions at their core that do overlap, but all have this special relationship in one way or another with these laboratories. And it's what I heard from several of you is that your organizations have been able to come into these countries where these military labs were already present and leverage their existing work in several different ways, whether it's infrastructural, leverage the networks of relationships they have, or just use the cutting edge state of the art facilities and practices that they employ, enabling all of you to fulfill your missions, working again in partnerships with each other and with them. And I also heard a couple of you say that what a loss it would be that the global health community if these labs for any reason had to be decommissioned or closed. And this is a very pertinent question right now as Dr. Hamry and General Peake alluded to. These labs always operate under a slight threat to their core budgets, particularly the budget that is allocated to their core research and development and product development mission. So segueing from that, looking a little bit at the future, how do these laboratories for each of your organizations factor into your future planning as you look at it, what might be on the horizon for all of you and what advice as these labs face the challenges that the General Peake described and in particular some of these funding challenges, what advice would you offer the laboratory commanders and the parent organizations very well represented in the room today going forward to ensure their continued viability. And again, I'll start with Dr. Dacock. Thank you, Michelle. As we look to the future and think of our own planning at CDC, we fully intend to continue and build upon as we can this partnership in the specific places where it already occurs. And I would highlight Cairo again and Kenya and also Thailand, but we are interested potentially in other places as well such as Peru, for example. It's difficult, I mean, I think the five recommendations that General Peake highlighted are all extremely important. I guess I would highlight one and that is communications. The history of these labs, their importance, their role in the world needs to be highlighted further. And I would make just two or three other recommendations as we move, as we think about the future. I'm glad the ambassador highlighted the, what's a bit of a mantra right now, the whole of government approach, which really is important. I think we, I agree with the ambassador, I think it, in Kenya, it's worked extremely well. Doesn't work so well everywhere and in a time of budgetary challenges, I think it's very important that we strive for synergy and efficient use of resources. So I think that is an important message for the future. You know, the world doesn't stand still and all organizations have to adapt and evolve in the face of changing circumstances. So the, I think years ago, these kind of units were very self-sufficient and there was even a time when their budgets allowed research to be done on it, funded only by DOD. Those days, I think, have gone. So we have to integrate better into everything else that's going on while maintaining the very special core functions and not losing the special characteristics of these laboratories. And just finally, the importance of partnerships, including with the networks, which have been emphasized, and maintaining evolving relationships with the countries in which these labs are based, I think is absolutely critical. And again, I, but I think there are just wonderful examples out there of very high practice, best practices and success. Thank you. Dr. Gordon. Well, if you look at the, if you look at the scientific, the medical and the clinical research data, contributions the medical research units have made, not only to soldiers, sailors and airmen's health, but to the world health in general, it's kind of easy to see why we look at them as critical medical research units. It's, I guess when I first heard your question, I thought of two very specific types of areas that I think we need to work on in collaboration. Clinical trials are often very complex. And if you look at the time it takes to develop the concept protocol, focusing on a specific critical question, then go through the review and approval process, initiating the clinical trial, conducting the clinical trial, collecting all the data, doing all the lab analyses, and then interpreting the results and seeing how that modifies or changes your clinical development plan. You can see the difficulty we sometimes face when there's a rapid turnover or a turnover of personnel at one of these research units. It is very rare that this clinical trial timeline is less than two years, less than a year. I, for one, have experienced the opportunity of working with a clinical trial in which we actually started the clinical trial, three months into the clinical trial, the principal investigator was relocated from the country unexpectedly. Luckily, we had collaborating host country scientists to carry on. It took another three months to find a replacement, another while to get that person up to speed. And just as things were rolling under its own steam again, another critical clinical team member rotated off the unit. So I think we need to work a little bit to help manage the turnover maybe perhaps reduce the turnover rates so that these long and complex studies can be continued with a degree of stability and consistency. The other thing I wanted to point to is a very, very important role in conducting clinical trials. And that is the review and approval process. It is extremely important that these clinical trials undergo rigorous review to make sure that they're scientifically valid and to make sure that they are clinically and ethically conducted. Now, we have our own internal review and approval process. The Army has their internal review and approval process. So does our naval colleagues. And so does the host country. And when we're involved with even larger clinical trials, WHO sometimes gets involved. So you can see the complex network of reviews and approvals that can go into a clinical trial. If you're one of the first reviewers, one of the later reviewers may make additional changes that then have to go back to the first reviewer. One of the things that medical research units have been very good at is helping us orchestrate and coordinate the various review processes so that the studies that are being done are the best they can be scientifically and stand up to the most rigorous scrutiny with regards to the ethical conduct of a clinical trial. Finally, I'd wanna say that the medical research units cannot maintain their positions. The world is changing, like you said. The medical research units actually have to stay on the cutting edge that they have been experiencing the last several years. And it's paramount to their continued success. Thank you very much. Dr. Lane. So we see the opportunity to continue to work with the DOD overseas labs as a critical part of our overall strategic plan. In fact, in getting ready for speaking here, I had a chance to talk with some of our divisions about what would they do if they didn't have the opportunity to do some of the work with the overseas labs. And one of the areas that is actually a third of our program, I realize it doesn't have the same impact within the DOD as our HIV program. We are currently absolutely critical on the collaboration and the partnership we have with the DOD for our HIV program. And again, I'm pleased to see Nelson, Michael, and Jerome Kim here today. They are responsible for the successful conduct of the very first and only successful HIV vaccine program. And I would be remiss not to point out Dr. Ed Tramont there in the back who was the director of the division of AIDS who insisted that that study get done. That's not a DOD thing. That's an NIH thing. NIH could not have done it without DOD. If we lose that capacity, we can't create that. We can't say, okay, let's take some of our budget and we'll build another Afrums or we'll build another rare Kenya. We can't, it's too much. We can't just drop in and do that. It takes too much time and too much effort. We'll have to do our work another way. And right now we can't see another way that would be anywhere near as effective as the partnership that we currently have. With regard to some of the challenges, I think it was very, the report was fantastic to read because it so clearly articulated themes that are not unique to these overseas labs but actually cut across not just international research but research in general. The concept of team, what has to happen, I think, to be successful is the PI has to evolve their thinking from all I have to do is do good research and I'll be supported and successful too. I have to do great research but the research has to be related to the mission of where I'm working. So we can come up with all sorts of ideas but within the DOD construct, within the international labs, those ideas need to be relevant to the mission of the DOD and there are so many areas where that's possible that I think it clearly can be done but it requires a bit of a culture change in how a principal investigator thinks about their roles and responsibilities. So related to that is a recommendation in the report that a tour of duty in a research facility and a research lab, particularly one overseas, may need to be more than just the standard two years and again I think as was just mentioned previously, you also need something even more sustainable than that which is typically a civilian workforce and ideally a civilian workforce within the country from the citizens of the country that one is working in. The final thing that I would mention again plays off another recommendation in the report which is this notion of an annual meeting to talk about what's going on within the DOD labs and I would think that to be a very good idea but I would extend that idea to include the partners and even to look at it as a way to talk about governance of research within country beyond just the country teams. How do you take what's been successful as a model in Kenya and then patchwork that into a model that's successful internationally with what we do within global health? So I think there's a lot of opportunities there. I do know from being in the Department of Health and Human Services and having some experience in trying to work an interagency program up at Fort Detrick that there are a lot of challenges and authorities in one department even being able to help things happen in another department and it often drills back down to this concept of infrastructure and something as simple as having a power plant. I can be a big challenge if there isn't someone who steps forward and takes responsibility and says that's part of sustained infrastructure that we need and we'll take this or having some new creative way to be able to provide that type of infrastructure. Thank you. Govinovich, as I prepared for the trip here, we reviewed the number of programs that are actually ongoing, which was very instructive and as I said, some of them have completed but others aren't going under or under consideration. There's a big collaboration, particularly in HIV vaccines, to follow on the Thailand trial that took place with the next set of trials that need to happen and that includes the DOD labs. Recommendations, I guess is what you asked is what should happen next. And I have to say, I'm going to quote Warren Buffett on this one and it goes something like this. It's not until the water goes down that you can see has been swimming with their trunks on. You gotta be prepared and part of that is first of all, it's gotta be at home. If these labs are not valued by DOD for what they do for DOD, we can all come and talk about wonderful partnerships but I'm very worried that that message and that history has somehow gotten lost here. And I don't know what the partners can do about that but I think that's mission critical. It has to be relevant to the DOD mission and I would challenge the organization back. The second is there's a set of voices that aren't in this room, maybe you represent them, which is the voices of all the partners at the laboratories themselves because one is impact on research that external partners do but the other is the incredible impact it has in country in terms of training and growth of national capacities that really become the rich variety of people that one works with. The last part of it is to continue to form those partnerships. For example, NIH is probably much better at thinking about long-term core support or core partnerships. That's not something that we do very well but we work very well in terms of strategic investments around specific projects. So you do need that mix of partnerships to be able to create a portfolio of projects that can actually sustain a site. And it is tough economic times everywhere and that's hitting every sector, every country, every company and they're having to do more with loss and that can mean actually potential opportunities for using capacities that exist if you're willing to look for them. Thank you. Well again, speaking from Chief of Mission perspective my very first point is involved the Chief of Mission even more than he or she is already involved and that's not special to me, that's sort of generic. The Chief of Mission really does have the ability to reach across government departments, to reach into DoD at senior levels with messages, to reach into state, to help the bureaucracy to see the cross cutting value of these programs to lobby for resources. We can help these units if they're working to achieve partnerships with foundations or businesses. We can be an advocate for that. I think that's an important point. And a broader point but I think a very important one in the Washington policy context right now is that we just got finished in the State Department completing the Quadrennial Democracy and Development Review which was actually moving almost in parallel, I think DoD had just finished their Quadrennial Defense Review and part of that was intentional. And of course one of the focal points of the QDDR is this again, whole of government approach but they're specifically looking for examples. There were several highlight labs weren't mentioned but some of the examples of state and aid collaboration with the military were actually far less important than the work that the labs are doing. So I think that provides a context to highlight that sort of collaboration. Publicity and public diplomacy are very important. I mean I hear what's been talked about in terms of having an annual conference which would bring together stakeholders. I'd almost say and I think it's possible go beyond that. I mean there are many success stories the Rift Valley fever efforts in Kenya just being one of many the work they're doing at HIV AIDS and malaria and highlighted to the American people. It's not that hard to do. You can do it through OutBed, you can do it through speakers going out to communities because I think there has to be a domestic constituency that drives all of our policy budgeting in many respects and help also expand the word to the host country population. It's interesting where the programs have their impact in Kasumo and Karicho. They're quite well known in Kenya but they're not more broadly known within the country. In fact at one point I went up and I did a presentation for President Kabaki on the whole US-Kenyan partnership. And when I got to, we actually talked about Walter Reed as one slide and what we were doing. When we got to that he sort of stopped things and he looked at his health minister and he said, did you know about that? What, you know this is going on? And a quite brisk discussion ensued. We were there for quite some time but to me that told me the importance of bringing the host country leadership into these programs more. And you know Kenya is a small player maybe in the scheme of things but host countries can be effective in lobbying at the Washington level as well. They see people in Congress. Shouldn't just be ourselves lobbying. Let them talk about the benefits of the programs. And then finally I think it's important to integrate these lab efforts in the broader fabric of what we call civil affairs. If you will, it's one of the buzzwords in DOD in terms of programs that you do with communities. That's what it is. But I think there are ways again of sort of upping its profile if you will within that DOD relationship and helping the local DOD advocates, the senior people on the ground, advocate for the program. Thank you very much to all of you for those comments. It's interesting to hear so many different facets, elements we pulled into our report echoed by all of you coming from your different organizations. And the issue of success stories is a very interesting one. In fact, we made a conscious decision. You will see this when you look at the report to add an appendix focused specifically on the achievements of these individual labs. And this was difficult to put together for a couple of reasons. One is when we went to the individual labs and to the rare and NMRC, we found that no such compendium existed already. And that was somewhat surprising to us. On the other hand, and I think we'll hear a little bit from Dr. Woodson on this, there is a culture in the military of keeping your head down and doing your work and not bragging about what you do, which is commendable in many circumstances. But in this particular instance has been, we argue in our report, a bit of a handicap to the military in terms of cultivating these champions and engaging in some of the public affairs strategies that all of you have just described. And I think we as a team certainly agree that that's an important component. And I hope we've done some justice to some of these labs in our appendix. Another strong theme I heard that I wanna touch on briefly is this issue of turnover. Again, we heard that in every single one of our visits to these labs from almost every single partner. I want to take this opportunity to highlight a point that General Peake touched on, which is that these labs, the course military active duty staff there is in most labs, 16, 17, maybe up to low 20s. Very small number of active duty military with anywhere from 150 to 300 locally hired staff, at least half of whom are sophisticated scientists, laboratory technicians, medical doctors and otherwise highly trained individuals. And what we found at all of these labs is they are the ones who form the institutional memory who helped to see the clinical trials through to completion and who also help continue these relationships of trust, particularly in countries like Thailand and Cambodia where loyalty is to an individual much more than to an organization. And so the way the labs have structured themselves does help them going into the future with this very small core military team and this vast staff of locally engaged scientists. This must be an event that relates to the military because we are running right on time. So I just wanna close by thanking our five discussants today. Thank you all for coming here and sharing your time with us. I also once again want to thank the women's memorial for welcoming us today. And in particular, it is such an honor to have Brigadier General Wilma Vaat here with us today. Really an honor to have you and thanks for coming. So thanks to everyone and we'll move on to Dr. Woodson. Well, next is my pleasure to introduce our keynote speaker. When you start thinking about the size of the organization that hosts and owns these labs in DOD, they're talking about just the medical piece is a $50 billion enterprise, 133,000 people stretched around the world. The man that is the principal for that, for DOD, is gonna be our keynote speaker, Drs. and Jonathan Woodson's couldn't be better qualified for this. In just about every dimension, you have somebody that will understand and understands the kinds of issues we've been talking about here. He's a reservist and that's how really I first came to know John was as a reservist who has rose the rank of Brigadier General, was one of our assistant surgeon generals for in support in the reserves, continues to hold that rank. But he is a physician who was out of New York City, where actually NYU as a medical school, but then to Boston at the Mass General where he's trained in internal medicine, general surgery, vascular surgery, board certified and all of those. He's been an academic in the faculty side of the house. He as a reservist during all of that kind of stuff deployed to places like Kosovo and Iraq. And Desert Shield, Desert Storm one. So you have somebody who really understands the depth and breadth of the kinds of issues that we've been talking about here. And we're really fortunate, not only to have you here today, John, but to have you in that job and we really appreciate it. John's gonna come talk to us and then we're gonna have a time after that for some questions and answers and a chance to involve you all as well. Well, thank you Dr. Peek for that very kind introduction and it's truly an honor for me to be here today with all of you as this report is rolled out. And I'm not going to repeat a lot of the comments that have been made, but I'm gonna try and footstomp a few key issues, particularly as I see it as the assistant secretary of defense for health affairs in this volatile, complex and ambiguous time we're living in. Dr. Hamry, General Peek, Dr. Morrison, thank you so much for inviting me to be part of this ceremony today. And first let me thank you for your insight and ambition in taking on this project. You know, it's a wonderful opportunity to actually be here in the Women's Memorial and I was walking around outside. It's not the first time I've been here. I've been here several times to celebrate a number of different events, but one of the things that's written on the wall out there is it says to tell their stories, which is very important. It's very important to tell your story. One of the things I do and have done as a general officer, particularly going around the country in the reserve components where I was meeting reservists who were reintegrating back into civilian life, as I say, you need to tell your story. The reason being, of course, is that at this point in our country's history, we have the smallest proportion of those who serve or have served to the relative population that we've ever had in the history of this country and that's a little bit of a dangerous thing in a democracy when the population gets disconnected from the military. We have an important and very rich story to actually tell in military medicine, which all of you are part of and the labs are certainly part of, in that the advances over the last 10 years, what we've done in force protection, what we've done in terms of preventing loss of life and salvage of life is really remarkable and of course a lot of what we've done has found its way into civilian practice and this is true out of any conflict. I used to give this lecture when I was up in Boston regularly about sort of the advances in medicine during war and it's a rich story that needs to be told and the key is that you're part of that story and so you need to be out there telling it. Before I get into sort of the couple of points I really wanna make, I was listening to all of the panelists and listening to the previous speakers and I was struck with a couple of things that I needed to really footstomp up front and one is that health and building healthy population is a worthy strategic engagement approach that in fact utilizing medicine and the building of healthy populations is a way of preserving the peace so that we don't have to get into these kinetic wars. If we build stable societies of which building healthy populations is an important part we can do a lot to prevent the misery of war, war being that dark side of humanity that we sometimes encounter and health can be part of that strategic engagement to prevent that. The second issue is the issue of building partnerships. The understanding that as we go forward with a global health engagement we really do need to make sure that we understand how to build partnerships and where we are in terms of the partnership and timeline. Sometimes the Department of Defense is the entry level and then we need to do the warm handoff to State Department, host nation as we build capability and capacity but we need to understand that partnerships are very, very important. So I wanna return now to just a couple of themes that points I wanna make. I wanna thank again the authors and all of the folks who worked on this project because you really have produced a document that really is gonna be a reference for years to come. This is really a remarkable and seminal document and I know that it wasn't produced at no cost but it really is a gift to us to have an independent and expert voice that speaks with passion and force about this particular issue. I want to concentrate my remarks even as I remember to thank the myriad of people who are involved in these kinds of projects that include people in government, people in the private sector and of course our host nation partners that there are a couple of things that I think we need to coalesce around. The first is I think we need to understand the importance of communicating, strategic communicating and it's communicating up, down and sideways. Up the government in terms of the value, laterally to all of our colleagues in terms of the importance of these kinds of activities in the whole of government, in the whole of military medicine and then downward in our ranks to inspire others to become part of this effort and make career choices. Later on we'll probably have an opportunity to engage you in sort of a two-way conversation and I think that's important in terms of what I want to deliver here today that although we'll start this conversation today I see it as a continuing effort going forward. So I'm gonna purposely limit my comments to the issue of communicating and then one other and then hopefully we can develop a dialogue later. You know the report that CSIS has published challenges along I think at least three significant lines. As noted already there's this imperative we have to better communicate the value of research laboratories to the nation and that it's a shared responsibility. Now you know value you can roughly say is cost over benefit. And so the issue is we've got to constantly put that out in front of everyone that for relatively little dollars we get a huge benefit not only in terms of protecting the citizenry of this nation and military folks in specific but the additive value to the world is just incredible and important again is getting back to this notion of strategic health engagement and building healthy populations and preventing disease. So the military research labs around the world aren't purely an army or navy asset. They're not essentially just a DOD asset or even just a federal government asset. They really are an asset in the fullest sense a real national investment in a national treasure that benefits every man, woman and child in this country and benefit many people around the world. The threat from the emerging diseases and increasingly virulent infectious diseases to our citizens is a serious issue. And of course I don't need to remind you that something can happen or someone can get infected in any part of the world today and get on a plane and be here and create an epidemic or a pandemic here. And so this is not to be taken lightly. We need to understand that the federal government is investing in substantial ways to integrate our capabilities again across government and that we have a lot of partners in this effort, the CDC, NIH, the DOD, the VA and of course other federal partners as well. Now of course my responsibilities as the Assistant Secretary of Defense is to ensure in some sense the value and the return on investment that the department makes in these facilities. And to some extent it can be seen as very focused. In other words I need to ensure in terms of the concept of force health protection that our soldier sailors, airmen, marines, coast guardsmen are protected from both natural and at times man-made disease threats. And I take that very seriously but that really only speaks to again part of the value of the work that you do and has been highlighted by this report. So on that vital mission alone, we can make the case that we get great return on investment but we need to be talking to a broader audience. And recently I spoke to an internal DOD audience where I tried to make this point that over the last 10 years of war, we've been at war, the U.S. medical forces have achieved the lowest rate of disease and non-battle injury which you know typically takes more individuals out of the fight than the war wounds, the traditional war wounds, the gunshot wounds or in this case these wars, the IEDs. And so we have the lowest rate of disease and non-battle injury ever witnessed in the history of warfare. That success started in our research laboratories. It begins as far back really as Walter Reed where you begin thinking about those diseases that are causing illness and taking soldiers away from their core responsibilities. And it results from decades of work and the development of the most robust inventory of vaccines and therapeutics in the world. So this is a tremendous asset that we're talking about. And that success is not ours alone and it's due to again as I mentioned before the partnerships across federal medicine in academia, private sector, as well as industry for that matter. And so we need to find ways of solidifying, harmonizing, synergizing these partnerships as we go forward. These partnerships need to be mobilized not only because of the research and development of projects but it needs to be mobilized now and communicating the achievements that have been made on these global health initiatives. It's through our collective interests and our collective voices, if you will, that we can all amplify this value proposition which is so important in today's climate. My second takeaway message is a small point that was made but it needs to be better understood as we strengthen our communication and our educational efforts. As was noted, the men and women in our military who serve in these laboratories emerge from a larger military medical community. They are often well aware of their historical context and the contemporary value of what they do and the contributions of their effort but they serve silently and in the background. And sometimes their value and contributions are not known outside of the small circles of their contacts and the people involved in their particular efforts. And so the impact of what they do has got to be made known. Make no mistake, their contributions and expertise are really valued and they know that their work matters but their work is done without fanfare and with real modesty and with a deep respect for the science and data and discipline of their art and their practice and their work. For those of you who are familiar with the men and women in the military, it's a trait that really cuts across many disciplines in the military. It really is part of our culture but the issue really is that sometimes silence is an important detractor as there are many other issues that in fact gain notoriety or become seemingly more important in the grand scheme and sometimes we have to highlight progress that has been made in order to create the balance in terms of priorities as we go forward. So I see I have a real responsibility to draw out your work. The people who work in the labs to help shine a light on this special cadre of professionals as we go forward. And I would argue that all of you can help me in this endeavor. I would like to ask all of you to consider how your organizations can turn your spotlight on these public servants and these public institutions and I get back again to this issue of telling your story. It's part of the history, the great history of this nation, but it's in part a necessity that we tell the stories again to get a balanced picture, a balanced approach and make sure that the priorities are correctly ordered. Through the leadership in the Army and Navy, we've developed a deep and respectful relationship with our host nation partners and I would really want to footstomp this that it's not about us only, it's about who we partner with, what the priorities of the host nations are and we need to respect this deeply and measure this as we go along. These laboratories are as much theirs as they are ours. Our friends in Egypt, Thailand, Kenya, Peru are rightly to be proud of these institutions, proud to house them in their countries, proud to staff them with their own medical professionals and be enthusiastic about the training and cultural educational opportunities that are afforded by their presence. Like us, they view these laboratories as national assets and this is the collective pride in fact that we can take in the establishments of these labs. And here's where our global health contributions intersect with our other national security goals where we can build and sustain professional relationships and yes, trust with medical experts and between governments even as we try to build healthy populations and support host nations. In Egypt, during the uprisings, our Egyptian colleagues and our military medical teams continued their work uninterrupted and relatively secure. Our laboratory was viewed as no less a national treasure as many Egyptian antiquities and we need to understand again that prominence and role in terms of the history. It is in our interest and that of other nations that we actually train together that we combat disease together for the reasons I've already mentioned that borders are really porous to many of the problems that you study and you make advances on in your laboratories and it's in our collective interest to understand how to prevent the spread of disease. So our laboratories are force multipliers for other nations as well as it's a force multiplier for us which brings me to my third point. We know we have to expand our communication and reach and we know we have to change how we communicate and yet we are in a very serious financial period in this nation and if you think we're not just wait a few more days as the rhetoric really ramps up and we get into an intense set of budget considerations. There are difficult decisions being made in the Pentagon and the Health and Human Services and in the State Department and even worthy approving programs are not going to be sacrosanct and this is why it's so important to understand the true value, cost, benefit kind of equation to make sure that it's raised publicly so that we can get the right perspective on priorities. It's not enough to communicate better or more broadly although this we must do. We also have to think differently about how we're organized, how we share and how we use the precious resources that were given. So this is why I was so encouraged by seeing the panel up here and seeing the numbers and different types of partners from private industry, academia, philanthropic groups because we need to be able to share in this vision and see how we can actually again synergize what we do, how we can coordinate what we can do and then hopefully reduce costs associated with these endeavors. Today probably none of us can do it alone but together we can all do it together and so we need to use this announcement, this meeting, this presentation of this report as a beginning to move ahead, to strengthen our partnerships in these endeavors. We have to think differently about how, again, we organize and we conserve these resources. We need to use the power of the study and the dedication of the leaders in this room to consider new ways of collaboration to enter the public-private partnerships and further our shared interest and one of my personal goals is to strengthen in many areas of the military health system, these public-private academic partnerships. Again, because I think it's healthy for the nation when the nation's institutions, private institutions, are tied to and understand the military. That makes for a healthy democracy. There are always certain issues and considerations that necessitate some of our activities remain behind a firewall, understanding the business that we do, but we can manage those issues without limiting our conversations and creating a certain transparency that will facilitate our work in general. I will be bringing some of these issues that I've heard today back to the offices or further discussions with the Surgeons General and with the DOD leadership, and I hope at some point to engage many of you in further discussion as to how we can build these partnerships stronger and better. I would like very much to come together at another time and begin to advance the strategic framework for moving forward, where we can explore at even a more granular level what opportunities exist and what barriers remain to foraging a more comprehensive partnership across the agencies, across the public, and the private sector, and with host nations. I had an opportunity not too long ago to be in Hawaii, and we were talking about this whole idea of strategic health engagement, and again, how it can be a very powerful and positive instrument of national power, and the work that you do, the labs out there are clearly part of that. So in summary, I wanna thank all of you for being here today, for the work that you've done, for the vision that you're creating. I wanna thank you for inviting me to be here today, and I look forward to any questions that you might have of me. Thank you very much. Anne Nelson, I worked for most of my career at the Armed Forces Institute of Pathology, but now I'm at the new Joint Pathology Center. And one of our tasks is to do more with less without sacrificing quality. And one of the pillars that we've talked about is this strategic partnership. And a lot of people who know me know I've done global health for a long time. But one of the things we're looking at is the industry model, the Toyota model of the deming cycle of continuous quality improvement, and also eliminating redundancy and repetitive procedures. And I think partnership beyond the health community with business and industry models to improve efficiency may help some of the funding as well as improving the work quality. Well, thank you for that comment. And let me just maybe say two things in reaction to that. Number one, I wouldn't have taken on this job if I wasn't sort of energized by challenge. You know, believe me, you gotta be energized by challenge in the contemporary environment. And one of the things that energizes me is the issue of finding novel solutions that will serve us well out into the 21st century and beyond. And the way to do that is I believe bringing people who come together who don't think alike, who may not have the same background because it's that intersection where you're gonna find new knowledge and novel solutions to the thorniest problems that we're facing. See, one of the reasons I think it's so difficult for people, you know, we get to these tough financial kinds of situations, is that they are only steeped in sort of the history of what has been. And so we need to create the vision of what will be and again, optimize these kinds of partnerships steel shamelessly in some sense from other segments of the business, if you will, or other disciplines that do things differently and achieve great success. So I'm with you with this on this particular point that we need to develop these partnerships in part because we've gotta bring people together who don't think alike to solve the problems. Yes. Thank you very much. My name's Bill Lierly. I currently work for the Homeland Security Department, but I worked in the Kenya Lab more than 30 years ago. I've worked for USAID, HHS, and the White House. And so I think whole of government and I have done so for many years. But I think we have to go also horizontally to think beyond the health arena. One of the real early lessons learned from HIV AIDS is as long as we looked at it just from a health perspective, we were lost. We had to look at it from the economic, et cetera, et cetera. So in the spirit of increasing partnerships, is there a way, especially within the DOD model that has developed within the aerospace industry, strategic partnerships with industry across many, many disciplines to start looking at the, not only the overseas labs, but the rest of our, quote, health infrastructure from a more holistic perspective. What are the, and I'm a recovering epidemiologist. I haven't done an odds ratio in 30 years, but I still think denominators rule. Can we start looking more at the determinants of health and perhaps the impacts of health in our organizational structures and not just compartmentalize ourselves in this all-steer funding environment that we're finding ourselves in. Thank you. So I think the short answer to your question is that we simply have to. Let me just give you a construct, which, I mean, if you read the newspaper, you'll realize this. But the issue is that we've got a financial crisis across government, throughout the nation, throughout the world to a large extent. And within DoD, let's just take the world I live in now. As the top line of the DoD budget comes down and the costs of healthcare and the things we do, let's say within health affairs, and I think General Peake talked to you about what my budget is. My budget is looking at $52.5 billion, that's with a B. That's not insignificant. And so what happens is that as that continues to grow, top line comes down. If we're not careful, we can pit priorities against, you know, what about health and all these issues. So what you're talking about is that not only do we need to communicate the value of health in terms of a strategic initiative, the added value, it's not just about paying for that CT scan for whomever, you know, or that third CT scan, perhaps for whomever. It's about the value of what we do in the medical community that adds importance well beyond what you think it might be, adds to the security of the nation, adds to the security of the world. And may in fact be more important than that new tank. Now that's a hard message to communicate. Okay, a hard message to communicate. But I think, you know, we've already talked about it now a number of times today about preventing, emerging infectious diseases. How in fact, you know, the issue of health or the lack of it creates instability and then we get into kinetic situations and we know where the tank now becomes important but if we could have prevented that, it would have been a lot better strategy. So there are a number of things we need to do and many dimensions and many ways we need to wrap this story and tell this story. Yes. Philip Ballard, Navy Bureau of Medicine and Surgery. Sir, you spoke extensively about how to get the message out, how to publicize what the labs are doing, horizontally, vertically, et cetera. Just in hearing you speak, I was jotting down some ideas about more specifics. For instance, do we need to put more public affairs officers there at the labs on site and maybe decrease some of the funding for irrelevant research that's not DOD specific? Do we need to do more social media? I mean, one tweet that goes viral could have more effect than a speech or a site visit or whatever. Do we need to have more congressional visits? Do the number of directors need to come to Washington more often? What are some of the specific things we're looking at to really get the message out? So I think it's first, you need to look inward in terms of what you're doing, what you've perhaps undervalued as a message. Look at your history, be able to formulate that and then put it out there in any vehicle that may be available. So social media is very important these days. But believe me, I have a public affairs group and if you feed me information that is important, I would be more than happy to put information out about the good work that you're doing through my channels. Because it is about force health protection. It is about the issue of partnering with other countries. It is about the value added in terms of public-private partnerships. It is about, by the way, savings that we create when we develop these strong partnerships. So we're willing to assist with developing that message because the labs have been a valuable part of our history. There's no doubt about it. Putting public affairs folks in each of the labs would in itself be a costly proposition, but I think we have a number of ways of getting the message out without, again in this day of scarce resources, trying to find new FTE billets to do that kind of work. Conferences, we have a lot of conferences during the year. And one of the things I'm trying to do right now is harmonize what we do in the conferences. And so if we're trying to get the word out to both the internal community as well as the external community, developing curriculum and modules that fit within our already existing conference schedule that no minimal cost to you is an important way of getting a message out because guess what? We have a lot of public media there at our conferences as well. And again, the issue is I think utilizing many of the vehicles that already exist, but be able to tell and shape your stories. We're not given, I think, as a group as mentioned before, to being self-promoters. And that's not what this is all about, but it's about telling a true and accurate story of benefit and value to the country. Yes. Sorry, sir. Former Afrums alum now at the Department of State, Kyle Hathaway, I first wanted to thank you for the address, it was fantastic. Secondly, I wanted to see if you could touch a little bit more on being at state and foreign affairs. Now kind of the value added as far as healthy populations and how that helps you avoid kinetic conflicts. So just thinking back to examples of some of perhaps Afrum's work up in Nepal or work of both the Army and the Navy kind of across Africa. One, your thoughts on how the military might highlight that more, but two, how your partners from the private sector and also from state and other agencies can help you with that message as well. Thank you for that question. Actually, I've had some wonderful conversations with some colleagues over at State Department talking about how we shape sort of the global health engagement strategy, understanding that no one department can do it alone speaking again to all of the things we've talked about in terms of the fiscal environment and the competencies that we each have. And in fact, we preliminarily started to develop as a first session sort of a case study seminar of when we've engaged in countries and when things have gone well and when things have not gone so well because we weren't synergized in terms of our involvement across again the whole of government or even with our non-governmental partners basically. And so it's about establishing sort of a vision that certainly recognizes a global health engagement again as a force multiplier, as an instrument of national power, smart power if you will. But how do we do it right? What are the competencies of the individuals involved? What do they need? What do they need to understand about engagement not only in host nations and helping work with host nations and setting their priorities and building their capabilities and capacities. It's the principle of teaching someone how to fish if you will. It's not about doing it all for them. What do we know about the friction points in terms of the handoff? Again, what should DOD be doing versus HHS versus State Department versus NGOs? How do we build trust in those partnerships as we engage? And then what do we wanna measure and what do we want to see as the end state? From my point of view, what I wanna see as an end state is stable governments and regions built on healthy populations that are prospering and so that we don't have to engage in kinetic wars. Thank you. Oh, I think we're out of time. Maybe if you have a short question. Okay, a short question. CESBOS laboratory are serving not only DOD, but they are like global health assets. Is there a way to look into the future, try to open up to other countries to contribute to the funding of those laboratories? Like someone mentioned Gavi not long ago, can't you get together and the pledge to put money in global vaccine alliance? Can we have a way of getting country to get together and country to be a fund so we can support those laboratories on a long-term basis? You know, I guess the short answer to that is yes. The question is how do we develop the proper strategy for doing that? You know, we should be engaged with other agencies, world health organizations and certainly other partnerships. And I think it just speaks to the issue that we've been talking about several times now is building those strong partnerships and understanding who does what, when, what kind of strengths they bring to sort of the game and then leveraging that for sort of the better outcome of the entire program. Thank you very much again for having me here. Thank you Dr. Woodson for a wonderful address. General Vought, thank you again for hosting us here today. When this building was actually constructed, my wife was involved in the exterior design and a close friend was involved in the construction of this wonderful place and it's wonderful to be back here today in this fashion and thank you so much for hosting us, Donna, who will thank you. A number of people from CSIS made very sustained efforts at pulling this all together. Seth Gannon, we've been negligent in really spotlighting the prodigious amount of work that Seth put into this over many, many months. Many people that are here today have helped us pull this together, Julia Noggle, Suzanne Brundage, Carolyn Schroet, Margaret Reeves, a number of summer interns who worked very, very hard, Daniela Choi, Matt Pazeski, Yongqi Zhou and Rebecca Kress and the many, many friends from the US military who are here with us today. We are going to remain active in this area looking forward and we welcome your thoughts on specifics, specific ways. We've collected a number of those suggestions in the last few days and I would just ask you all to think about that and please feel free to drop an email or place a call. Jim and I have both been begun thinking about this and Seth and my other colleagues and there are some clear messages that we're taking away. The tell your story, don't be shy and make the case argument comes through very powerfully and that we need to be more specific and concrete. That DOD has to step forward and value the labs in a very much more explicit and forceful and high level that it's important to reach higher and broader to bring in the kind of champions that will help elevate the work and the understanding and we need to get our friends here and hear their voices and by that I mean the people of Peru, Kenya, Egypt, Thailand, Cambodia. I just a point that Gina made, it's one that we felt very powerfully during our visits. The people that we engaged with in those countries remember very vividly what has happened in their countries and the contributions that were made. People would recount and this was across quite a spectrum of political views, would remember vividly those moments when there was polio, when there was H1N1, when there was HIV suddenly, when there was cholera and on and on and they began to own these institutions because they saw the US military and so committed responsive rapidly and effectively in the ways that they went about doing their business and I think that was one of the most profound impressions that kept coming back over and over and over again in our engagement was just how powerful and profound the relationship and the bond and the impressions were that people carried. So I wanna thank you all. This has been a wonderful two hour session here today. The report is available online. This event we've recorded, it's being webcast live. It will be posted on the site. I wanna thank those people who came in online to join us today. I'm sorry we didn't collect your questions and opinions to bring forward that wasn't really possible today but we're very grateful that you have joined us and I wanna thank everyone here today for being with us. Thank you. Thank you.