 Good morning and welcome to CSIS. We're thrilled today to be able to welcome Ambassador Niels Delaire, Ambassador Leslie Rowe, Todd Summers as our speakers here today on The Whole Question of the Future of Diplomacy 2013 and Looking Beyond. And we're thrilled that Katherine Bliss, a senior advisor here, is able to join us to run this session today. I'm Steve Morrison from CSIS. We were very, very busy in the latter part of 2012 putting together an analysis across multiple sectors of what had transpired in the first Obama term in global health policy, and that resulted in the volume that many of you have contributed to and I hope have benefited from, which is global health policy in the second Obama term. In that course of that work, we put an enormous amount of emphasis upon diplomacy. There's an entire chapter. Katherine was the lead author of a chapter on international diplomacy. We put an enormous amount of emphasis upon the partnerships with multilateral institutions. Todd Summers was the author of the Global Fund chapter and contributed significantly to many of the other multilateral pieces. We put a very high focus upon the indispensable value of high-level U.S. leadership across the entire spectrum of efforts and you'll see that reflected across the different chapters. We put great emphasis upon bipartisanship as fundamental to the successes of the last decade in terms of Congress, but the broad consensus within American society that gave it, that empowered and made it possible for this administration and the prior administrations to do some remarkable things in global health. As we put this volume together, we called upon many of our friends in the administration to help us and Niels was particularly generous in sharing his time with us over extended conversations in several different settings and many of the other key senior officials within the administration also shared with us their views over the course of that and we're very grateful and I think the quality of the product, the level of detail and nuance within it is reflective of their input. I'm very grateful to many people on CSIS staff who helped us pull today's event together. Carolyn, Shrout, Matt Fisher, Alicia Kramer, Jacob Eckles and Rachel Wood among others who are here. I'm also very grateful to the many authors of the chapters in this, many of whom are here with us. I've already mentioned Catherine and Todd, but we're also joined Becky Katz is here, Nellie Bristol, Janet Fleischman, and I'm probably missing, haven't identified several of our other authors. At the end of the day, we drew upon over a dozen different expert authors to bring this volume together and we're very grateful to them. So thank you all for being with us. This is very important for us for the reasons I've laid out to be able to carry forward this discussion around diplomacy, the diplomatic agenda, what lies ahead as Catherine will explain. 2013, there's a burst of opportunities and challenges on the horizon diplomatically and we'll be talking about those today. We're also joined online by a few hundred people who've kindly agreed to join us through that and welcome to you as well. So with that, thank you so much and please join me in welcoming our esteemed panel here today. Well, good morning. And let me reiterate the welcome that Keith has already offered. I hope you can hear me. Is this... It's not on? It's not on? Okay. All right, let me get it a little closer. Does that work? All right. I'm going to have to keep it technical as she is. Let me just hold it here. 2013 is shaping up to be an extremely active year on the global health agenda, particularly with respect to multilateral engagement. On the one hand, there are a number of replenishment processes that we'll be getting underway of the global fund replenishment, which is looking to shape up over the course of the fall, the replenishment for the GAVI Alliance, the World Bank, IDA. At the same time, you have the regular set of meetings that engage a variety of countries on global health, the World Health Assembly, the G20, the G8 meetings, all of which will be coming up. And finally, there are some special meetings and discussions as well, not only the discussions around the high-level panel regarding the post-2015 Millennium Development Goals, but also the UN General Assembly Resolution on Universal Healthcare. So there's a lot to be discussed. There's a lot at stake for global health, and there are a number of opportunities for the United States to contribute to the engagement of countries and the support of countries for those processes. We are very fortunate today to be joined by three experts, three people who have really been working these issues on the ground, who are here to share their perspectives with us. We have two from the United States government and one from CSIS, who has been very much involved in some of the recent discussions around funding and reform at the Global Fund and who can share their perspectives. I want to first introduce to my left Assistant Secretary for Global Affairs at the Office of Global Affairs at the Department of Health and Human Services, Dr. Nils Delaire. Nils Delaire is also the U.S. Representative to the World Health Organization's Executive Board and previously served as the CEO and President of the Global Health Council here in Washington, D.C. Also to my left is Ambassador Leslie Rowe, who is in charge of day-to-day operations at the new Office of Global Health Diplomacy at the Department of State. And in that capacity, she's very much responsible for helping to link the operations on global health at the Department, at the headquarters level, with what happens at the embassy level and in the field, and making sure that ambassadors and the officers who work with them in a variety of capacities are able to fulfill the U.S. government's work on global health diplomacy at that diplomatic level. So my far left is Todd Summers, who is currently Senior Advisor with the Global Health Policy Center here at CSIS in Washington. Todd has also been instrumental as the Chair of the Global Health Board, the Global Funds Board, on strategy investments and it's the SICK, an impact committee. I remember the SICK part of it. Todd has been instrumental in working through the past couple of years of the reform process to work with countries and with the board to envision a new vision for investments. So we're very fortunate to have these three here with us today. This is intended to be a conversation, so I will first turn to the panelists with a series of questions to elicit some conversation and debate and discussion among them. And then we will turn to you and the audience to invite comment, really to engage in the conversation as well. That's the goal here is to really identify the key priorities for the U.S. and in the context of the multilateral process and to have a conversation about how some of the priorities and approaches will play out. So we will turn to you, the audience, after about 45 minutes to an hour or so. And I will invite you to wait for a microphone, which will be passed around. And because we have our online audience as well, to speak into the microphone and identify yourself and your affiliation so that the conversation can continue. So let me start by turning to Assistant Secretary Delaire at Health and Human Services to ask you to set the stage for us for this conversation. What are the major issues on the global health agenda? Particularly with respect to multilateral engagement this year, what are the U.S. priorities within that context? And can you give us a sense of what these mean for global health and why it's important that U.S. leadership really play a strong role? Thank you. First is the microphone working since we already found one. Can you hear me? Okay, good. Let me just start with a brief overview of global health diplomacy. Ambassador Rowe, I'm sure, will talk about this as well. We reflect sort of different angles on the issue of global health diplomacy. But I go back to Will Rogers' famous quote, diplomacy is the art of saying nice doggy until you can find a rock. And that's very different. I like dogs. And it's a very different concept from the concept that we use in global health diplomacy. In fact, global health diplomacy is the art of finding a good hamburger to share with the doggy so that you can work together on tracking something else down. And we're seeing that right now in China. When Secretary Sebelius and I traveled there for the U.S.-China high-level meeting in the end of May of 2010, we were there with Secretary Clinton and Secretary Geithner. And each of the departments, cabinet departments, had a separate set of conversations with their counterparts in the Chinese government. And as you all know, we continue to have issues of currency valuation and trade. We continue to have differences in terms of geopolitical issues. But at the end of that meeting and the subsequent meetings that have taken place, one thing that was highlighted was just how well the United States and China were working together in the health arena. Now, this has real payoff. We're seeing it this week with the emergence of H7N9 influenza virus in which the Chinese have been very proactive because of the long-term engagement with the U.S. Centers for Disease Control and others to help them build their surveillance system in our multilateral engagement with the Chinese in developing means to address global pandemic. This is an area in which global health diplomacy is working directly to protect both the Chinese people and the American people and the world. Obviously, there's a lot to be discovered still about this virus, but it's been remarkable how quickly things have gone and that is a tribute to global health diplomacy. So this is a good time for global health, a growing recognition of global interconnectedness. But at the same time, we recognize with the fiscal realities not only here in Washington but around the world that we have to do things better, smarter, to the extent possible, cheaper. And this is where the agenda for the, not only this year but for the coming years comes in. You asked what the key issues were coming up and I could probably do this for 40 or 50 minutes. I won't, but let me raise some of the issues that are at the very top of the agenda for both bilateral and multilateral discussions. You mentioned the U.N. General Assembly universal health care resolution. The United States was deeply involved in those negotiations through the State Department but with a lot of input from my department in terms of the recognition whereas in past discussions at the U.N., the U.S. was quite reluctant to sign on to something that seemed to confer a new universal right. Well, in fact, universal health care is the underlying premise of the Affordable Care Act. So this is an area in which the Department of Health and Human Services had a strong interest in being an active and positive part of the global discussions about this and that helped to move the resolution forward and continues now with, you know, how do we actually do this? How do we work together? And there are a whole set of follow-on activities at WHO and other places. The Global Fund. I sit as the alternate U.S. board member on the Global Fund to fight AIDS, TB and malaria. And the Global Fund, having gone through some substantial changes over the past year and a half, two years that I think Todd will be talking more about, is now facing the next replenishment, looking to find the resources to carry out its important mission. And that's a very important part of our agenda moving forward. In terms of some key health issues that are very high on our radar screen both at WHO and as I said, also bilaterally, pandemic preparedness and global health security is extremely high on our agenda, obviously underlined by what's going on in China today. But we also recognize that the issues of pandemic preparedness and the potential for catastrophic natural events, leaving aside the possibility of human-caused events is one that we need to build robust systems that really cover the entire globe. And that includes the international health regulations, which is an obscure thing for many people, but it's actually the reporting system around the world for unexpected events that will help us to get early warning in place. Polio continues to be a very important issue for us as well as for others with only three remaining endemic countries. Non-communicable diseases has emerged on the global stage as an area in which all countries have strong interests in which we need to work together on a policy front to find common ways to combat some of the leading contributors to these devastating and extraordinarily expensive illnesses. In addition, we now have a growing set of concerns around drugs circulating in the global market that are substandard, spurious, there's a long term for it, I won't go through that. But bad drugs basically that are sold as if they're good ones, which are both killers in some instances and in some instances because they have small amounts of the right kinds of medication in them lead to resistance to those drugs such as Artemisinin for malaria, which could have devastating consequences. And finally, last but certainly not least, the work going on to define the post-2015 Millennium Development Goals which will be immensely important in terms of setting the global agenda and the recognition that these goals are likely not to be just about the poorest countries, not only the health issues there, but given that in a globalizing context we are now seeing pockets of poverty in middle income and upper middle income and even upper income countries that need to be addressed through common means. The MDGs are likely to reflect that. So what do we do to make this new model of engagement work? There are two sides to this. One is that technical expertise which my department through the Centers for Disease Control, National Institutes of Health, the Food and Drug Administration, Mental Health and Substance Abuse Administration and others represent some of the highest technical expertise in the world. We're not always terrific at the diplomacy side. And being right does not make you effective. And so one of the things that we work on at my office at Global Affairs is bringing diplomatic skills and know-how into the technical dialogue. But in turning this over to my good friend Leslie Rowe, the other thing that we need is the diplomatic side of the discussion aware of, conscious of and committed to the health side. And we see the work being done by the new Office of Global Health Diplomacy as being a perfect match to the work being done by my Office of Global Affairs at HHS. So this is a budding partnership but a very positive one. Well, thank you very much. Clearly a very small agenda with very few. I'm sure we'll be out of here in five minutes or so. Let me turn to Ambassador Rowe. You have recently joined a fairly recently formed office that's still less than a year old, the Office of Global Health Diplomacy. And you are charged with carrying out much of the day-to-day operations in linking headquarters and Washington area discussions with what happened in the field and ensuring the diplomatic consistency that links the foreign policy and health work. I wanted to ask you to say a little bit about the office. Tell us a bit about its mandate and how the vision is developing as the office becomes very active. And if you could also tell us about the work that the office is doing in terms of interagency coordination, how important interagency coordination is in terms of defining and executing the U.S. global health agenda when it comes to the diplomatic approach. Well, thank you, Catherine. And thank you, Steve, for the opportunity to be here and talk to this group today. I'm really delighted to be here with my colleagues also to be working with Ambassador Goosby in the newly formed Office of Global Health Diplomacy. We actually opened officially in mid-January. A year ago I was in Mozambique thinking about many other issues as well as global health. And we're very fortunate to have a lot of support for this new office. I must tell you, I developed a passion for global health about a decade ago when I was in Kenya at the birth of PEPFAR and continued with my subsequent posts in Papua New Guinea and also Mozambique. And we have wonderful interagency teams at post. I will tell you that sometimes when you're in the wilds of the developing world you really wonder if people in Washington have a clue as to what you're doing in the field. And so coming back to Washington, it's really been gratifying to see the number of people who are representing organizations here today who clearly are interested in, engaged in and care very deeply about global health. So I thank all of you for that. I mentioned that we have very strong support in the new Office of Global Health Diplomacy starting with Secretary Kerry who cares deeply about global health. And of course we've seen his very strong record as a senator for many years. One of the strong supporters of PEPFAR from the very beginning. And we see more recently as a secretary in his very first speech at the University of Virginia in which he talked about the AIDS-free generation eradicating polio, reducing maternal mortality and supporting people to avoid malaria, TB, and other diseases. So with that it's a great start for our office to have that kind of support from the top. I'm going to be a little more pragmatic in my presentation because as you mentioned I'm responsible for the day-to-day operations and communicating with my colleagues in the field. One of our main three goals in the Office of Global Health Diplomacy is to support our ambassadors and their teams, the Deputy Chief Submission and also health teams and other people in the country team to make global health a priority and a part of the daily diplomatic dialogue that ambassadors engage in. I mentioned that I've worked with our very strong interagency health teams over the years and what we want to do is to basically use all the tools in the toolbox to make global health a priority. Ambassadors are already very much engaged in global health. I think it's pretty standard operating procedures. We have access to many different people at all levels of government and in communities and so for instance if I was going to have a meeting with the President or the Prime Minister or the Ministry of Finance, Ministry of Health, I would always ask our country team, I'm going to talk about X with the President, but is there something that we need to get more high-level attention on and can I raise that issue? I think this is standard for many ambassadors and we want to make it even easier for them to do this by creating some tools for them that they can easily pull out of their toolbox when they're going to those kinds of meetings. So for instance in the couple of months that the office has been in operation we've been looking very carefully at our training institute and the kind of curriculum, how global health issues are incorporated into the curriculum. We're developing modules. Everyone in our new office and we're bringing staff on gradually will have public diplomacy as part of their mandate to be able to develop talking points tutorials and speeches for ambassadors in the field. We have people in the field that do this already but we want to as I said make it easier for them to do that. So there will be a lot of focus on those kinds of tools for ambassadors. The other one I would mention to you is that our new global health diplomacy website is now up and you can tune into it at www.state.gov.slashghd for global health diplomacy and you'll have an opportunity to see a number of instances of our model ambassadors who are out there doing global health with photos on a wide variety of global health issues as well as their teams in USAID, HHS, CDC, DOD, Peace Corps. And in addition there are some other helpful resources there, links to a number of government websites but also the global burden of disease website, the NIH website which shows World Report, all of the health research projects that are going on all over the world. So this will be a base not only for you all to see what we're doing on a periodic basis but a useful website for our teams in the field. And I encourage you, one thing that we really would like would be your input. You all have been engaged in global health for many years and this is a work in progress so we really welcome your comments and input on how we can strengthen this website, strengthen training for our teams overseas. I mentioned support of ambassadors and their teams. The other two areas that they will be talking about will be country ownership of health systems, health systems strengthening and also sharing responsibility with our partners. So we want to give our ambassadors talking points, information that is useful. We were talking about replenishments earlier that Niels mentioned and that will be an area that we hope ambassadors will be able to do their part as well in terms of seeking new donors and expanding the support from donors that we have. Again, many of our ambassadors already do this. I mean I distinctly remember about a year and a half ago when support for the Global Fund was not as rapid as we would have liked from some of our committed donors, talking to one of my European colleagues and encouraging them to talk to their capital about the importance of supporting the Global Fund and the shared responsibility that we all have for global health. And just one last point that I'll mention actually too. In terms of country ownership and shared responsibility, we are working with World Bank. I'm quite excited about this event in two weeks to convene ministers of health but also ministers of finance to talk about sustainability and capacity building sovereign funds and that will be happening in Washington in a couple of weeks. So that's an example of some of the work that we are doing. The one area that I should have started with is how important interagency collaboration is to our office and I really start with that premise. It's wonderful to be on the podium with Niels. Niels and HHS are a perfect example of the kind of collaboration that we have had since the beginning of the office. Niels invited me to join the delegation headed by Secretary Sebelius to go to the World Health Assembly. I've had the opportunity to come over and talk to our HHS health outages. Very interesting and stimulating conversation. And we were together in a plenary session a few weeks ago down in CDC talking to all of our HIV AIDS HHS staff abroad. One of the things that I've found to be most important frankly in every job that I've had around the world is to get out and meet people and to seek their input, find out what's on their mind and that has been a thrust of our office from the beginning. I've had wonderful briefings not only at HHS but at Peace Corps, USAID very thorough and exciting ideas about how this office of global health diplomacy can support all of the partners in global health. So we will be collaborating and continuing our communication on an ongoing basis with all of our interagency partners. So Todd we've heard an outline of some of the major preoccupations of the US government this year and what some of the key opportunities for engagement bilaterally and multilaterally will be. Leslie has mentioned a bit about the new office of global health diplomacy and how at a practical and logistical level some of the training and the relationship building and outreach will take place. You've been working very much with the Global Fund over the past few years really working with countries and hearing input from the process of the reform and the creation of new mechanisms. And I wonder if you could share a bit of your perspective in terms of how you see the broader set of countries identifying some of their priorities around these issues how some of the decisions take place and how the US strategy either play into those or correspond in a way that builds to a larger support discussion. Thanks and hello everybody nice to see so many old friends here. As you said I've been involved with the Global Fund now for about 10 or 12 years. I think Ron McKinnis and I went to Brussels when they were first setting it up actually with the Global Health Council team. So I've been involved kind of watching the Global Fund grow up in the space when all this energy around global health has been taking off. When I started working on health it was with President Clinton and you recall we were trying to get our first 10 million dollars for the global AIDS effort. So we've come a long way from there. One of the things that's been interesting to see is how the US plays with respect not only to some of the countries that are fighting the diseases but also other donors. So the paper that Steve mentioned, the compendium that Steve mentioned we covered five multilaterals the Global Fund, GAVI, the World Bank, UNAIDS and WHO and there are certainly others but those are the five that we sort of picked on and we outlined in the paper some of the challenges that we saw steering those organizations in the face and some of the recommendations and it was done very much from the perspective of the US government so we didn't pretend that we were trying to give the world guidance we were really looking at this from the lens of what can the US government do but it spoke to how the US could play a much more effective role working with other governments that are donors and other governments that are implementers in the civil society groups that are often very involved at both levels so I wanted to focus in sort of two areas one is around policy and one is around money. Policy is really where I think the US can and should and has been playing a really important role and looking at the government level it gets really dicey really fast so we're sitting there trying to figure out how to deal with Uganda with a president that wants to not only criminalize male to male sex but actually make it a capital crime and you'd imagine what it's like for the US government to be a donor in that situation and to face the stresses where you're being asked well how can you possibly fund a government like that well if you don't fund that program then people die because they don't get the services they need so we're constantly in this dilemma if you will to exert our influence without putting people in the firing line of those debates I think that's a really interesting and important discussion I think it's also interesting to see how we could potentially work with other governments sort of multilaterally on some of those so rather than dealing with one of those governments bilaterally maybe we could work together with some of the other donors that have some presence and some influence to be urging for changes in the issues that affect marginalized population and girls and some of the challenges that obfuscate success in the fight against the three diseases so I think in these policy efforts the US can and should play an effort there's also policy debates that happen even among donors and you touched earlier on one of the ones Catherine around middle income countries you know 72% of the world's poorest people live in middle income countries and a lot of our policies still treat poor people as if they only live in low income countries and that is a global challenge and it comes right up in the global fund board meetings it comes up in GAVI board meetings it ends up with PAHO and WHO we really have to be smarter as a community of funders and as implementers about how we deal with very changing dynamics across the world and what it means to be a middle income country what it means to get or not get concessionary pricing what it means to be prioritized or not prioritized for funding and a lot of these places that's just one example of a policy issue where I think the US could work more closely with others and helping inform and debate and discuss those issues the second area I wanted to touch on was money we just had a discussion this morning around the global funds or punishment of where the US could perhaps take a more effective role in getting other donors to the table we've had fantastic success in getting the US to step up as a donor some of us are just still marveling at how well the global fund does including in the last continuing resolution where we got $1.6 billion really a remarkable statement of hard work by community advocates and by politicians and by the US government and kind of making the case for the global fund but outside two-thirds of the money for the global fund comes from other countries from France and from the European Commission and from the UK and from Australia and Canada and we have worked to do bilaterally with them to try to get them to match our money but we were talking earlier about the opportunity to work trilaterally I don't know if that's a word where we actually maybe can push the Canadians to call the Brits to call the French because so much of this really does have to do with kind of the club of donors it's lovely to talk about changing the trajectory of the diseases and the opportunity that we have to move the dial and take advantage of these new vaccines and yet so much of the decisions around the stuff are bald politics so we could be not only using our bilateral influence and I think we're doing a lot of that right now but also maybe pushing some of the other governments who are donors to be exerting their influence the second area where we need to focus on money is the implementing country governments themselves many of them are not doing near enough in terms of financing their own responses I wrote a blog post recently around Nigeria Nigeria leaks $4 billion a year in lost oil revenues it happens to be more than the Global Fund and GAVI combined I think in terms of a annual output I sat in the discussion the other day it was confidential so I won't talk about it but Nigeria's malaria phase 2 grant where 4% of the contribution was coming from the national government and from the states, zero that just simply is unacceptable so how do we and maybe some of the other donors and maybe even some of the other implementing governments go to President Jonathan and say look we are happy to support your efforts to fight malaria but they are your efforts and you need to put more skin in the game I'm very interested to see how the US can use its diplomatic muscle and perhaps do that in combination with others to get many of these implementing governments to step forward on the financial front so policy front, financial front I think where we can have the most influence Thank you, Niels You raised an interesting point that I'd like to reflect on in terms of the broad theme of global health diplomacy which was specific to the Uganda situation with some of the punitive laws that are being debated in their parliament right now about gay sex This is an area where working at really three different levels is terribly important First is at the programmatic level and clearly with the programs in the field that are supported by USAID and CDC and others through PEPFAR having the programmatic backbone to actually deliver effective services and to withstand those kinds of political pressures is key Secondly is in the area of bilateral and as you correctly pointed out trilateral discussions both the US government on the diplomatic side and the US government working with other major partners who have relationships themselves with the Ugandan government are having I think substantial influence in keeping this from moving forward We do not expect this to move forward into becoming actual law And then thirdly, we have to look at this from the standpoint of global norms and trying to create a new environment in which these kinds of laws simply cannot pass and survive So starting about a year and a half ago in my role with WHO we started slowly building the case for LGBT access to healthcare services This is under the broader umbrella of universal health coverage We believe that if it says universal it actually means everybody that we like or they like And so we had a special event at last year's World Health Assembly that Secretary Sebelius spoke at on LGBT health I had a very wide and interested audience but we let that simmer for a year as these discussions take time in Geneva and in the multilateral environment Coming up this may immediately after the World Health Assembly at the next executive board meeting it's our intention to introduce together with partners from Brazil, South Africa, Thailand Norway, Australia and others a resolution on LGBT access to healthcare And we're running into headwinds We expected this from the usual suspects But there's been a lot of groundwork done and we believe that we'll be able to prevail to bring this to final closure with the 2014 World Health Assembly with a resolution on LGBT access to healthcare So that's the long arc that we have to look at when we're looking at how to use the tools of global health diplomacy One other issue which has come up a lot We just had a recent trip to South Africa Again, we write papers around that That's what we do here And one of the issues that was really staring us right in the phase very early on was violence HIV there is so strongly connected to the atrocious rates of violence against women and PNG, another place where the rates are absolutely astonishing You have a better chance of being raped than you do of graduating from high school I think that we have to figure out how it is that we play a constructive role in those discussions Obviously, those are deep domestic issues that are cultural, they're religious and they're not necessarily around laws But at the same time if we're going to really be effective in fighting HIV in South Africa what we heard right from the start and all the way through our five day trip was if you don't fight gender violence in South Africa you will never make headway So we're investing a lot of money $500 million a year or something like that Fighting an epidemic where one of the main causes is kind of still not being addressed as directly as we want So I know there's a lot of commitment in the US government to do it so this is not a push but I think it just raises the real biting challenges that we have to confront TB in Eastern Europe most of those countries are ignoring TB and particularly MDR TB particularly among migrants and prisoners and the folks that are often most affected by the disease So one of our multilateral challenges is how it is that we together work to come out with a new approach to addressing some of those populations because none of those three diseases we're going to be able to do well if you don't figure out how to deal with some of these tough issues Creating the right funding environment for carrying out some of the work that is envisioned in the strategies from any of the different multilateral organizations talked a bit about creating the right enabling or policy environment and what I want to turn to now and to pose to Nielsen Leslie is to ask you to talk a bit about US diplomatic partnerships or collaborations with other countries and perhaps not with governments but with the non-governmental communities the advocacy groups and the corporate sector What are the relationships that are most important in reaching out on funding and in reaching out on some of these policy questions and we've already talked a bit about the resolution or the plan that Nielsen mentioned for the next executive board What is the kind of traditional partners the donor community that the US will reach out to to create messages to create support for funding and policy What is the role of the middle income countries which many of which the BRICS in particular are becoming very active in policy debates anyway around global health How does the US reach out to them? What are the messages that the work in terms of trying to create those kinds of collaborations and then finally what is the relationship with the corporate sector and with the non-governmental groups that are very active with the global fund and certainly have quite a bit to say and to contribute around the other debates as well Let me start with the last part of your question rather than do a long response I'll start with that and then I'll start with Lessa for more You mentioned how are we starting to work with the BRICS Well in fact, as was mentioned my office has a set of health attachés Lessa came and met and spoke with them a few weeks ago when they were all in town for a meeting and we've identified a set of key countries where the Department of Health and Human Services has a lot of ongoing activities through NIH, CDC, FDA and others and in those countries we've assigned health attachés who are employees of my office but who work for the US ambassador there and interestingly you mentioned BRICS and countries where we have attachés right now are Brazil we're talking about getting one in Russia India, China and South Africa strange coincidence and we of course have an attaché in Geneva which is not a country but thinks it is so the importance of an ongoing in-depth dialogue in which we have technical expertise on hand working deeply together with the diplomatic side helps us to identify issues in which we can work together in the multilateral arena as well as identify common priorities in the bilateral arena and we see this as a very important way of the future I mentioned country ownership as being one of our major goals and by that we don't define it as simply country ownership by the government we really feel that country ownership is throughout civil society community groups, women's groups and local and non-governmental organizations I mean we have relied in the national government for decades on our non-governmental organizations to implement our very effective health programs and that will definitely be a thrust and it's definitely a thrust of missions abroad, embassies abroad that we go out into the communities because we feel that if at the local level the community level people really take ownership and become advocates for their own global health that will necessitate their putting pressure on their local officials eventually national officials to provide the kind of health care that they really want so we define country ownership pretty broadly that said, since we do deal a lot with governments and we talked about trilateral agreements one of the privileges I had while I was in Mozambique is that we signed my Brazilian counterpart and I along with the Minister of Foreign Affairs a trilateral agreement to work together with the Mozambicans, Brazilians, Americans on health issues and also on food security and that was just about a year ago the push to get it done at the end but we did manage to do it and I think it's a good example of emerging economies I served in Brazil at the very beginning of my career when Brazil was a recipient more than a donor partner and it's really gratifying to see this evolution the way Brazil has taken responsibility for its global health and now is in a position to reach out to the Lucifone communities in Africa and expanding I think to other communities as well so we will hopefully sign more of these kinds of trilateral agreements and we need to look beyond the traditional partners the BRICS emerging economies are our areas and countries that we'll be looking at Can I come back to the first part of your question? Yes, please You mentioned how do we work with governments and NGOs and the private sector and our focus is about improving health it's not about getting along but the point is to improve health and so it depends on the particular set of issues involved part of this means that we have to maintain open and collegial relationships but also honest and frank relationships so that people understand there are things that we're going to differ on whether it's with another country or with a different sector we will try to be as clear as we can about what our aim is in doing this but for instance we have been increasingly engaged in internal discussions within the US government on trade issues because increasingly in today's world trade has huge implications on health and whether that is trade in tobacco products or issues of pharmaceuticals and intellectual property protection we believe that the health perspective needs to be strongly represented within the United States government as part of that dialogue we don't make the final decisions as to what USTR does that's for the White House to decide but we want to make sure and I think it's really for the very first time that this perspective has been strongly introduced and our secretary is deeply committed to this I'm laughing because when I worked for the Clinton administration we tried to have meetings with the US trade representative and they really didn't want to talk to us too much so one day we got a panicky phone call that ACT UP was scaling the walls of the trade building next to the old executive office building they were throwing ladders up the side and they were coming over the ballot what should we do? we say well I don't know we're going out for lunch call us and let us know how it went so it was kind of our nice way of saying it would have been nice if you talked to us before maybe now there's some anxious I mean I think it's a perfect example of where we need to figure out how to work together with an industry that sometimes we don't agree with the interest it doesn't make sense for the USTR to be negotiating a bilateral trade agreement where we're forced to buy drugs at a high price and then put Gaby and Global Fund in the position of having to pay higher prices that they can't afford so it's a real challenge for us the bad drugs issue that you mentioned is a good one the IOM just put out a report around counterfeit and fake medicines although I think they are very clear they don't like the word counterfeit but the bad drugs is maybe the best way to say it on the 29th of April here at CSCS we're going to be doing something in the afternoon on that issue we're working with the IOM and the FDA and it really is one of those very critical issues where you have to figure out how to come together across sectors and with many of these governments China is the producer of many of the world's best generic drugs they are the producers of most of the artemission that goes into the anti-malarial they are also the production factory for many of the bad drugs and so it's an issue that they're struck with and it's an issue that we need to work with them on India the same thing so maybe it's a good example of one of these things where we need to come together and build new relationships to try to figure out how together we fight the proliferation of bad drugs that are out there just also addressing the issue of private enterprise this is an area that I've thought a lot about over the last few years we've had tremendous support from governments around the world in global health but there I think we can do more with private enterprise and it's interesting to think about the fact that the bulk of our assistance U.S. government assistance which by the way is now 25% global health represents 25% of our overall assistance around the world the bulk of that is in Sub-Saharan Africa and I think you've read and noted that there is a lot of interest in Sub-Saharan Africa is one of the few areas of the world that is actually growing we had about 7% growth rates in Mozambique the last year that I was there there's tremendous interest among American companies to get engaged in Africa they're learning about Africa and more traditional markets there are other parts of the area of the world and there are possibilities of mutual interest here as they get more engaged in developing energy resources looking at their ability to support the public sector public interests of the countries that they're working in particularly global health there are great opportunities there about a year ago we did a large conference worked with USTR and other commerce in Mozambique we had about 100 different American and international companies that attended it the president of Mozambique gave the plenary address I gave an address and frankly my message to those companies was you can do well in Mozambique but you can also do good so don't forget your social responsibility as you come and develop and assist in Mozambique's economic and social responsibilities you have a social responsibility so we're reaching out plan to reach out more to private enterprise and get them more engaged and look at symbiotic ways to support global health let me key on that as well doing domestic health care and health and human services we recognize that about three-quarters of the US health care expenditures are dealing with the consequences of chronic non-communicable disease we also recognize that around the world today close to two-thirds of all deaths that occur worldwide now are due to NCDs and that four-fifths of those deaths are occurring in low and middle-income countries no longer what I used to characterize as a disease of affluence in fact we're seeing it in low-income urban slums throughout the world when we look at the drivers of this the key diseases being heart disease stroke, diabetes, mellitus these are driven often by diet I'll leave the tobacco aside that's sort of a category to itself but everybody has to eat we used to be hunter-gatherers and we liked our food salty, fatty and sweet and that is sort of how we're programmed the food industry and beverage industry has responded to that by meeting market demand and are now driving because of processed foods are driving the global obesity, diabetes and heart disease stroke pandemic what do we need to do to change that we need to engage with the food industry we're not going to do away with it and we wouldn't want to but we can certainly help to influence the directions of sodium levels of trans fats sugar levels in sweetened beverages and other foods and one of the things that we've heard is that the responsible parts of that industry and there are a lot of them would love to have a meaningful dialogue that's not just with the United States but with the international dialogue with leading economies to set a set of standards because then they don't have to be in an arms race to up the amount of sugar and their drinks to get greater market share if everybody agrees we're going to keep it to this level then you can start to bring the global burdens down and this is a part of the multi-sectoral approach to both global health and the diplomatic side because we need to enlist other governments as well We've talked a bit about 2013 and already gotten a bit into what happens beyond 2013 but I just want to end with this portion of the discussion before we open for audience commentary and questions as well just to ask the three panelists to say a bit about what's on the horizon kind of beyond these replenishments and the high level panel and some of these other activities and moments that we've been discussing and from a health diplomacy standpoint how does what happens this year in terms of the replenishments in terms of the outcome of the post-MDG discussions and others, how does what happens this year and how the U.S. interacts diplomatically with these processes how does that influence what the U.S. should do to prepare for what's around the corner So I'll start with Neil Boy, that's a broad question Let me take one element of that The world as we're keenly aware is in the midst of a profound economic and health transition Globalization, the dramatic changes that have occurred in terms of the shift from low-income to low-middle and middle-middle-income economies China, India and increasingly now in parts of sub-Saharan Africa We're seeing a huge shift and whereas when I started my career in global health a number of years ago there was really a bimodal world there was the poor in developing countries and then there was the rich and the focus of global health was really on poverty health Now what we're seeing is that it's much more of a spectrum and one of the things that we the United States government need to do and are in the process of thinking through is a more nuanced analysis of this transition from countries and societies that simply need help to on the other end of the spectrum countries and societies where an active technical and professional engagement is deeply beneficial to both sides and the spread among them and instead of saying you get to here and then you're no longer an aid recipient you drop off and we don't have anything to do with you anymore Now we're really looking at ways of engaging across that spectrum at reasonable levels at much lower cost when you get out to the further advanced societies but not simply dropping off the screen So I think that's one of the things that you can be looking for over the second Obama term as we sort of look in a more sophisticated and deeper way at global health I agree with everything you said Niels I think we're all aware of concerned about the fiscal difficulties that not only in this country and among our partners that we're facing in the future we have to be cognizant of that and sensitive to everyone's concerns in their own countries and I think it will mean that we will have to look for even better coordination among our partners bilaterally and multilaterally whether it's on the international level or it's in countries with global health teams that are working there and also just to make sure that the countries in which we're working that they're aware of all the resources that are available new funding model in the global fund and that will take some education to make sure that countries are aware of how they can access funding to support their needs so I would say better coordination among all of our partners and making sure that all the resources are well known so I guess I'd end with this part with talking about accountability I think that we have a lot to do to help citizens hold their governments responsible for doing a better job and addressing their health needs both in the positive way for bringing vaccines that can help protect children bed nets that can help children and moms HIV treatment those things which ought to be available and often are missing only for lack of government engagement so I think we need to help citizens find ways to be holding their governments more accountable and then we need to figure out how to hold the donors more accountable for fulfilling the promises that they have and putting forward the money that we need to do this work we are talking about a constrained physical environment but what we're talking about in terms of scale of money is small in comparison to many of the other things that are out there I guess we need billions but in global currency billions is millions and thousands so I think we can do a better job there and lastly I think we have to figure out how to hold some of these multilateral organizations that play an absolutely critical role more accountable for what they do or they don't do we go into some detail in that in the papers but many of these institutions like Global Fund and like GAVI depend on a network of partners being effective with countries bringing civil society to the table bringing technical expertise to the table and when it works it's a beautiful thing and you can see dramatic and real health improvement but when it doesn't work often times you're stymied to figure out well why aren't people held accountable when I see a Global Fund grant going out to fight an HIV epidemic and an injection drug using environment and 75% of the budgets for printing I want to know who wrote that proposal I want to know did the UN AIDS person light himself on fire before this showed up in Geneva I mean how do we end up with such a massive waste of money and it's not to find blame it's to figure out how do we just get out of this because in this tough environment we have to be accountable for making the money work and that's a place where it just simply doesn't so I feel like the way to bring some of this stuff together is to increase the transparency increase and improve the governance and really hold all of our work each of us to account for whether or not we're really making a difference in fighting the diseases alright well we've talked about accountability and coordination and collaboration and multi-sectoral engagement and now it's time to engage the audience in some commentary and questions as well I see a number of hands already let me ask you to as I identify you please wait for a microphone to come your way because we do want to be able to both record this and engage the online audience and let me just ask you to please state your name and affiliation make your intervention brief please because we do have a lot of energy here in the room I'll take a couple of questions and comments and then ask the panelists to respond and then we'll go forward again so let's start over here please Hi my name is Nicholas Bergfeld I'm a medical student at Yale and my question is for Dr. DeLair in your recent health affairs article you list a bunch of priorities that the global health and the federal government will focus on going forward and in a lot of them there's sort of a unifying theme that wasn't necessarily addressed that comes up not only with neglected tropical diseases food and water security catastrophes and then also influenza there's a linking factor to all of those and something I was thinking about yesterday there was a New England Journal article on health and what I'm curious about is if there's any thought process in this aspect of government about how would you coordinate those types of things and how would you go forward to try to think of this in more of a bigger perspective Thank you let's turn over here in the back please Thank you Thank you very much Hernan Rosenberg previously with the Global Fund and Pan American Health I thought I think an important question in the issue of global health is the question of global health governance and I think that I would have like to hear from the panel some views on that particularly because you know most of the governance setups like WChun and whatnot are meant to be intergovernmental so in other words the main participants are sovereign states we see that that causes a problem in terms of the assignment of resources and the problems are not to do with governments but with the particular pockets of population as been mentioned but at the governance level you have now the Board of the Global Fund and other hybrids where the private sector participates and governments may be corrupt whatever you like but at the end of the day there is an election and somebody has something to say about what they vote for or not how does that work in terms of the non-governmental animals that are part of the governance that's one point is an interesting race issue about food if you let the of course the private companies are doing what they're supposed to be doing if the market wants sugar, fat and salt well let's sell that so how do you see a mechanism to do some sort of a balancing act at the global level with this because otherwise we end into the globalization of bad food which we don't want either okay let's see we haven't been over here yet so over here please thank you for a wonderful presentation my name is Manos Harrison and I just came back from a full bright at Georgia, Tbilisi and my question goes back to lots of points that you basically made but how do we do it is a question you talked about accountability and you talked about policy effect of the policy and I saw policy written piles and piles and piles of them all around and it's where we leave it and how do we take it to implementation and perhaps goes back to gentlemen's questions into if there is a global approach to governance about health then how do we keep these states accountable into the money that's trailing constantly there but the outcome is not really in the health of the population thank you okay thank you and let's take one more and I want to not to make you run around too much with the microphone let's see actually why don't we take those three and then I'll start over here so what I've heard is a question about the relationship of many of the policy discussions to global warming this question of governance pardon me and the role of the non-governmental sector within some of the organizations like the global fund how do you balance in this kind of discussion about in particular around food and health how do you balance market demand and some of the regulatory measures under consideration and then finally this question of policy it's one thing to write it and have it there but how do you actually achieve the implementation so let me start with Todd so I'll jump to the questions around governance and maybe a little bit around how do we do it but I think you can tell us maybe since you just came back how do you actually do it in Georgia global fund's been a really interesting experiment right around governance it's one of the few international boards that actually has rules that are designed to promote inclusion so for every decision of the board this formal half the board has two groups the implementers and the donors and you need the majority of both sides for something to pass so you can have kind of one group lording it over the other in terms of votes we have three non-governmental positions on the implementing side we have northern NGOs we have southern NGOs we have affected communities on the donor side we have private foundations in the private sector the rest seats are generally government honestly I think the biggest gravitational governance challenge at the global fund is the voice of implementing countries the NGOs are really good at talking sometimes it's like shut up because they're so good at it and they understand deeply the policy issues and they're often sort of sitting next to ministers of health who kind of have plunked down at a global fund board meeting among a million other things they've got quick talking points they don't really understand the depth of the issues going on their levels of detail and acronyms that they don't follow and you see conversations happening where three quarters of the room is completely unaware of what's actually being discussed and it's very frustrating because those decisions often really make a difference we've struggled a lot with this issue Haare is here representing minister Tedros who was the former board of the chair it's very difficult to get implementing country governments to the table in an effective way they don't organize themselves naturally they don't come to the global fund board meeting and speak on behalf of southern eastern Africa or Asia or Latin America so we're asking people to do very difficult things that said I think it's been extremely helpful to have everybody at the table and painful and ugly as it sometimes is to work through the compromises that let us all feel like what comes through has broad support so the strategy the five year strategy that worked on we spent a year on the road traveling around meeting with different constituencies and in the end when we sat down at the Accra board meeting to approve it every single board constituency not only said yes but they said yes enthusiastically and they knew what was in it when we got to the new funding model very painful very long discussions when we finally said yes to it people understood what was in there and they affirmatively supported it so I think that there is something to be learned there although it still is obviously a work in progress the translating all this policy into practice so we have a new global fund strategy we now have a new funding model but it's really about a very different way of doing business with implementing countries we'll see I think honestly I go back to saying accountability and transparency is probably a big antidote to this the more people understand how much monies are going into their countries from donors what's supposed to be accomplished with those monies and some indication of whether or not that's happening allows citizens to hold their governments and the donors that are funding those governments more accountable so I think that that's at least a bit of it which is making a lot more of what we do open to the world to inspect and comment on and hopefully correct Leslie I just want to make a comment about accountability and governance and also implementation as it's related in the field I will tell you that this is a cheap concern of our ambassadors abroad and their teams I mean we're very much aware of the economic situation in the US and we want to make sure that every dollar that is spent on our global health programs and all our assistance programs is going into the right kinds of programs and being managed effectively and that's a real challenge in Mozambique we had over 300 million dollars a year of which the bulk was global health funding and I was very cognizant of our responsibilities to make sure that this was being used effectively it's a challenge and it's the role of the chief of mission working with their teams to be monitoring and evaluating consistently as not only health officers go out in the field but other officers to visit projects to see how they're going and to really begin giving a once over to see if this is effective expenditure of our funding and if it's really I think probably the most important thing is it benefiting people on the ground which is a real challenge so all I can tell you is that we take those responsibilities seriously and that will certainly be something as we move more and more into country ownership which is a goal for countries to be doing all their planning and their implementation their monitoring and evaluation and eventually managing all the expenditures in global health this is something that we're going to be paying a lot of attention to in the next few years Nils Let me just reflect on this for a moment from a personal standpoint what you see up here is the bureaucratic avatar of somebody who spent 20 years in the field actually running health programs I try to wear my suit well but it's not what I feel I am and my fundamental mindset is always about the pragmatic what can we do to change something that's important I love a quote from WC Fields with all due respect to think tanks and Washington groups who said my doctor told me I had to give up half my sex life I don't know which have to give up thinking about it or talking about it so we try to think of ourselves more as may west kinds of people that's an old reference but the idea then this is going to come back to hot you Nils right we've gone from hamburgers to may west this goes back to a number of the questions here so you asked the question about climate change and what's not clear to us we certainly see the connections between climate change and human health in a wide array of things the question is what can we from our operating position do about it and it's not clear to us what we can at this point so we have not actively engaged 20 years ago we would have said the same about trade and today we've got better levers to actually start to have an impact on the trade discussion so we aren't doing something about it in the area of the issues of global food how do you address food at this level we recognize that food is a huge international industry that whether we're with them or not with them that the multinational food companies have huge influence in terms of what people put into their mouths and so engaging with them as constructively as possible providing not only guidance but we're possible some leverage points in terms of global norms is a very important aspect of this this is not to say that we turn everything over to global industry but rather that we recognize that they play a very important point ultimately when we go about doing things we try to look at where this is going to really have an impact downstream and not in 30 years our time horizon isn't that good but in the next 3 to 5 years we'll be doing it as soon as possible and I think that's where that's sort of where our sweet spot is is trying to influence middle term policy so one plug while we're here since I have two US government officials I think that one of the challenges with that accountability is actually access to information so we've seen a tremendous improvement and thanks to the internet you can now download the cops for pep fire you can see some of the things we don't see the budgets we don't see the stuff that really allows us and many of the people working in these countries to understand what exactly is going on who's getting money to come help our citizens how much are they getting what kind of overheads are they charging I think we have a little bit of work to do ourselves to figure out that line and I know there's a line there around how do we maximize transparency and accountability on our side because I think there is still a lot of suspicion out there that our money is not being used so we can help lead the way in terms of accountability thank you I know I said I would turn over here let me turn all the way where's our microphone oh great thank you let's take here and here to start and then I know we've got a few over here as well hi I'm Ann Pence and I'm currently with Covington and Burling which is a law firm but I'm not a lawyer I'm a development economist so I spent most of my life at state and AID in the MCC and building on the MCC experience which I started four years before the organization was created because I was part of the team that looked at how to set it up I wanted to ask the group about the upcoming discussion of the post-2015 sustainable development goals and that process and to say that when we first did those millennium development goals that started in 1991 by the way there wasn't any focus on country ownership or accountability and you know I think the U.S. has led the way not always easily using the MCC model to make information on grant agreements and their programs and their budgets available to local people and I'd like to know if there's appetite in the international community to build in some of these accountability structures into a robust and ambitious set of you know next era sustainable development goals and how those of us here if that is a goal of yours could support you and build momentum for that not just in donor countries but in the countries that receive partnership resources technical or otherwise so that we can move forward in a way that gets results for people who don't have voice very often in these processes Thank you then we'll go one row back just over here Thank you My name is Laurent Iber and I work mostly on the framework convention on tobacco control and support and development and implementation and my questions were in reference to the MDG review process I was wondering about the U.S. position especially towards the understanding these two overarching health goals one of addressing extended healthy life expectancy to universal health coverage so I was wondering what the U.S. positions if there is a position already vis-a-vis those and also if the U.S. would support an NCD related target not a goal but maybe a target in the MDG review process in the area of trade I found that quite interesting and I was wondering whether what would be in your mind the best outcome particularly vis-a-vis the TPP and other also trade agreements and the last question is related to the FCTC ratification I understand the U.S. the FCTC was a Mongol set of other treaties that were potentially going to be submitted to the senate last year that did not happen and whether you see that as a possibility with this next three or four years of this administration Okay, thank you We'll go over here, Janet Thank you very much and thank you for these very interesting presentations My name is Janet Fleischman and I work on global health here at the Global Health Policy Center and I wonder if you could reflect a little bit about the importance of that principle of GHI the women girls and gender equality principle to the work of this new office of global health diplomacy we were honored to have Secretary Sebelius here in March speaking about these issues and her looking forward about the new administration and the priority given to these issues but it would be great to hear from you Ambassador Rowe about how you see this as a way that the U.S. can help catalyze approaches to integrating these issues in the countries you are working in and then let's take one more where am I let's just go back here I don't want to wait I'm Susan Newcomer I'm in the Population Dynamics branch of the NIH I remember Nils negotiating part of the negotiating team at ICPD in 1994 so I go way back with issues around population and family planning I'd like to hear your comments on the Gates Foundation family planning 2020 program and how the U.S. government is or is not working with that group thank you okay so let's hold and we'll give the panel a chance to respond and hear questions and we'll do another round in just a minute but I've got here that have been posed in terms of the post 2015 sustainable development goals what's the place of accountability and I think the question was is there going to be appetite for discussing integrating better integrating accountability and how can the U.S. perhaps support that discussion a second set of questions was around the U.S. positions the potential for a NCD related target in some of the upcoming UN discussions and then also the potential for ratification of the framework convention on tobacco control where does that stand third question around the place of the original GHI core principle around supporting the health of women and girls where does that fit in to the plans of the new office of global health diplomacy and then finally a question about family planning and to what extent is that corresponding with or related to some larger plans of foot through the Bill and Melinda Gates Foundation and others around 2020 so please I'll start with Nils a broad range of things I'll touch on them I know our time is short here certainly in terms of the the post 2015 MDGs yes there is very real appetite for transparency and accountability built into these and obviously this is a work in progress but that's certainly something that we're we're encouraging on the issues that you raised concerning the FCTC and NCDs first of all with respect to the MDGs we're looking you know the challenge here is we're trying not to come up with 15 health MDGs but in terms of a one of the targets we would very much like to see NCDs which are now a global problem and not just a problem as I said earlier of the rich encompassed in that you asked some challenging questions about US trade negotiations which I really am not at liberty to discuss but just know that what I talked about earlier is very important to us and we're working very hard in the process that takes place within the government and as far as the FCTC ratification this was very close to going up to the senate last year ultimately based on the the perception that there was one treaty that was ready to go that there was strong feeling that it would actually get senate ratification it's the law of the C treaty and if you follow that that wound up not passing and so that was a pragmatic decision not to send it up because they wanted to get one thing through it's still very much on the docket but it's going to depend very much on the dynamics in the senate and then last on the question of the Gates Foundation's 2020 push on reproductive health and family planning I think this is a terrific and extraordinarily important contribution one which certainly fits well with the department of health and human services domestic commitment to assuring that all women have access to family planning and reproductive health services as far as the international side I can't speak for my good friends and partner agency at USAID I know that they have a very active family planning program I used to be at USAID but I'm not anymore but I certainly have the sense that there is a strong engagement there I'll focus on the last question on the issue of integration of women and girls issues this is one of the GHI principles with which we along with our other interagency partners are committed to implement so the answer is absolutely yes we plan to spend a lot of time we're working already with our partners at state in the GW office as well as in USAID and our other partners to look at how we integrate women and girls issues into everything that we do so I'll speak on behalf of USAID they're firmly committed to that just a couple notes one millennium challenges there's actually a lot of interesting lessons to be learned and I don't think we've got enough depth so I don't want to leave that completely off the table but I think there's a lot around the compacts that they sign which really articulated in a much more clear way what each is going to do in that relationship there's been some work around women and girls issues the legal frameworks they did some very interesting stuff there around the MDGs I think this whole universal access to health idea to me is a mistake so I'll just put that on the table because it's a means to an end it's not an ending of itself and I'm afraid if there's something about it so it sounds great and it sounds laudable but until we can actually find out something we measure so maybe underneath that there are these targets but you know I do worry about us having something that sounds lofty but ultimately doesn't allow us to hold ourselves accountable for whether or not we succeed and around the family planning and reproductive health work actually this is a really great issue where we need to figure out how to talk to Europe because they can't understand our conversations over here and yet a lot of these policies are said in international environments and you talk to anyone who's on the other side of the Atlantic or the Pacific frankly and they just don't kind of understand this whole American reluctance to talk about reproductive health or our sexual health and rights or any of the other agendas which are quite common over there so this is a place where our politic makes any kind of intelligent conversation quite difficult but we got to get through that and I'm afraid if we don't figure that out really quickly we're going to lose the momentum that I think the Gates Foundation and Melinda particularly have helped to catalyze. Well I think we could probably spend another 45 minutes to an hour with each of these questions and I know that there are many questions that we won't be able to get to this morning. I want to thank all of you for coming to spend part of your day here and for having come to engage in conversation on the outlook for global health diplomacy in 2013 and the US approach to diplomacy in the face of multilateral replenishments, discussions and engagement. Please join me in thanking our expert panelists this morning and let me just remind you I think there were some little bookmarks that you received on your way in which gives you some information about where you can access the volume of papers on a wide range of policy issues around global health in the second Obama administration term. Thank you very much.