 Welcome. This beautiful afternoon. Thank you all for joining us. I'm Steve Morrison from CSIS. For many of you this may be your first occasion to be here at our new building and welcome. This is a new phase in CSIS as we move into our 51st 52nd years and people here are very excited about this change and I think it gives us all sorts of new opportunities to to engage with our friends like yourselves and so thank you for being here. The second point is congratulations to the editors and the authors to this volume that we're here to talk about today. Non-communical diseases in the developing world addressing gaps in global policy and research and I hope you've had a chance to at least acquire a copy. Maybe you haven't had a chance to read through and digest it. I think as we'll hear in the course of the presentations in the conversation today this is a really important piece of work. Important if only because it has asked some of the most fundamental questions about what is it that needs to happen in operationalizing a strategy on NCDs in low-income and lower-middle-income countries what should the priority focal areas be and how do we get there and there are four or five key themes that I'm not going to preempt our speakers will hit on those today both Lou and Jeff on where the analysis carries us but I think Lou and Jeff and the authors in the volume I think you all deserve enormous credit for helping us think this through. It doesn't surprise me Jeff has been an academic in his origins and a medical and health academic before having a very distinguished career with Merck and then a career in Global Health Council and now with Raven Martin and this is in your genes man. This sort of thinking and analysis, convening, getting people focused around, thinking hard and putting words on paper in a clear and very intelligible and forceful way and so congratulations and of course partnering with Lou Galambos from Johns Hopkins University and this has been his life in producing these kinds of very forward-looking and visionary analyses. He's a professor of history at Johns Hopkins University. He's co-directs the Institute for Applied Economics, Global Health and Study of Business Enterprise and so we are gathered here really today to hear from the two of them and then to have a broader conversation and we've been very fortunate having Sally Cowell join us who's the Senior Vice President for Global Health, the Merrin Cancer Society, familiar to many of you for the decade of her work at PSI and before that all of the different work that she did stretching back to as a career diplomat, as a deputy director at UNAIDS, as a key personality on matters pertaining to Cuba and on and on and on and Trevor Gunn who's the Managing Director on International Relations at Medtronic, also a good friend, also a person who brings enormous sort of intellectual weight. He's an adjunct professor at Georgetown, a PhD from London School, a trade expert, a public health expert and a geopolitical strategist. So we have quite a combination of backgrounds and expertise to come to this conversation here today and what we're going to do is ask Lou to kick us off today with some opening eight to ten minutes of presentation around what does this mean and where do we look forward from here and then we're going to turn to Jeff to offer some additional remarks around the volume and where it points us and then we'll turn to open things to a conversation and we'll have Sally and Trevor help us kick that off and then we're going to turn it to you and ask you to join that conversation and we'll try and get to that point fairly rapidly. So without any further ado, I would like Lou to open us up this afternoon. Welcome, Lou. The floor is yours. Thanks a lot. It's good to be here. It's a beautiful day. Frequently, you get a lot of bad news in in the newspapers. I still read a newspaper, two of them. And so I have some good news for you to start out with. And that is that the biggest major in undergraduates at Johns Hopkins University is now public health. I have 126 students in a course on the history of global public health since World War Two. And it's a joy to teach them. A lot of them have direct experience. They've done internships. And so it's a marvelous experience. Great enthusiasm. So I'm really happy to be here. And Jeff and the other contributors want to thank Steve and his team and in this beautiful place. Wow. I'm blown away. So it's a nice place to be. But some of the news is not good. As most of you know, non communicable diseases, which is our subject matter, which includes cardiovascular disease, diabetes, asthma, chronic respiratory infections and cancers are the leading causes of disease worldwide. An estimated 36 million people. This is a stunning number. Die from such diseases each year. And what is less commonly known and certainly among my students is that 80% of these fatalities occur in low and middle income countries. So it's not distributed evenly over the world. These statistics are stark. And they hide, I think, the human toll and what this does to societies. In 2010, cancer alone killed 8 million people in a picture similar for other NCDs. One in four deaths globally from heart disease or stroke 1.3 million deaths from diabetes. Current trends continue to be a 17% increase 17% increase in the NCD burden over the next decade. Africa, for instance, and by that, I think my main references to Sub-Saharan Africa, see the growth see a growth of more than 25%. The absolute number of deaths will be greatest in the Western Pacific and Southeast Asia regions. The good news is that that many of these fatalities are are preventable, both through programs that aim at reducing high risk behaviors, tobacco use, alcohol abuse, poor diet, sedentary lifestyles, styles, and it creating better environments. Progress can be made there through improved treatment and service delivery for patients who need now chronic care. Cost effective interventions to reduce the burden of these diseases exist. And sustained action can prevent millions of premature deaths. Most of the medications that are needed are now off pattern and can be used in generic form, which makes a tremendous difference in terms of cost, as you know, a global movement for action on NCDs has been gathering momentum in recent years. Now largely because the efforts of people like you in this room who have an interest in the issue and are looking ahead, the UN General Assembly passed a resolution on the prevention and control of NCDs in 2010. It's very interesting in teaching a history course to watch a series of movements develop and to watch how it gathers force and the number of people and institutions around it. And there's usually a great surge and then a turn in the movement. So it's wonderful to watch. And one of the things I like to teach is that that some of it has elements of contingency. And leadership still matters. Everybody thinks of the great environmental forces that shape all this. And they are important. There are economic and political factors, but also leadership shapes this. And we try to bring out some of the leaders when we do this. This is a global movement, though. In September 2011, the UN convened a high level meeting that you know about that led to the adoption of a political declaration, laid out a clear plan for global surveillance, monitoring and the things that would help that in a health system response to prevent and control NCDs. In May, just of last year, the 65th World Health Assembly set the first voluntary global targets for a 25% reduction in premature mortality from NCDs. And the target there is 2025. Last month, the World Health Organization issued a draft terms of reference for the UN interagency task force on task force on the prevention and control of noncommunicable diseases. I want to get the title right. And this week in Geneva, right now, the who has convened a member state consultation on a proposed global coordinating mechanism to support work on the global NCD movement. As we'll talk about this afternoon, there are clear roles in for civil society and the private sector to work together with the public sector in answering this call to action. In 1978, 1978, and you had Alma Ata, and you had a call for action, but it did not include the private sector. You couldn't do that at that time. In 2000, you could. And today, you can. And today, you have to. And so I think multi sectorality is a very important subject. So there's a clear roles, I think, defined for the private as well as the public sector. Policy makers need to decide how best to incorporate NCD responses into existing funding streams, money matters and programs. The path forward on NCDs is and will always be contested. There'll be debates, critiques, they'll continue to pour out while health care workers will continue to implement and refine a set of rather ambitious, measurable, time bound, achievable targets and metrics on NCDs. The global monitoring framework will provide accountability if governments and their partners implement and support independent mechanisms to track progress and build capacity for coordinated multi sectoral actions at country, regional and global levels to fulfill the commitments that have been made in 2011. These actions should develop along four related lines. First, there'll be efforts to achieve better integration with other health system priorities. Second, this will be accompanied by new efforts for implementation of best buys. That is, we do have to pay attention to cost all of the time. The proven cost effective interventions that can help prevent NCDs are to treat those that are most prevalent. Third, integration and implementation will require attention to innovation. This has been for the last 40 years, my major subject of interest, which is innovation in the public, private and in the nonprofit sector and the way they work together when it works. And so this is an extremely important potential for development in the future. Things like poly pills, comorbidities, the things we can do that bring things together and make it better, make better use of our resources. A new multi sectoral partnership will address this. Fourth, as always in health care, there'll be a search for additional investment. There will be a search for money so that adequate resources are available to meet these NCD challenges. This was the context in which Johns Hopkins Institute for Applied Economics, Global Health and the Study of Business Enterprise. And in this we were led by Jeff, no doubt. Jeff is a formidable leader in this regard. And he helped us get the Institute involved to make actionable recommendations. That was our goal. To come up with something, we all had a general picture of what to do and sort of what needed to be done. We wanted to translate that into actionable recommendations. The members of the NCD working group included Sir George Elaine, Robert Black, Johns Hopkins Felicia Nall at Harvard Global Equity Initiative, Margaret Crook, Mailman School, Sanya Nash Nishtar, Hart Vile Pakistan, Richard Lang, who helped us, Seren Soran Matki at the RAN Corporation, Kenji Shibuya at Tokyo University, and Brian Whitegate at the University of Montreal. Also Prashant Yadav at the University of Michigan. Jeff and I were also part of this working group. We built on the 2011 RAN report on improving access to medicines for non-communicable diseases in the developing world. The working group decided very quickly to focus on these five specific areas. These were accelerating regulatory harmonization, an important subject, which has tremendous political aspects, structuring supply chains more effectively, improving access to interventions, restructuring primary care, and promoting multi-sectoral action. And that brought out the book. That's what the book is focused on, which Jeff and I co-edited with Rachel Calvin Whitehead. It's the product of a collaborative dialogue among the members of the working group. It identifies what needs to be done and offers a framework for how to approach this work. Now I'll turn over to Jeff, who's going to provide you an overview of the book's recommendation. Thank you. Thanks, Lou. So I'll just take another couple of minutes to walk us through in a little bit more detail what the recommendations are from this collaboration that Lou talked about. And also, I'll be surprised if you don't tell us when you have a chance to intervene later that we've missed something that's really important. And as I said, I won't be surprised because we aren't suggesting that these five areas are the only things that need to be done. These are five pragmatic recommendations for things that can be done now to really move this agenda forward. So the first, as Lou mentioned, Brian Whitegate from the University of Montreal has a chapter that talks about regulatory reform. And when we think about access to health technologies, particularly access to medicines and vaccines, it's fair to say that a lot of attention focuses on how affordable they are in lower and middle income countries. But the reason that regulatory review is so important is if the medicines aren't available in those countries, there's not much you can do, whatever the price is. And as we know from experience, for instance, with getting HIV medicines into Africa over the last 10 or 15 years, because Africa has 54 different regulatory bodies, it often is a challenge to make sure that a given antiretroviral is available to everybody who might need it across the continent. So that's why regulatory reform is so important. And this comes under two headings. Lou mentioned regional harmonization, which is one possibility. And there are many initiatives along these lines. And the chapter provides much more detail on this. But the idea there is that if you're a small country like Togo, it may not be necessary for you to have as rigorous a review in Togo as you might if you were South Africa or the United States for that matter. And that there are, through the regional economic groupings like SADEC and Comesa and the others, there are initiatives now that the African Union is also trying to bring together in a harmonized way so that a country like Togo can really depend on review, the technical review that's done elsewhere, and then just make sure that that's consistent with their own regulatory and legal framework. But it would be a much more efficient way of ensuring that medicines can get to more people rather than having 54 reviews. There might be a harmonized review on a regional basis. And this applies as well in Asia and Latin America. The other point is capacity building. And that, you know, obviously this audience thinks about capacity building in many ways. But here, the chapter really focuses on the possibility of stringent regulatory agencies working with like the FDA and the European Medicines Agency, the Japanese FDA, working together with agencies in lower and middle income countries so that they can help build the level of skill in the national medical regulatory agencies so that they'll be able to do a better job on a range of things, not just the technical review of dossiers, but also, for instance, building laboratory capacities so that they can deal with questions of counterfeit and substandard medicines, which is a big problem that regulatory agencies in these countries face. The second area has to do with supply chains. And this is where Lisa Smith and Prashant Yadav from the University of Michigan have contributed a really interesting chapter. And what they do is step back from this question and really look at the structural obstacles that impede access to medicines and other medical supplies to people in developing countries. And they look at this from the manufacturer all the way to the patient. And the critical issues here are the fragmentation of supply, because in many countries there are just so many, you know, uncoordinated ways that medicines are imported and then made available that often you just don't, you have poor economies of scale, poor coverage, and leakage from the supply chain. And so it just doesn't, isn't the most efficient way to ensure that people get the commodities that they need. So they look at a variety of ways of solving this problem, for instance, accredited healthcare retail networks and also wider use of differential pricing in a more systematic way. And so that's an important area. The next area that we focused on was what can we learn from the HIV epidemic that can be applied to NCDs. And this is where Sorin Matki from the RAND Corporation had some interesting ideas. And he focuses on really two key issues. One is the importance of partnerships so that companies who are involved in helping to deal with NCDs can, you know, not only can bring novel products to the market and that's the second point, so I'll get to that in a moment. But they can work together with other players in the healthcare systems to set up partnerships that will take advantage of skills that companies have and bring them together with community and government stakeholders to try to do a better job of creating programs that, for instance, will train community healthcare workers to help complement what doctors and nurses can do. They can think about ways of applying methods for improving adherence to therapy, which will help improve health outcomes. And a number of other examples that Sorin gives. The other example actually Lou alluded to in passing has to do with product innovation. And there I think there are some interesting opportunities for work on what are known as polypills where, you know, there are so many comorbidities in NCDs. People with diabetes will have high blood pressure. People with elevated cholesterol, you know, will, you know, may have also have high blood pressure. So there actually are some initiatives already in looking at ways that you can formulate some of these medicines into one pill that will treat many conditions at once or several conditions at once. So that's another area. The fourth has to do with primary care. And, you know, this is, well, you know, people often say I love all my children. So, you know, I love all the chapters in the book. But this is probably the chapter that I like the most. Margaret Crook and Gustavo Najenda and Felicia Knall have written a really interesting overview of the way in which reconfiguring primary care can actually help us get more health for the money that's invested in health systems in lower and middle income countries. And they look at just as Lou talked about four eyes of integration, implementation, innovation and investment. They also look at four eyes. Some of them are the same. Integrating primary care across, you know, for instance, you know, this audience knows well the work that PEPFAR has done to build a platform that has really made it possible to much more efficiently treat people not just with HIV and AIDS, but also to bring other interventions in, say, maternal and child health. And also, I think there's an opportunity to do this in NCDs as well. So they look at ways that you can integrate across the primary care platform to deal with a range of different conditions. They look at innovations in service delivery, for instance, how you can use community health workers for task shifting. They look at the importance of including communities in the voice of the patient in designing the programs that are going to provide improved primary care. And I think that's a really important point. And then the fourth is to look at the ways in which new information technologies can help extend the reach of primary care. And so they give some examples in Latin America and Asia and Africa where M Health initiatives have actually done a good job of doing that. And then finally, well, actually, there are two other chapters, one by Sir George Elaine and Sonia Nishtar looks at the importance of multi-sectoral and intersectoral collaboration. One of the things, they actually make a distinction between those two. Often they're used interchangeably. But what they say, first of all, they observe that the political declaration mentions at least 15 times the notion of multi-sectoral partnership. And it's interesting, I just one aside is that the political declaration may have said that, but it's interesting to me that when the WHO convened this member state consultation this week on the global coordinating mechanism, the first thing they did was decide that they didn't want anybody but member states sitting in the room. But we can come back to that. But what Sonia and Sir George do is make a distinction between multi-sectoral and intersectoral. Multi-sectoral would be a whole of government. This is the easiest way to talk about it. So that you want to have not just the health ministries involved, but education and agriculture and sport and transport and communications because all of those ministries, all of those sectors have something to contribute to health solutions. And then they talk about intersectoral cooperation and here another way of thinking about that is whole of society. So it's not just the organs of government or an interagency approach within government, but you want to work with civil society and the private sector to convene partnerships or to create partnerships that can actually help to translate this mandate of the political declaration into practical action. And then finally, Stuart Gilmour and Kenji Shibuya from the University of Tokyo take up the same theme as one of the cross-cutting themes throughout the book. And they talk more about the importance of thinking differently about global health governance so that this kind of collaboration and coordination among sectors really becomes part of the DNA of work in global health because that's a way in which we'll really have an opportunity to improve the equity and efficiency and responsiveness of health systems in NCDs as well as in other areas. So that in a pretty big nutshell are the set of recommendations that we offer. And as Steve said, we're offering this as a way to try to help focus what's been a very broad-ranging debate over the last couple of years into areas of work that will actually move us from better policy, which is important, but to translate that to programmatic action that will really help us reduce the burden of NCDs. So thank you and I'll stop there. Thank you very much. So you've focused us into these five areas. You've reminded us that political leadership, Lou, that political leadership is essential. You've hinted around that there's still quite a bit of residual antagonism and suspicion around the private sector, although the private sector remains absolutely essential to what is going to happen. And you've given us these five key points to think about. So Sally, from the standpoint of the American Cancer Society, from your background at PSI and elsewhere, how does this framework look? And what would you argue needs to be, you know, from where you sit right now, what needs to be the sort of sharpening of priorities looking forward in lower and middle income countries? Well, thanks very much, Steve. And let me join the others in congratulating you and CSIS on this beautiful new building. I must say for many, many a lunch on the basement of K Street, it's awfully nice to be looking out at the trees. And I must say more importantly, to have the same high quality programming that went on at K Street move over here to Rhode Island Avenue. So thank you very much. And thanks for the invitation. I think this is an enormously important book because it's so pragmatic. I've always been a fan of not sitting on your hands while ringing them. I mean, I think we need to get on with things and we need to translate lofty ideals down to what can really work on the ground and what can governments do and what should they do to stop talking and start doing. And I think we know what to do in many cases. And this book lays that out very carefully. I guess the one, I'd make a couple of additional points and and it comes out in the book, but to my way of thinking that quite strongly enough. And you wouldn't be surprised coming from the point of view, I suppose, of the American Cancer Society, but you shouldn't be surprised from any point of view that for me, if you don't do anything else, do something about tobacco. I think tobacco is the only risk factor, which is common to all four of these large diseases that we've talked about. And it now accounts for one in six of the NCD deaths are tobacco related. There are 15,000 people a day who are buying dying from tobacco use and another 1000 who are dying from the effects of secondhand smoke. So tobacco is key. 600 million people who are alive in the world today, which is almost one tenth of the world's population of now 7 billion will die from tobacco and half of them are now children. So way back to the 2011 high level meeting and I must say to CSIS report going into that meeting said start with tobacco. It's a way to frame things and it's been talked about, but it should be the lead engine and I think we're not making enough progress on that. And that should be the framework convention on tobacco control exists. It's been signed by many nations. It's not necessarily being implemented. Even now all around this town and other town trade talks are going on. The tobacco trade is a key part of that. So I'd like to see some focus on that. As Steve mentioned, I have a I come from the AIDS world really to the AIDS world and then to reproductive health and now to non communicable diseases. And I think from the AIDS epidemic, we learned a few things that are key here. And one of them is that money is crucial. You know, money alone isn't enough. But without money, you really won't do very much. And today, the spending on NCDs by international donors and by country governments themselves is nowhere near in proportion to the epidemic. So in 2009, the spending by the international, the official government money going as donor money to support health programs, about 1% of that was going to NCDs, whereas globally, non communicable diseases are about 45% of the disease burden. And in some countries, of course, very much higher than 45%. But 45% and as this book points out, increasing to 75% over the next couple of decades. So the spending is lagging. That was true in the AIDS epidemic too. I speak from somebody who goes way back in that to the time when priorities were otherwise. And it took real political will and real political commitment on the part of countries themselves, and also on the part of donor nations to reverse that. So I think without the political will that you saw that led to the establishment of the Global Fund, which turned on the taps for money, we would not have made the progress in attacking the HIV AIDS epidemic that has obviously been made all across the world. So I think we need to get the spending up there. I agree, certainly that multisectoral and I would not call them PPPs, but PPPPs, private public people or patient partnerships. I think it's true in all diseases, but especially for these non communicable things. I mean, you are your own risk factor in many ways. So we need to involve people. This is not something that can be done to you. It's something that you have to participate in. And certainly, it's something that writ large, I think our industries and businesses, the private sector in health care is important. At the community level, I know this certainly from my work at PSI, the sort of half of the health care in the world to low and middle income countries into low and middle income populations is in fact delivered by the private sector. We also know the private sector supplies a lot of all of the products that we eat and the products that we use in our daily lives. So I think it's important that we involve the private sector in this conversation. And the final thing, and again, this alludes to the book when it talks about primary care. I think we ought to remember that really non communicable diseases are a game changer in terms of the agenda on women's health that we have been pursuing for the last four decades. All of the MDGs are really measured around pregnancy, preventing mortality, from pregnancies, from unsafe abortions, from things concerning women and their reproductive life. And certainly it's important to continue focusing on those things. In many countries of the world, the Sahel, for instance, Mali and Niger and other countries still have really, really, really high births per mother. And no one says that it isn't important to have people have the number of children that they want to have and have families of a smaller size. But in many countries, it's really cancer and other non communicable diseases have overtaken pregnancy and HIV as the primary driver of death in women. The good news about the last 30 years and the really significant progress we've made in maternal health and HIV and AIDS is it gives us so many more points to intersect with women throughout their life cycles. So we need to be capturing that. We need to be, when women come in for anti natal care, we certainly need to be testing them for gestational diabetes, for high blood pressure, preeclampsia. When a woman comes to have an AD inserted, why wouldn't we do a cervical cancer screening? And then speaking as the only woman on this panel and also of a woman of a certain age, let me also say we need to talk about women beyond their reproductive years and to be continuing to involve women who are not only extremely vulnerable but also in so many cases the supporters of their families and the providers of health care need to keep women healthier longer and keep them from dying prematurely. We know what to do and there are lots of exciting movements that came out of the high level meeting like a women and NCDs task force that I hope we will be able to employ to make a real difference on the ground in communities and nations and families. So that would be my comment on this extremely valuable book. Thank you, Sal. Medtronics has been really in a lead position for some time now in trying to stir discussions and get the Alliance supported and lead up to 2011 and partnering with lots of different institutions around the world to contribute to a greater training capacity, skill levels, understanding, applied research, and like Trevor, you've been a very guiding hand in all of this process. How does this framework look to you? What would you add to it? How would you sharpen it up from your standpoint? Adding is tough to do because it is, again, adding my congratulations to the authors, certainly it's a path-breaking work and certainly hits directly at one of the fundamental problems is how misunderstood non-communicable disease is and the fact that it, most in the world would probably say it's not relevant to the emerging countries and it hits directly at that theme and I think that that's exactly where it ought to be. Perhaps it's more in the second category, Steve, of sharpening that I'd make some suggestions. Certainly I think that we need to get a right definition on multi-sectorality and intersectorality, however that's called, but I certainly want to compliment Sir George's continued leadership. That chapter in the book is a part of it with his co-author and it's correct, as Jeff has said, I think that the private sector feels at times that we're just one big private sector and sort of lock us in a closet and don't come out and maybe when we're screaming you'll open up the door and that's not the appropriate framework for the modern society in which that is not what the major leaders of the world had in mind when they put those 15 references. I've heard 17 references, 15 references, but there are a lot of them. And if you look at the MDG Eminent Persons Report, Homie Hamras just down the street was the author of that. Major report in advance of the MDG goals. NCDs are well mentioned and the role of the private sector equally critical to the success in those. So we, you know, I always say spell out the rules of the game, figure out what it is. I realize that there's a part of the private sector that certainly it's not welcome and I probably have the same personal views exactly consistent with Sally's on what that is, but there are a lot of other parts of the private sector and other organizations, educational institutions, architectural organizations. Look at, you know, one of the most clarifying moments was when I visited Steve a little bit ago and John Hammer, the president of this place, we stopped in the hallway to talk him and he went into this extremely graphic discussion of how this actually building was built and how exactly they got lead standards met. And, you know, that's not your normal discussion you have with a CEO of any organization and you've got to engage all these people in this discussion. You know, we're going to be across sectors. We'll have no success if everyone isn't involved. Even if we disagree with each other, we need to be involved and we need to be sitting at the same table. And whatever we call it, Sally, whether it be PPP, PPPP or whatever we call it, I certainly welcome the issue of the attitude I think is relatively the same and putting the patient in the middle of it and I certainly think that that's the right way. We're starting a new activity over at the Institute of Medicine. We have to be on that part of that activity where we are going to be sitting down again in that sort of multi-sectoral way to figure out what is the right way forward. And as you look at why PPPP, PPPP, whatever they are, are done or not done, you really come down to this issue of conflict of interest at really at the core and really kind of look, the financial services industry went through this particularly after 2008. It can be done. There are reasonable ways to disclose these issues and disclose your conflicts and those issues when we go into conversations where I go between I'm on the ink part of the business and when I cross over to the philanthropy part of the business, my colleagues have shown the leadership that you've seen on the philanthropy part of the business. They deserve the credit but there's also legal lines and ethical lines that when I go back and forth between those lines I very sharply always try to point out. And I do want to, again I think Sal you said it beautifully which is Rachel Nugent, a dear colleague of mine and Sir George, Rachel and I particularly before the high level meeting would have these quarterly coffees, sometimes lunches, really healthy stuff in addition. And we would sit down and try to figure out what are the basic principles that we wanted to adhere to that ultimately some of which are actually embodied in the political declaration. And Rachel who is now out at the University of Washington did I think a seminal report that deserves repetition that talks about the percent of global donors right now in the NCD space. It hasn't changed very much but the reality is the epidemiology is changing much more quickly to the negative without that action. I think that, you know, I always look at ourselves in the mirror and I hope as an organization we always do that and say, okay if we call for multisectorality, we call for the public sector, if this is a major public health challenge, the public sector also participate, are we actually participating? I think some of the things in this area and they're well documented and we're happy to disclose any of the figures or results that we've got behind those. I think most of you know we've recently put a very major commitment on the street in the past two or three weeks that some may know in the room which amounts to about $16 million over the next five years. That is a philanthropic commitment. We're very interested in local engagements and we're not stopping there. But in a certain sense we need the public sector truly to participate. It can't be in a very strange way, I feel at times that we're leading the public sector. That's not a great place. We need the public sector alongside us. Even if we sometimes disagree or have issues, we all need each other in a certain sense. It sounds trite but the reality is that's the modern reality. And what we need going forward for solutions here Steve. Thank you. Thank you very much. I'm going to offer just a few remarks and offer some sort of counter thoughts to some of these five areas and ask our participants to react to some of this and then we're going to open things up. In terms of just a few remarks, we got through the last decade of explosion of commitment and interest around infectious diseases. This decade is still to be defined, right? And we did have the global burden of disease report almost a year ago which was to my mind a thunderclap and in terms of the data, the analysis, the quality, what's happened since then. And now we have the move towards the post-2015 framework. The sea change of discussion now around universal health coverage. So we're in a different era. We're in a different decade. It's still to be defined. Work like this helps us to define that. So I think it's important to emphasize that. Now on the five points, on the regulatory authorities piece, I think this is very timely. We have, yesterday we had Peggy Hamburg here from FDA. And Peggy Hamburg has been a leader joined with Brazil and many other regulatory authorities in trying to find a way forward of creating much higher levels of cooperation and capacity building across regulatory authorities. So the timeliness of this suggestion I think resonates with what's happening within our own government and many other governments where the regulatory authorities are looking at this. But I think we need to be very humble. The amount of confusion and data around illicit, the illicit marketplace is quite staggering. And it is a health security problem and I think in terms of sharpening the argumentation, the resistance that we're seeing emerge across multiple areas and the inability and difficulty of engaging India and China meaningfully into this is fundamental. So I just put those out as cautionary points but I think that this you've identified a very quick evolving issue that is a priority in other places for many of the same reasons. On supply chains another key area and I think we need to be fairly realistic. Supply chains are a very useful device for supplying cash to political campaigns and to offshore accounts. Supply chains supply different value for different people and the health sector has been a honeypot for years in low income and lower middle income countries for supplying value in other directions and one has to ask how do you turn that around and where do we see what does it take to correct that deep seated set of habits of corruption and diversion, financing of political campaigns and lining of offshore and inshore accounts. On the public-private partnership this is very the whole private sector issue I think it's very contested territory it seems to me. This is the big puzzle that people have to grapple with which is the antagonisms and suspicions concentrated around the food and beverage industries the difficulties that pharma has on conflicts of interest and the like. The medical products industry that Trevor represents is perhaps better positioned to navigate some of those tensions and play more of a convening and intellectual leadership but there are others many others obviously within the food industry who have stepped forward perhaps we could hear a bit more about how do you move through this very contested terrain. On the prevention and primary care place, piece of this I think only to say I think that there is a sea change underway and I agree with Jeff this is the sweet spot I think for where change is really possible. If people are talking about universal health coverage they're talking about expanding primary care access and the like it's the foot in the door it's a change of outlook and norms and political commitments that point people in that direction and that's very good. On the integration issue ag, transport, urban planning and the like I would say even more powerfully urbanization if you look at those places that are facing galloping urbanization that is where this possibility of integration and the absolute imperative of integration comes into force and obviously China's dialogue with Jim Kim and the World Bank looking at 150 million people moving into the next 15 years moving into the coastal urban settings and having to think in a much more multi-sectoral way about how do you prepare for this reality and if you don't prepare you're going to have an absolute catastrophe and every government in Africa every low income government fears in its own way that urbanization will overwhelm it in its own way if a peasant agriculture is not preserved if other opportunities are not preserved so I think there I would make that argument even more powerfully I think that the framework is I think those five organizing concepts are very valid and they point us to some really tough challenges. Perhaps I could ask Jeff and Lou to offer some thoughts here from Sally and Trevor and then we can open the floor so thank you. Sure, well thanks to Sally and Trevor and Steve for those provocative and really interesting comments on what they my first reaction is that it just reinforces the conviction I've had for a couple of years now that this is such a rich and complex set of issues that we better figure it out because the future of global health really depends on sorting these issues out in a way that leads to effective action. On just a couple of points I'll make on to draw together some of the things that all three of our commentators said I think I'll start with where Steve ended with urbanization and it's already the case that more than half the global population lives in cities and that percentage is going to increase over the next 20 or 30 years but the cities I'd venture to say that most of us in this room when we have a mental map of urban centers we think of places like Washington DC New York, London, Tokyo but the cities in 2030-2050 if you just think ahead to where these trends are going we're going to see that most of the top 20 cities in the world in terms of population will be in China and it's places like Lagos not London that are going to be more like the cities of the future and so I think it really makes sense for us to think about how to integrate the challenge of dealing with growing urban centers with making sure that providing for the health of people living in those centers and the surrounding urban areas is really addressed in an effective way now that's sounds ominous on one level but on the other hand it really is an opportunity because one thing about cities is that it's easier to reach people in an urban center than it is to find all the people out in rural areas who live in very small villages and it's just as much more complicated to reach them that's one reason why we've seen a lot of attention recently to the last mile that is getting health resources to people who are far away from urban centers but I think it's you know if you apply the Pareto principle if we come up with solutions that will work in major urban centers we'll really be able to help most of the population and then we can also address additional ways to reach the rest so I think that's really an important point and the other thing I just want to say really is Sally and Trevor and Steve have all talked about the importance of partnership and collaboration and I many of you know that I spent 20 years in the pharmaceutical industry before I went to the Global Health Council and now I try to help all kinds of clients solve puzzles they have around global health issues but one of the again I'll use the word conviction a conviction I have based on that experience the problems that we face in global health now are so complicated and so just so challenging to really deal with at scale that a solution that focuses only on whether government is going to meet the challenge is unlikely to succeed in the same way that a solution that focuses only on how the private sector can do it or communities can you know find ways to organize themselves and take care of business on their own isn't going to work I think the only way that we're going to be able to deal with this complex set of issues is to find a way to ensure that everybody has something to contribute is part of the solution and we can negotiate all of these you know difficulties around conflicts of interest around the skepticism that one sector may have about the other if we just focus on finding something we can agree on to work together to solve and then use that as the basis for trying different ways of working together when you succeed with that that gives you an opportunity to move on to the next thing and over time that just leads to you know more and more confluence of interest and convergence of activity around the big problems that need to have everybody engaged to solve so I think that's those two points I think are the ones that stuck out to me from Lou I will give you my note of personal involvement and that is I believe adherence is an enormous problem that's going to grow it's bad enough in our societies and it's going to be even more in the lower and middle income countries and so I see primary care primary care is the rate controlling institutional change as I see it myself and that's just a personal observance finally about tobacco I say that my sister died of secondary smoke and my father died of primary smoke I've often felt that if I'd had a video of my father dying it would discourage quite a few smokers I didn't have that and wouldn't do that but it is a crucial issue so I'm really happy to see these kinds of suggestions bubbling up because that's what we want to do so thank you Trevor and then Sally and then we're going to come to our audience here folks never said they had a problem hearing me but there we go for those that are remote regulatory harmonization I think Jeff you called it out or someone else called it out I think that really has to I mean all barriers some of which are tremendously are artificial to access governments need to do their work the private sector needs to do their piece when it comes to this and this is where the regulatory harmonization piece kind of bothers me a bit because if I look at the WHO map which I have great respect for the work that they do and I'll be into WHO medical devices for them next weekend in Geneva presenting on trade agreements but what I would say is as I look at their map of countries that are regulated for medical devices it looks like all the countries are regulated for medical devices but the reality is only about 65 are actually regulated for medical devices they have any real competency I'm talking countries like Chile who just decided a very advanced country who just decided to regulate medical devices and it's still in draft form and so I do see as well donors such as colleagues that are doing great work over at the World Bank under Gates funded project that are working in East Africa and that regulatory harmonization is only confined to drugs whereas I think the real mystery to solve is actually for devices that are not easily solved we need to break down some of those artificial barriers and see what can be done in that particular area obviously tariffs we have something called the information technology agreement negotiations that are occurring as we speak in Geneva it's another area that governments we can help but there's limits to what we can tell the government and there's a good sense of revenue as well for those governments but at the same time they actually do prevent access to technology to other services that actually may be able to bring slow the pace of some of the trends we're talking about Sally just one very quick comment and that's for all that I said we need more investment by governments there will be another global fund created for NCD so I think most of that investment is going to have to come from the private and public sectors in the countries around the world and I think that effective advocacy and getting people involved and advocating for better or for worse most countries in the world now are democracies and they are at least somewhat responsive to the public will of their societies and so I think we need to energize people in these countries to encourage their governments to invest and governments have to think that the prevention and treatment of NCDs early on is really an investment and not a cost you know there's a difference between a health care system and a sick care system and governments I think would be smart to get on with that as soon as possible and to encourage the private sector and cities which are walkable and preventing obesity and doing something effective about tobacco but invest early and often just like Mary Daley said about voting I guess okay why don't we we've got a number of folks we'll take comments and questions we'll bundle together several there's some hands in the back so we'll start on the backside there Lois and then we have three or four please be brief please identify yourself yes sir please be brief we'll do four or five and we'll start with those in and around you Lois so you kick us off hello everyone my name is Lois Pace I'm with the Lyft-Shawng Foundation very much appreciate Ambassador Koal's final comment around there not being new money so Lyft-Shawng Foundation as people know has been on the hill has been meeting with the administration and what we continue to hear is how can we do more with less and so I'm wondering Jeffy talked about are there specific case studies therein that explain how people can actually be doing i.e. addressing NCDs now with the platforms and frameworks that we have whether that's through maternal child health programs or through PEPFAR there are only a few examples still Partners in Health, Pinkerman and Reverebin I need more in these meetings that I'm having with state with the White House and with congressional offices thank you just in front of you there Hi, Carolyn Pryor from Millennium Challenge Corporation nice to see you Trevor we had a non-communicable disease program health project in Mongolia that was very successful and my question we had a nearly 50 million dollar budget so we were very unique I think in the NCD portfolio field right now in terms of what we could do and our advocacy spanned many different types of advocacy including even a drama series a soap opera of sorts of 30 episodes regarding non-communicable diseases and I was wondering what in your experience is the best way to get the people part the advocacy that's worked in your previous experiences has radio been the solution TV, public outreach campaigns what works because we did so many different things it's hard to discern what actually worked it was successful but we were able to spend so much money now when I'm talking to other donors that are trying to work in this field it's hard to say oh this is and I understand obviously there's unique country context to all of this but it's hard to say oh this is a good way to go because we were able to do so much fortunately thank you yes my name is Michelle Farmer I'm with Jepaygo I just have a question I mean I want to thank you all for all your wonderful comments and the perspectives very important areas and challenges but one area that I haven't heard much discussion around is adolescence and young adults and the role of the need to try to address NCDs in this context I mean we think about best buys as an example doing a lot with prevention and early intervention with just a few dollars I think that addressing the needs of adolescents and young adults age 15 to 25 would be a very important area having a big impact on obesity tobacco use and a lack of physical activity all as precursors to the major non-communicable diseases so I'm hoping that you can make some comments about opportunities to intervene for our citizens as well thank you thank you very much for a lovely presentation my name is Manos Harrison I'm with Project 216 I had a Fulbright in Georgia and the focus of my work being there was to develop the cancer control policy for therefore I brought all this multi-sector you name it together to draft that and it was coinciding with the UN 2011 September on NCD where I became contributor and editor of their NCD so I easily can say working in that region with the folks that they're very heavy everybody has been very heavy with the influence of WHO to actually regulate or perhaps just sign the policies that's what I want to say so signing the policy and then taking it to and implementation is where we actually do not have the capacity in those underdeveloped or developing countries there is no institutional capacity or human capacity to deliver any part of that from advocacy to prevention name it my office was in the cancer prevention center where the doctors and patients simultaneously smoke thank you okay let's pause for a moment lois put at pose the question around what are the examples of building off existing platforms where the case studies of being able to do more with less and extend into the NCD range Carolyn pointed us to the question around the people part and the innovations radio TV campaigns Michelle's looking at adolescence and Miss Harrison posing this question about how do you address these gaps in policies Jeff you want to speak to a few of those and then we'll open it up for you guys to jump in on which piece of this you want to comment on sure let me just make a comment on Lois's question first of all the chapter on primary care does have some other examples of where this kind of integration is working and I think you'll find those useful differences point to some other examples that are there in the literature I actually think and you know this is just my own opinion but I think that PEPFAR is the best example we have of how integration is actually enabling the program to get more health for the money and to do more with less you know many of you are familiar with this but I was speaking with Eric Gooseby just before he stepped down to return to California and if I remember the number correctly and Steve or others will correct me but I think that in the last 4 years they've tripled the number of people on antiretroviral treatment and the budget has been flat so that is a pretty powerful statement about how you can get more with less just by attending to the efficiency of how you deliver care and treatment and also to make sure that you just get rid of duplication of effort and really do the best you can with the materials the resources that you have now when you then expand that and also part of what PEPFAR has done in addition to getting more people on antiretroviral treatment there are also tens of millions of people who are getting access to maternal and child health to breast cancer and cervical cancer screening and they're also looking at integrating other NCD interventions onto the PEPFAR platform in different countries so I think that's the biggest and best example that we have of how this can work and the reason that it's so powerful is if you just think about it for a minute to the other comment you Ms. Harrison was making about Georgia you know yes as in many other lower and middle income countries there's a lack of institutional and human capacity but part of the problem is that you'll have a cancer center here you'll have a center that looks at maternal health here you'll have you know it's just all different kinds of interventions and in each of those centers you'll have investments in a variety of drugs of equipment training facilities and clinic facilities which could be used to provide care in other other priority areas as well and that's why figuring out a way to integrate planning to integrate the use of resources to integrate from the perspective of the patient and after all patients don't present with just one condition they have often have multiple conditions to figure out a way to do this so that it makes sense from the patient point of view and also the best use of the resources seems to me Steve was asking what's the next 10 years and global health going to look like I think this is going to be a major focus over the next 10 years because the only way that countries will begin to approach what they hope to do with the use of available resources because Sally is absolutely right I think there's a vanishingly small chance that we're going to see another global fund for NCDs so we have to make the best use of the resources that we can mobilize and so I think that this is really going to be the key set of technical and issues at the core of the move to universal health coverage Luke of those four issues that were put on the table and we're going to harvest some nuggets out of the volume to point us to yes well out of both personal experience I am the oldest single working parent with two teenage daughters that you have probably ever met and I want to comment on adolescence I have a lot of experience with that and you have to go through the schools that's the most cost-effective way you have to get people at school age and has to be done through teachers who care and that's much more effective than radio they don't listen to your radio programs they listen to theirs and TV they watch but they have cleverly learned how to get rid of the commercials and so that's my observation on adolescence about cancer control and about the problem of unit capacity I think that's a tremendous issue and Jeff touched on this I think I'm a little more optimistic about that I'm a little more optimistic about money but I think you get spill overs from all of these programs spill overs you get spill overs from clinical testing and I think those are extremely important they're hard to measure but I think if you look at what's happening on the ground that's what you see so I think that that's going to be probably more effective in a certain sense than some kind of major rationalization of a program I think that a lot of these programs where there is a breakdown in communication between parts of the treatment program I think that's a major problem but I think it's really hard to rationalize these in part because you change everyone's job Thanks Steve just two comments quickly about adolescence to Michelle's question I think the cost effective things that you can do are adding HPV vaccine for both girls and boys especially for girls and now some data out this week shows that as little as one dose rather than the three dose regimen may be effective the price for GAVI eligible countries is now down to $5 per dose so even at three doses that may be affordable in non-GAVI countries certainly in this hemisphere through a very innovative PAHO Pan American Health Organization negotiation with the drug companies I think the price is $13 per dose Mexico has already reduced it from the regimen from three doses to two doses so I think it's becoming again political will being extremely important we've seen that in even Texas and other places I mean you have to want to do it but then I think the resources are there to do that and male circumcision which we know has a huge impact on HIV so I think those are two relatively low cost interventions for adolescents that would make a big difference the other thing I would say is how important it is to have correct data I mean one of the things we learned in the HIV epidemic at the beginning and I was with UNAIDS was that everybody had their own data countries had data Harvard had data WHO had data UNAIDS created their own data and nobody could agree on the data it was an important point for advocacy and for fundraising to get some agreement on the data so I think to the point about cancer control and cancer registries I know that for cancer I assume it's true for other NCDs terrifically important to know what you're looking at what your population is facing to begin to design cost effective interventions to really take advantage of those best buys that you may have available to you and I'll jump perhaps on two of the questions if you don't mind Steve so first of all to compliment MCC on their leadership and currently for your leadership who would have ever thought that that leadership would have played itself out far away but there we are and you guys have done a great job I'm sorry you're wrapping it up and hopefully there will be more but I mean at the core of it the issue of and I think Sal you hit on this I think there's a lot more discussion and we'll be having a discussion on the hill next week specifically on this topic of tying this whole discussion to growth and how NCDs actually tie into growth now we know that health to wealth or health to growth is not an always easy argument to make but I also know not enough thought has been put into it and I think that's very very important but you didn't ask that question you asked the question about what message is the most important and I would say too employer to employee and peer to peer and what I mean and people don't think about this but if you think about you know our employment problems here in the United States 7% 8% that means a lot of other people are employed and guess what they're listening to their bosses and organizations are creating great incentives and if you're not hearing messages and actually getting incentives like discovery the vitality group covers under discovery to actually get you know healthy food or we you know I got email from my folks today fill out this health questionnaire and you'll get you know $100 off on your you know health insurance this year those are all good things and I think that's a very powerful medium because there's a perception issue that just doesn't want to go away and they keep on emailing into you until you relent peer to peer I don't think I have to talk to more but I think that's a very very and even if you you know poo poo some of the efforts at the private sectors maybe I think you would understand that that's a very important channel okay if you're a government employer your private sector employer and jail employer and I care who you are I mean that's going to be a very important and Michelle I want to come down and hug you for that question from Jepayago because a colleague of mine from our philanthropy and myself were the people that really were kind of the movers behind a specifically Jeff Mears here the co-chair together my colleague Jeff Justin Custer the NCD Roundtable but you were directly involved in something that we helped to start called NCD Child and you know I can tell you how many discussions I've had with UNICEF over the years about this discussion you know you wouldn't want to you need a calculator let's just put it that way and it is so commonsensical if we're going to talk about prevention what is more commonsensical than talking to kids about the right things and what is more important than the mother to child or father to child communication pattern when it comes to this let's use common sense we don't need to start with you know advanced medical technology we need to start with good common sense NCD Child I think we're largely the lone funder of that and led by a visionary woman down under by Dr. Kate Armstrong and Jeff you're on that and UNICEF is actually on the board thankfully and I think it's their window into this discussion I don't think you can get any better marketing vehicle than UNICEF in the world and we're very proud to be associated with but we need help we need people that are actually interested in this activity child.org and we need other companies organizations of all shapes and sizes to be active educate on this effort and active on this effort so the exact products are facts for life right it could be a global publication that's going to talk about some of those commonsensical things that we consider common sense but may simply not be common sense in other parts of the world those are very important a lot of other very practical things that have come out of it some have already been produced and you know all in on this one so thank you for that question thank you down in front here we could have why don't we take we'll collect some comments over in this quadrant yes please identify yourself Crystal Lander Management Sciences for Health and I have two quick questions both I hope are challenging the first one is we talked about PPPPs I love that Sally question is other than tobacco what industry would you not want to partner with on NCDs and then the second one is related to PEPFAR I was in DC when we worked on PEPFAR 1 and 2 it was not easy but PEPFAR 1 had very clear goals what do we want to accomplish as PEPFAR goes into its phase 2 really phase 3 it's looking at what do we want to accomplish now things have changed a lot so the question I'm asked on the hill often is what do you want to accomplish with NCDs and for us that's challenging it's a lot of things that fall into it but it's something that we clearly need to answer so what is what do we want to accomplish what would success look like thank you here we had a question here hand up right here and then over here thank you my name is Amit Chandra I sit on the board of the African Federation of Emergency Medicine and my question to the panel is how you see acute care services and pre-hospital care and on a related note how you see injury prevention and the issue of road trauma specifically fit into the non-communicable diseases debate, thank you thank you, right here and then Keith behind you my name is Laurent Ebert with the Framework Convention Alliance and almost over 10 years after adoption of the FCTC and almost 9 years after it's entered into a forest implementation is fairly low and some people argue that if we were able to at the country level there's a lot of incoherent positions like the Czech Republic for example on one side right across the FCTC adopts a tobacco bill on the other side it's involved in a trade challenge against Australia in support of Philip Morris so some people are arguing that integrating NCDs and tobacco control in the post-2015 development agenda could help create more coherence at a national level so I would be curious about what indicators would you think are appropriate in the post-2015 development agenda under whether it would be universal health coverage or extended life expectancy overarching goal and what type of NCD target and then indicators would you like to see under that that was one question and the other one is about tax and fiscal policies which have been identified as the best buy but also could be a source of resources for implementation of NCD policies at country level thank you very much for your timely presentation and Steve for organizing this get together we know what to do to deal with these challenges we have a mountain of evidence with this economic or others to know what to do to address NCDs so my question is what are the obstacles and how do we overcome the mainstreaming of public health into primary care plus and the plus being access to basic surgical care which will deal with the issues and help to address maternal health and to address the disability tsunami that's going to hit us as part of the NCDs so the obstacles and how to overcome them thank you at least one more round here yes please thanks for this stunning panel I'm learning a lot right now I'm from FHI 360 I'm working in health communication and my question is to Sally and others what have we learned in this area from the HIV epidemic for NCDs because one of the biggest mistakes we've made is to individualize risk and not look at social cultural context and economic context of behaviors and what is planned to be done differently for NCDs in this area who would like to jump in one suggestion actually it relates both to this question and the one that raised a couple of other issues around road accidents which in some countries in Africa at least are the largest killer of children under 5 and you're right it often isn't mentioned in discussions around NCDs I think one of the things that we learned from the HIV epidemic and Sally may want to jump in here as well is we really began to make some progress in a more systematic way after the money had been raised so you went from the millions to the billions but then I think that the three ones were introduced along with the mantra to know your epidemic I think that that really helped to ensure that countries were able to take a systematic look at the issues that they faced and that helped in allocating resources so that you could really make progress on getting more health for the money so and the three ones some of you will recall were to have one national plan for how to deal with the epidemic one national agency that made all the efforts and one monitoring and evaluation framework so this gets back to the point that Sally mentioned about you can't do this if everyone has his or her own data you have to have one common framework and that applies as well to NCDs now many of the countries in lower and middle income countries are developing their NCD plans that was part of the work that was put in motion by the WHA when they adopted the global action plan so in the course of doing that I think that the question of how you can coordinate acute care with chronic care how you deal with mental health issues with road accidents with injuries as well as the NCDs that we've been talking about today whether you deal with the elderly population with kids or with adolescents all of that is going to look different you can't make any categorical statements that will actually help people deal with the issues in front of them so I think that insight from the success in the latter stages of the global response of the HIV epidemic is going to be important over the next couple of years for dealing effectively with NCDs at the country level thank you Sally? I don't really have much to add I think I would say that it is really important to take care of things and to get patient empowerment for dealing with a lot of these things I mean one of the things I think the American Cancer Society does very successfully and I think probably other groups as well help patients with navigation just to help you know whether you come in through acute care or however you come into the medical system how to navigate that how to get the services that you need I think that's going to be important as we go forward I'll answer your question there were two sort of related questions our medical colleague here and also our colleague over here Keith I heard the first name but I didn't understand your organization by the way oh CGH okay very good that makes a lot of sense I think they're sort of tied and let me give you a medical technology perspective hopefully that's relevant to public health I mean certainly so if you look at our philanthropic commitment that we've announced our new sort of $16 million commitment it's very focused on building up front line health workers very much health systems perspective trying to build up that front end and that's particularly necessary in emerging economies but certainly I think a lot of companies a lot of organizations my colleague is here from GE Healthcare Mary Ann Ring there's a lot of other companies that are here and also public and private sector actors who are working together are building out secondary care tertiary care we as a medical technology company we know a little bit about exactly the incidents that you're talking about manufacturing 71,000 technologies gives you that right to talk about that but we know that we need to change our business models we've got it so thankfully at least in our company we've got a Bangladesh CEO that very much is concerned about exactly the problems that you're talking about so you've got to change your business models you've got to make technologies that are simply more relevant we've just announced two weeks ago a kidney dialysis version of what GE Healthcare did relative to ultrasound but doing it for kidney dialysis a portable kidney dialysis unit which could be put up in your overhead airplane hangar that is instead of 300 liters of water it's going to take 3 those type of things that happen in India and others that's find places in the world you've got to change the technology landscape we're well in advance in trying to do that but we're still in the early stages of the game and it goes on and on so I'd say that a lot of things have got to change in the public health arena and that is just the absolute resolute lack of doctor capacity forget about surgical teams you know it well we're talking about just resolute lack of doctor capacity at secondary and tertiary health care levels in vast majorities of countries and we think that those investments are also necessary we're going to be a partner in making those investments along with the public sector let governments themselves decide which direction to go certainly in Africa a tremendous amount of the health care is already being delivered by the private sector so that's not an intellectual debate for them you know wherever the best care is got you don't simply have to jump on the next BA flight to go to London to have that done it should be done locally and you should have that operation with your family in present as opposed to at great distance when these type of things happen Lou you have a comment I think what cuts through all the questions is how do you get a movement started and I think my own view historically is that you're right now at the point where the highly generalized discussions the affirmation of the need has taken place at the international level and you're now moving into a period when as this book did things get much more specific and you look for solutions in part of the world not the entire world and it seems to me you also look for the resources in the same way then you're looking for some success stories that sustain resources people don't like to give money if you talk to a development officer people don't like to give money because you're in distress they like to give money because you're succeeding and so those I think will come out and that was one of the important results I think of the of the Gates and Merck combination in Botswana was to give a demonstration of what could work and I think that could happen that we're right now at that phase and so that's I think the way we see the book down in front here is a person who would like to do you have a microphone do you have a microphone Jeff has been patient no let's get a microphone Jeff's been patiently and then here and Sam and we'll come so yes okay thank you stop talking I appreciate your comment Sally my name is Kelly Buchanan director of operations at a company called Anywhere we are working to bring medical instrument sterilization to the developing world that is portable and power free addressing treatment of NCDs through central surgery my question is what kind of advice could you give to a company in product development phase who is willing and already talking and collaborating with both ministries of health in Africa and co-designing with patients Jeff and then in front here and we'll come to you Sam in a moment just a second thanks Jeff Meir the public health institute congratulations on a great panel a little commercial which Trevor already preempted but Justin Kester from Medtronic and I co-chair a group called the NCD Roundtable that meets in Washington once a month for many of you are members of this roundtable it's very focused it's dedicated to Washington DC based advocacy Sally we will welcome your participation now that you're at ACS so if you have questions about this you can go to our website ncdroundtable.org or see one of us after the meeting my question is we talked about a bunch of donors today we talked about the private sector we talked about government we didn't talk about international financial institutions and I'm wondering if anybody on the on the dais would care to comment on the role Sally you touched on it a little bit with PAHO but it's broader than that it's the bank it's all the IFIs and they are not lacking in funding so we'd love to hear your perspectives on that thank you so we have one question from Ariella through Twitter recommendations converge or diverge from the current post-2015 discussions hello I'm Elizabeth Ransom and I just finished 5 years with the university research company international health company I'm going to be starting work with the US government public health initiative next week pending my security clearance and I want to thank you for an excellent panel and a wonderful discussion so Mike one of my questions is I noticed that no one mentioned the seredip today's panel and I wonder if anyone knows what public health issue is highlighted today it's World Diabetes Day World Diabetes Day that's right and I wanted to mention it because it's the day that Charles Banting invented insulin and for me this is a very important day because without insulin I would not be alive and so I'm between jobs so I'm here as the P the fourth P in the model that Sally mentioned so the other question my professional had is I'm a communicator I'm wondering about the name I've been so excited about this NCD movement but non-communicable diseases it says what you're not but not what you are and I'm wondering if you might consider re-looking at the nomenclature thank you can you just hand that to Sam here Samuel Denny Jones stand up oh I'm sorry I don't know travel might remember you had a meeting about two years ago I asked the same question and the issue you said there might not be a global fund for NCD what if there was what would you actually use the money to do and that is a difficult question and at that time I think at that time it was posed differently the lesson I learned from HIV AIDS and from malaria as well was that the money came but by the time the money came there was a clear consensus evidence-based consensus on what a package of activities you could put together and what outcome you would get if you remember HIV was called 2.7.10 it was very clear that you had to treat 2 million people about 7 million infections and care for ten million the outcomes were very clear and how to get to those outcomes were clear but do we have a clear set of activities not broad consensus not broad framework on what these activities could be but you could put together so that a donor would say look I'm not willing to find concepts and frameworks but I can find activities that would lead to these outcomes and hold you to those outcomes you're going to set off a very interesting fight hi Lee Yerkes I'm retired sorry I was late and I apologize if these two points were covered I was involved in the initial procurement of U.S. government funded for antiretrovirals pre-PEPFAR in three test countries Ghana, Rwanda and Kenya and fortunately that was successful and PEPFAR resulted from that but I was very interested to hear Jeff's comment about the and I'm not surprised that the number of patients supported by PEPFAR has tripled with no increase in funding because I know the cost of treatment has come down significantly but I have two very quick questions number one what has been the impact of the successful HIV AIDS treatment programs on the advent of NCDs among that population and number two has there been a look at integrating the diagnosis and treatment of NCDs in that target population and at those very successful treatment sites thank you I'd like to suggest we'll come back I think we'll have time for another round what I'd like to suggest is we start at Sally and just work our way down here Sally would you like to and just pick off whichever pieces of these multiple questions you care to address they're all really good questions and I feel like we could be here all night which would be great I think certainly in the HIV AIDS epidemic the international financial institutions began to play a big role and if you look back at the World Bank already put out a paper in 2011 my feeling about all of these things is that they're political institutions as well they're not just run by their management they're run by their boards the people who represent the US government and the UK government and all of the other governments who are donors to them I also have a career in the US government and I know that there isn't necessarily unanimity among US government institutions so I think somebody has to be really pushing on the US executive director to the World Bank and to the Inter-American Development Bank and all the rest of these things but it's like turning around Queen Mary's it takes a long time it took a long time between when it was beginning to be recognized that there was an out of control HIV epidemic going on in sub-Saharan Africa and when the funding really flowed so I agree with Lou I think we're somewhere in the development of that and it's actually history repeats itself as tragedy and farce we will have learned that delay doesn't serve anybody and we need to work on it faster to the question about sterilization and being able to do that I think it's terrifically important surgery is going to be and we look at all the low hanging fruit and that certainly prevention is a low hanging fruit some of the things that don't need surgery seem easier to do but I think certainly in cancer we need to have surgery and I think that can't be sustainably done by five doctors from Harvard flying in for a week and feeling good about it and then leaving I mean we have to be able to transfer those skills and the skills are not only the skills to do the surgery but the skills are how to maintain the environment in which that can be done sustainably but I think every country will need some tertiary facilities to be able to handle these kinds of things so you know I'll leave it there I mean on diabetes treatment I have forgotten that today was World Diabetes Day and how important insulin is to that but we also know that insulin the price of insulin varies so incredibly widely throughout the world to get some conversation going and also the kind of how will we get diabetes treatment insulin out to people who need it is that a a kit where you can buy at a fairly low cost both the syringe and the insulin and package it the way we've been able to package some of these other things that's part of what the book talks about but I think insulin is going to be extremely important to facing that. Thank you Lou. Just very quickly I think that integration of activities is going to be extremely important in this what I see is this first phase and we are just at the point where we're trying to make things specific and where specific experiments or attempts are going to be made so I think that if that works at the primary level that the effects will come up it seems to me to the secondary to what in the British system the secondary level and maybe to the third level ultimately that's going to involve changes in education in other countries and these are going to be relatively expensive again the model that's talked about in the book about supply chain integration about integration or harmonization of regulation is going to be one of the factors that's going to make that possible because every country is not going to be able to train all of the doctors all of the nurse practitioners and all of the technicians that they need so I think that the movement that started in this way is going to force change along those lines thank you we had Elizabeth ask about the name our web person asked about how does this all fit in the post 2015 agenda sure one reason Elizabeth when you asked this question about that we call non-communicable diseases something else is that everybody who's been advocating around this for the last several years has wished they had a better answer to that question so if anyone has any bright ideas I'm sure we'd all like to have a different name than non-communicable diseases that were actually for something but let me just comment quickly on a couple of these very good questions Kelly asked a question what can we offer what advice can we offer to a company that's trying to start up in this area and I think actually the question was posed about international financial institutions by Jeff is part of that answer just to give you one example I mean first of all the World Bank and the other IFIs are massive institutions with a whole range of issues that they're working on I think that the timing right now given Jim Kim's new strategic direction for the World Bank to end extreme poverty and also to address poverty in middle income countries as well in the lowest income countries and given Jim Kim's background in trying to reconfigure global health himself before he went to the World Bank I think that it's an interesting juncture for trying to encourage the bank to take a look at how to integrate health into more of the work they do and through the IFC they created an Africa Health Fund a couple of years ago along with other donors and I remember in talking to the people who were responsible for that one of the things they created them was that they put this money out there several hundred million dollars to try to help small and medium enterprises do more for health in lower and middle income countries and they just couldn't find any projects to invest in so there's an opportunity for you is to see whether you can persuade them that they should invest in your project and then on because it's World Diabetes Day I just want to make a comment about that there are million people around the world who are living with diabetes and that disease is growing at an alarming rate the International Diabetes Federation just issued its latest Diabetes Atlas and it shows I forget the precise number but it's going to be close to 600 million people in the next 10 or 15 years if something isn't, if we don't change the trend right now and one of the things that's critical in understanding the Diabetes Epidemic today is that in many cases depending on which country you take most people who have diabetes don't know they have diabetes this is not dissimilar to what we've seen in other disease conditions in the past but a lot of what government can do is to work on the prevention side the earlier you intervene the less it costs just as a general principle so if we can just find ways individuals and communities and patient groups and others to just get the word out to people here are the things to look for here are the risk factors here are places you can go to get advice if you think you might be ill that actually is the first step on a path toward really finding a much more effective way to deal with more of these conditions and then that relates to the last thing I'll comment on the post 2015 discussions about where should health fit in the new set of sustainable development goals and I think that the kinds of things we've been talking about today and that we address in this book have to do with the debate around universal health coverage which has been at the core of the discussions around what should the next set of sustainable development goals look like I have really dealt with questions about who should be covered what should be covered how much of that should be covered the governments and their partners are going to have to get down to the question of how do we actually do the things that we've decided should be covered under universal health care and so I think that it's the kind of pragmatic suggestions that we've been talking about how can you improve regulatory environments how can you do better jobs better job on supply chains how can you actually get primary care to cover more of the health conditions that affect people at that level are all going to be relevant to really implementing the decisions that may be made around universal health coverage as a new sustainable development goal I'll hit 1, 2, 3 actually I'll start with our colleague over there because you sort of asked a pre-commercial question which is what do you do with a new innovative technology space and you know we are the largest in our sector the fact of the matter is 85% of the companies are small medium sized companies a doctor has a great idea they decided to perfect the idea it's not starting with a lab scientist it's great it's very clinically inspired who then turned to an engineer and we're very interested in those discussions I think one of the parts that's actually been missed here is the fact that the finest innovations and to change this landscape and by the way to re-import into the United States you know into the United States are ones that actually started well overseas in very resource poor economies and what I try to talk to you on kidneys is with Apollo it is a private sector, a large private sector player in India, get the point but still I mean that's the type of inspiring activity we'd love to talk to you more about that and I think that we need to inspire solutions that we can re-import into the United States we've got a slight problem in terms of percentage to GDP that we're spending on healthcare I think that might be a secret but I'm not so sure multilateral development banks Jeff you know I was a big critic of multilateral development banks until the high level meeting and we track some of us very closely and here's my conflict of interest statement we could actually commercially benefit from following those and I'm declaring that out front and I tell you we actually follow those we actually make money on those projects so just so you know that conflict of interest and statement finished I would say that you have a remarkable amount of leadership actually coming out right now from a different institution Islamic development bank people don't think very much of World Bank certainly well I got a very interesting email from some very high level people at a very large IFI recently people that I've been trying to engage for three years when we put our new commitment on the street, the philanthropy commitment on the street and that was really helpful but I think what you know look in an obvious way look at unilateral donors like Luxembourg they've done some very very important things and let's look at them but also look at the other UN institutions they've actually been tremendously responsive and I mean UN Family Planning Agency UNFPA it's tied to the mother child great leadership coming out of UNFPA I got a solicitation today from UNHCR they're talking about refugees and NCD education around UNHCR it's a public solicitation not top secret Helen Clark head of UNDP of all things it's almost risking her presidency I'm sorry executive directorship on this discussion I mean let's be proud of those let's celebrate those rather than necessarily talking about those that perhaps are less responsive I think they'll come and if not Margaret Chan I'll track them down and find them and if not Ban Ki-moon we'll find them to Ariello I think on the 2015 discussion certainly it gets very important I think she was asking about the consistency point between us and perhaps with our external look I think to stay the obvious we've got a report on the street which is a high level eminent persons report please read it because it does have three references there to NCDs and that's a lot I was told by Homie Hamras and so that gives some confidence that it's certainly in play exactly the how and Jeff was talking about that to a great extent are very important but I do you know yesterday was opened up I think a global the largest ever global survey trying to solicit worldwide feedback on those MD post 2015 goals so participate as well thousands have already done so in the context of this high level persons report let's just make it right whatever form it takes let's be participative so thank you thank you I apologize to some of our listeners who are patiently waiting to pose questions we're running out of time I apologize perhaps you can engage some of our speakers after this I want to close by first of all thanking my colleagues Matt Fischer Jessica Alpert who did a very good close read of the book earlier Alicia Crane Lindsay Hammergren who put a lot of time into making this event happen I want to thank Raybin Martin Laura who's Jeff's colleague who's done a terrific job in preparing this and thinking this through I want to congratulate the authors the editors the contributors to this volume I think that you've really made a major contribution it's as Sally emphasized this is pragmatism at its best you've offered us five points no more than five key points that's incredible discipline and you know if you'd gone to six you would have lost me and you have a framework it hangs together and it's driven by optimism and it's driven by an appeal for leadership and for sort of practicality and sensibility and I think a conversation is evolving I think the conversation is evolving in very positive directions and to significant degree it's because of your leadership Jeff and Lou and Trevor and Sally and many of you that are here in this room who are really at the center of this movement so please join me in thanking our panelists and thank you