 So thank you all. This is really meant to be a conversation among these three experts around some of the questions and issues that Dr. Fauci touched on towards the end of his presentation, which is, how do we think in a strategic and long-term way about guaranteeing that there is a robust engagement by the private sector over the long term in bringing forward new discoveries in developing new vaccines and also being present in the production and distribution side of things. And these are complicated and difficult issues. And we'll hear about many of the competing tensions around guaranteeing that there are finances at the front and back and guaranteeing that there's sufficient incentives, guaranteeing that there's enough of a mix between the profit considerations and the considerations around equity, high volume, low cost access. We know that partnerships is the broad frame in which these relationships over the long term are sorted out. And we know there are many other issues that surface with respect to defining what your goals are, looking to the future with some specificity as to what the products should look like, preserving public investment at the early phase in the back phase, talking about quality and the like. We want to bring this discussion back to the question of US leadership and policy, because ultimately we're trying today to think about the role in the policy environment here in Washington in trying to guarantee the stability and the robustness and vitality of private sector engagement in this area as we look forward. Margie, I'd like to ask you to kick things off with a few minutes. We'll go Margie, Julie, and Gina with opening remarks, and then we'll carry forward a conversation and we'll ask you to join us. So welcome and thank you. Great. Thanks, Steve. A great introduction. I think you covered everything I was going to say. So maybe I'll turn to Julie. Just kidding. When I thought about what perspective do I answer the question that Steve posed, how do we assure a robust market for vaccines and really have the incentives that the private sector needs to participate in that market? I thought, what perspective do I come at this from, given my history? And I thought of the Joni Mitchell song I've looked at life from both sides now, spending 26 years with a pharmaceutical company and running global vaccine business and now being the CEO of a product development partnership focused on coming up with an HIV vaccines. But fortunately, I come to the same answer looking through both of those lenses. The only way, as Tony clearly stated in the Q&A session, to address this is public-private partnerships. And each sector has an absolutely critical role. And I'll focus more on what the private sector needs. But clearly, the public sector provides the funding, provides the funding, upfront research and development to remove that risk, which is so critically important when you're talking about diseases for the developing world because to ask a private company to invest R&D dollars, especially with a tough economic times and financial situation that most participants in the industry have found themselves in, to ask them to take on that risk, especially before you have proof of concept, is a very difficult value proposition. So the public funding that's available to support that research, the NIH funding, the funding that comes to organizations like IAVI and other product development partnerships addressing these diseases of the developing world, we're able to channel that to various researchers, including pharma vaccine biotech companies, to help support that early research and remove that risk. Also critically important then is a market being available because to make the subsequent investment decisions, private industry needs to know when they get to the back end, should they get to the back end of that development cycle and introduce a vaccine that somebody's actually going to fund it. And certainly there's no guarantees, there'll be competition and that's all expected, the industry knows how to deal with that. But to not know that when you get to the end of a development cycle where you may have invested hundreds of millions or well over a billion dollars, that funding will be available for that vaccine, it's just not something that's going to cut it. And so knowing through organizations like GAVI, knowing through the funding that comes from governments like the US as well as foundations like Gates Foundation, knowing that funding is available overcomes the second critical hurdle. Clearly then, private industry is absolutely essential as Tony said, I love the analogy to his daughter, I don't know why I didn't say his wife, I know he's happily married, but anyway. That was a great answer and I was pleased to hear it. And when you think about why is that true, there really is no broad-based vaccine that's come from anywhere other than an industry source and in many cases a public-private partnership. When you think about all the tools needed to get through that R&D process, whether you're talking about some of the game-changing technologies like sequencing, high throughput screening, whether you're talking about the bioprocess development to actually come up with a way to make that vaccine and then to be able to scale it up to produce hundreds of millions of doses a year, clearly you need industry to do that. Also to introduce vaccines, to be able to figure out what is the right product profile and working through partners, organizations like GAVI, WHO, SAGE, what's the right presentation of that product? Do we need a multi-dose vial or will this not be utilized in a campaign such that you could end up with a lot of wastage with multi-dose vials? So all of that clarity is needed up front but there are a couple additional things that are needed. One is accurate demand forecasting. How big a plant or multiple plants do you need? Will this be widely adopted? Will this have a universal recommendation for everyone at a certain age or will this be targeted to more high-risk populations? And from a funding perspective, will the funding be there for all countries or more endemic high-risk regions? You need clarity on that in order to be able to move forward with that investment decision. You also need to know that IP protection will be there and we know there's a few examples around the world where that's been an issue. You need to know that if you're developing this vaccine and expect there to be a high and middle income market but you're going to have tiered pricing and be able to provide a very affordable price in the world's poorest markets, you need to know that that IP protection will be there to justify your investment. You also need to know that from a regulatory perspective there's going to be support for efficient trials, you're going to be able to have low-cost manufacturing and perhaps tech transfer to organizations that may be able to take advantage of a lower-cost labor base, particularly in the South. So there are a lot of characteristics that are needed but fortunately we have a lot of very positive examples of things that have happened and that's why we have many vaccines in development even for the big three, HTB and malaria, where across those three we have four million deaths per year, most of which occur in the developing world. So we now have pipelines of seven candidates in the pipeline for TB, over 20 for malaria plus as you heard Tony talk, very promising results have come out over the past year and for HIV, he talked about the RV-144 results while modest, we can build upon that, we have some clues as to why that may have worked and then very importantly over 25 other candidates in the clinic, some taking advantage of the technology that Tony talked about, broadly neutralizing antibodies. So I'll just end with what Tony said, this can only happen through effective public-private partnerships. Thank you, Julie. So thank you for allowing me to be on the panel and I agree with everything that Margie said, in fact she taught me most of what I know so I'm very happy to support and agree with what she said. However, I also just came from Zambia and so this video is really remarkable to me. I came from Zambia where Zambia announced that it's the first African country to make a commitment, a national commitment to reducing cervical cancer among women and girls in that country and many of you know that cervical cancer is essentially an opportunistic infection associated with HIV infection. So in our world where cervical cancer, fortunately it's rare because we have screening and we have tools to detect and treat it, in the developing world cervical cancer is common, about 25% of the women in Zambia with HIV infection have cervical disease and it is a killer, it's the number one killer of girls and women in those age groups so it's a remarkable experience for the president and the first lady of a country that just had a peaceful change of government to stand up and make a commitment to this disease program in their nation. So why did that happen in Zambia? But it happened first and foremost because of the national leadership. The first lady is an OB-GYN doctor so that certainly was a big help but it also happened because of the leadership of the health ministry that you met, the leadership of the ambassador who was also on this video, the leadership of the missions from other countries who are there supporting this effort. It happened because of the leadership of the CDC in the country. Our CDC leader Larry has been out experimenting with inexpensive ways to diagnose and treat cervical cancer in the HIV clinics there. It happens because of the USAID investment in logistics and supplies. Happens because of the medical leadership of the teaching hospital there, the Zambians who are out but it will happen most importantly because of a woman named Mildred. Now what Mildred is doing is bringing women into her clinic, HIV infected women into her clinic. She's examining them, she's applying vinegar to their cervix and then taking a picture of it with a camera that has a magnifying lens and when she sees lesions that are white that's a sign that they're probably cervical disease and early stages of cancer. She, if she has a doubt about that, she flashes that picture by email to the doctor in the teaching hospital who's on call to run to the computer, check out the lesion and if he agrees that it looks suspicious she immediately takes a canister of carbon dioxide, frees off the lesion on the cervix, the woman goes home and does not have to worry about cervical cancer in her near future. Mildred is teaching women all over Zambia to be able to do this. So we're now in a situation where we have an inexpensive screen, we have an inexpensive treatment, we have trained personnel and we have a vaccine that can essentially eliminate the hazard for a whole generation of women in Zambia. Now that happened because of leadership, it happened because of ingenuity, it happened because there's a CDC that knows that there is a problem with cervical disease in the nation and can track the epidemiology and the unmet health need, but it also happens because there is a vaccine. And when we sit in the United States and think about cervical cancer prevention with the vaccines that we have, they're expensive, they're not easy to have distributed properly in our society because we don't have school-based programs, but we have the capacity here to protect our girls and women very easily from a disease that really should go away. But in the rest of the world, that vaccine is a lifesaver and we wouldn't be able to think about a cancer pre-world for women if we didn't have those vaccines. And the challenge is how do we make it cheap enough so that we can afford to use it in those nations? And one of the things that I've learned is that when Margie was talking about the market commitment, there's no better way to get the cost down than to increase the volume because once you've covered all that R&D cost, all the costs of the things that you try that fail, all the costs of building the plan, all the costs of the regulatory environment, all of the money that you have to put into it, at the end of the day, once you have covered those costs, any additional dose of the vaccine you make, you can make essentially for the raw material price that pulls it together. And that's how we get the cost down so that we can afford to bring vaccines into the areas of the world where people need them the most. But in order to do this, we have to know that there's procurement. So we need Gavi, we need the United States government committing to Gavi, we need UNICEF, we need the mechanisms that many of the developed world nations are contributing to assure that we can purchase the vaccines and that there's a future commitment to do that, not just this year, but five years from now or 10 years from now. We also need one other thing that was really remarkable in Zambia, and that was the mobilization of the partnerships. Susan G. Coman for the Cure is now working globally to mobilize women, build advocacy, and start at the grassroots to engage people in the awareness that cervical cancer is a preventable disease, and that women need that protection in order to thrive and to be able to raise healthy children who are benefiting from all the other vaccines that get distributed in the world. So you've got leadership, got the vaccine, you've got these incredible partnerships, and now we have social mobilization so that awareness and demand for these life-saving interventions can come through. I believe if we can do this in Zambia, we can do it anywhere. Thank you, Julie. Gina. Thank you. I guess I'm here from the perspective of a non-governmental organization, I guess we were called, the Bill and Melinda Gates Foundation. And our focus really is on the global health aspects and the global health impact of vaccines. Tony showed a very long list of potential candidates for the life course, and out of those, we don't focus on all of them. Not only because of budgets, but because we have to set priorities to be able to deal not only with the R&D, but our commitments to Gavi and on the implementation side. And those priorities are set according to disease impact. The potential for preventing disability life-years lost. And so there are a group of diseases that we do prioritize, and of course it includes HIV, TB, malaria, but a number of others, including pneumococcus and rotobars. The challenge is in terms of answering your first question, which is how do we ensure engagement of the private sector? And I will define that very broadly, not only pharma, but biotech and the developing country manufacturers, so include private sector outside of the United States, is that we have sort of a triple challenge. For many diseases, not all of them, we're talking about first and manned vaccines that don't exist yet. So we're engaged with US and European innovators because really this requires innovation. And we've made some of those investments, but largely that depends on the number one funder in the world, which is really NIH. The second is that when we do have a vaccine, we need it at really large scale. It's either the world's birth cohort or catch-up campaigns that go beyond one birth cohort. And you take any competent, mature company that's used to dealing with markets in the US and Europe, and you're really talking about a much larger commitment in terms of the facility that's required, and therefore you have the potential for efficiencies of scale, but boy, do you have to make investments to get those potentials in efficiencies of scale. And I think the third challenge is that realistically, the problem in terms of cost effectiveness analysis is not one in which you would limit that analysis to R&D costs, but you have to look at what the potential cost effectiveness would be of vaccines at the end. And those vaccines have to compete not only with each other for attention on the global stage, but with the other potential mechanisms for ensuring impact, you know, in malaria, it's bed nets. Do you buy a vaccine? Do you buy a bed net? Do you spray personal protection, prophylaxis, and how do you pull together the story of how you would maximize impact? So we give industry a very large challenge indeed, and I think larger than if they remain focused on Northern higher profit markets. Now, under the framework of the decadent vaccines, and Tony alluded to it, which is really a collaboration to bring together all of the parties that are working on the various aspects of vaccine R&D on one side to delivery and financing on the other side. As I thought about the various work streams, and we're funders of the secretariat on this, the concept that came out of a speech that Bill Gates gave at Davos in 2010, saying there is so much potential for impact with ROTA and NUMO HPV being introduced this decade, but for the R&D base to really generate the next generation of vaccines, it really has to be the decade of vaccines. And so it's both. It's both about delivery and maximizing impact, but it's also about the R&D base. As I think back to the challenges we face when we had Jim Grant, the last time that vaccines were really beginning to be scaled up is that the challenge in the global stage has changed. It's not a single entity that drives or owns the entire agenda. Countries have to make decisions. There's Gavian as a financing vehicle, but then for vaccines, every single district has to meet certain performance characteristics and make decisions about where they put their resources. So the decade of vaccines is really about bringing leadership to bear across the value chain. And I think an example of that is the work that has been done on a malaria vaccine. You asked me to address one vaccine. So let's talk a little bit about malaria because it's easier than HIV, right? We have some things, we've got years of research, HIV has a lot more money. But we have a human challenge model. The most advanced vaccine was just recognized by Time Magazine as the number two invention or medical breakthrough of the year, which was rather cool, you know? But let's look at where that vaccine came from. The collaboration included pharma. So it actually was born out of a collaboration with Walter Reed in the Department of Defense Laboratories, which is something we haven't talked about. There really has been so much support for R&D particularly in the elected and emerging diseases coming out of those laboratories and their engagement with GlaxoSmithKline. And if I were to show you what is now a 30-year picture of that vaccine in its first iteration, it's the second iteration, and it's third, the trial in Gambia, there's a whole lot of work that got done and then here the Gates Foundation got involved. Really from the trial that had been done in the Gambian adults then to supporting to prove that it worked or didn't work and it was actually quite risky that it wouldn't. Actually thought that was the likelihood when we made that decision was to prove that it would work or not work in children. Has a couple of things going for it. The partnership structure, the challenge model which demonstrated the concept that it worked in humans, which is think about the enormous investment that industry had to make an HPV vaccine, not knowing till the very end they were gonna have something, not only was immunogenic, but it actually worked. That's pretty scary. And then what it has had is the ability to do, it has an adjuvant. And I want to focus on the adjuvant because adjuvants per se are very expensive products to develop, they have to be developed with a vaccine. And the reason this worked for GSK, I think, I'm not speaking for them, this is my assessment, is that because of the human challenge model they were able to test adjuvants and optimize. Malaria occurs so frequently, you can do a trial in 2000 toddlers and figure out if it works or not. And you don't need to spend five or 10 years and do it in 90,000 people. So really they were able to optimize the vaccine and then take it down into infants for the results that just got announced in the New England Journal just out of the first year of the study. So the industry is important, having a good scientific base with the human challenge model, having the product components like an adjuvant program to enhance the immunogenicity, which is challenging for a parasitic disease. I think those are all critical elements that allow a company to engage in something which really will not be a product for the North but really be limited to a product for the South. So maybe I should just stop there, I'm likely to take it further. Thank you very much, this has been very rich. I'm very pleased to hear the reference to the DOD Overseas Medical Research Labs which are terribly important and under recognized in the contributions that they've made historically and continue to make. And also congratulations on the Pink Rib and Red Rib initiative which is really quite innovative and exciting. And when it was first rolled out in early September, mid September here in Washington, it was amazing to see the excitement and the presence of Secretary Clinton along with President Bush and Mrs. Bush and the many other partners from the corporate side that had come forward like yourselves to join into this effort and to make use very systematically of those 250 PEPFAR clinics that are now becoming the access point. I wanna bring it back to questions around US policy. You made a strong case for strong upfront public sector investment as part of setting the incentives for the discovery and development. We're in a tough budgetary situation right now. We're in a very austere and uncertain climate. You could make a case that we're in an exceptionally austere and uncertain sort of climate. So the question I guess for all of you is how do you make, how you best make the case? Because this is a long run investment. These are not necessarily well understood and brought among a broad public but they're so fundamental to guaranteeing that those partnerships take place, that the development and discovery of new products proceeds along a course and that you can build towards that. That's one big question I was hoping you could speak to and related to that is do we need in this time that we are in, do we need a renewed focus on some of the innovative financing alternatives to both build into that, thinking about how we get through this difficult period because this difficult period could stretch for a while and what you're saying is you need the very long range thinking, that's what the decade of vaccines is about, that's what the private sector is looking for. So maybe if you could jump in, is Margie doing it? Sure, in terms of how do you make the case especially with these tough economic times, I think you have to focus on three aspects especially if you're within the US thinking about the leadership role that we play in global health. Look first at the human aspect, clearly that's what drives our global health agenda is doing something to help those more vulnerable, less fortunate and so with all of these diseases, unless you've got the vaccines that can prevent the illness, you can only get so far. We should absolutely make the best use of all prevention treatment technologies that we have available today. As Tony said, we'll bend the trajectory but the holy grail getting to the end will require a vaccine. So you can model that many different ways, sure you can model it that if we could really control human behavior, you could get to zero and I wish we could but we all know we can't control human behavior so we'll get to something less than zero. So let's let the experts who understand what you can achieve with human behavior and many groups have put forward projections. Bill and Melinda Gates Foundation had a project where they put forward projections but you clearly can't get to the end game without the vaccines and how does that impact human beings, how many millions of lives will still be lost. Second is the economic impact and when you think about, I'll take HIV since I know the figures much better there, if we're spending globally $15, $16 billion a year right now to get, I think it's between six and a half and seven million people on treatment over the next couple of years and the projections have been if we go out to 2030 that will be over $30 billion a year to continue that treatment. I can't tell you exactly what a vaccine would cost when you get through that catch up cohort and get to immunizing a full cohort but it's in the single digit, low single digit billions if you look at any other model that's out there and so thinking about it from the cost effectiveness, the total impact on budgets globally, that's a clear argument and the third aspect to look at is just the leadership role of the United States, the United States government, the United States research institutions. We have been the leader in innovations like this and just imagine the pride we will have as a government and as a company if we reach that holy grail and we bring out the ultimate solution to these devastating illnesses. So from a 40,000 foot level for the United States government and the policy makers here, I would say it's really, it's about the three Vs. It's about development, it's about defense. When you think about the threat that infectious diseases bring, it's not just for those people over here as we learn over and over again, we're one traveler away from an infectious disease problem in the United States. So we have every reason to be thinking about diplomacy, development and defense in the realm of vaccination. Development in particular, it's not just health which is what motivates me to get up in the morning but it's about development from a global standpoint of economic security for the countries where people will have lower birth rates because they have more confidence that their children can grow to become adults. It's about development of the systems to deliver and produce vaccines and what an incredible force of economic growth this could really be and has been in nations that have taken this on. It's about development of capacity and infrastructure and rising into the global economy. Vaccines are a very important tip of the spear in those areas but they are also very important diplomatically when we launched the pink ribbon, red ribbon campaign in the country and I was just there last week, outpouring of human emotion, their love for the United States, their appreciation for what we do as a generous nation is really emotionally overwhelming. It is such a powerful statement that our country that has so much is willing to do this for the people who have so little. It's an absolutely epitome of the United States government at its best and it makes me personally very proud to be a part of it but I think many people in our country don't realize that their tax dollars are doing such good in the world and it's really important that we step up as policy leaders to continue to make those investments. Now those investments need to go to the NIH. There's no question that that's the powerhouse of basic research that fuels that kind of research all over the world. That those investments also need to go to CDC because if we don't have a CDC we not only don't understand where the disease threats are but we don't have the laboratory and the programmatic support to get immunizations with the technical capability where they need to be and we must continue to fund those DOD labs. They are the front line of defense particularly for influenza around the world. If we didn't have the DOD labs we would not have the surveillance capability that we have for understanding which flu strains are emerging and which parts of the world and what do we need in our vaccine in the United States. So it isn't just about a platform to put money into the global fund or to put money into the GAVI fund. It's about supporting those agencies in the U.S. government that are globally relevant and really provide a front line of defense of diplomacy and development for all of us. Chena, would you care? So in the best of all worlds I believe that global health compassion and understanding the impact on diplomacy would be drivers for U.S. investment. I think there are drivers for our investment. This is why we engage. This is what we see when we go out to countries. But I think what resonates when we're talking to decision makers here who are trying to make the difficult trade-offs and financing and investments in NIH, et cetera, are numbers. So the person who asked the question about and vaccines do very well on that. Prevention, highly cost effective. Really when you think about what you could invest in and you can make projections. It's called modeling. There are people who are spending their careers doing this. What you could invest in that would have the biggest impact U.S. and globally. And you test vaccines against other health interventions. They come out number one. And we have to be rigorous about bringing those numbers together, about utilizing them. I love Tony's figures. I don't know what the sources of those data are, but he's rigorous too, so I'm sure he's looked. In terms of not only impact on lives but impact on dollars, we have to make the case. And having made the case, and we need to bring the funders, the donors around those kinds of investments. I think the numbers have to speak for us. And we have to be rigorous about developing those numbers and driving their use. Thank you. I'd like to open the floor for some comments and questions and just stand up or raise your hand and we'll bring a microphone to you and please identify yourself and offer a quick comment or question and we'll bring together two or three at a time and then come back to our panelists. There's a hand right here and I think there's someone in the back row. So why don't we start with you, ma'am, please? Hi, good morning. My name is Ashley Weatherford. I'm from the Best Shot Foundation, a global child health nonprofit. And first of all, I'd like to thank the panelists for coming out today and taking the time to speak to us all. And my question is given the recent trends in economic and budgetary constraints, what is your overall sense of the future of public health programs in the next five, 10, 15 years including vaccine R&D and other health interventions? Thank you. There's a gentleman right here. Please. Sorry, Matt Lawler from HHS. I just wanted to ask about prioritization. So Dr. Fauci showed some slides with probably 75 worthwhile targets but giving diminishing resources and given what seems to be a broadening number of NGO private sector and government partners interested in this space, is there a value in bringing people together and focusing on two or three or five or some limited subset and really galvanizing more support around a limited list of threats? Thank you. We have a hand here, please. Thank you. My name is Ann Thompson. I'm with World Vision and the Core Group Polio Project which is funded by USAID and the Gates Foundation to play a part in eradicating polio. I just was wondering if you all could comment on the drive to eradicate polio in relation to resources and priorities, those types of issues. There's a question right here. Hand up. Then we'll come back to, we'll take the fourth. Yes, sir. David Curry, Center for Vaccine Ethics and Policy at University of Pennsylvania. I'm interested, perhaps for Julie, the Decade of Vaccines Collaboration has been mentioned a few times and obviously that longitude has interesting implications for industry. I was wondering how industry is participating or will participate in the refinement of that strategy. Thank you. Julie, do you wanna lead off? I mean, we had a question specifically directed to you and then we have a question around polio, around prioritization. How do we, how might we prioritize? And then Ashley's very broad question around what is the future for the next five to 15 years look like given the austerity. Julie. So I'll start. First of all, with respect to the future, I'm very bullish about vaccines in the future. I think that we're slowly but surely making progress on the big three, as you said, but we're also, I think, really beginning to build the social mobilization, the political mobilization, and the private sector mobilization necessary to really pull forward and continue to use this very cost effective intervention for protecting health. With respect to polio, I, you know, the world's expert in polio eradication is sitting here, was sitting here in the room, Steve Kachi, and we just have to do it. There's no question about it. It needs to get done. We can do it. Look at India right now. I think this is the longest India's gone without a case. This disease can go away and we have a responsibility to make sure it does. And yes, the last cases are very expensive on a relative scale. But once it's done, it's done. That's it, bing, bang, boom. And it's just hard to have any other talk about it. It just needs to happen. The question about prioritization is really the toughest question. And one of the challenges that I think we are maturing into now is an appreciation that ultimately the decider about what the priority should be is first and foremost, the person who's receiving the vaccines, mom or woman or child, but more importantly, the country. And it is tempting to sit in the United States and think we know best. But in actual fact, a country's agenda to understand and make values about their own health priorities is really the most important aspect of making decisions about prioritization. Many countries welcome the support and the input from technical experts in health economic data from outside of the country, but ultimately we need to be in a position where our vaccine agendas are first and foremost addressing the needs of the people in the countries who are making and paying for them. Having said that, I also think that prioritization is changing. We're seeing now multinational companies put enormous emphasis and investments in vaccines that will not be marketed in the United States. Merck is doing that, Glaxo is doing that. Companies are stepping up and saying that we have a responsibility here. This isn't just about the developed world. This is also about using our excellent science and our capabilities to solve problems in new markets. And we're doing that through partnerships. We're doing that through creative funding mechanisms. Merck has a wonderful partnership with the Welcome Trust called the Hillam and Laboratory. It's a nonprofit vaccine developer in India that is taking products that right now are not suited for developing world use because of cold chain requirements or various other characteristics and trying to repurpose those vaccines in ways that will make them easier to use or less expensive to use through the leverage that that kind of partnership can build. And there are many examples of this kind of innovative solution. So I think the prioritization process is beginning to have a better match with the true health needs in the world, not just those in the countries that can afford them, but in the countries where people need them the most. Gina. On the topic of polio, it's our number one priority. And I'm optimistic not only about polio, which has its challenges, but also about the whole arena of vaccines. And that's not only because I'm an optimist, but I also work for an inpatient optimist who wants to have, who saw a lot of money. And we all know about that. On the issue of prioritization, I do want to support NIH and other like-minded organizations that must keep a warm research base and make investments across a number of diseases at the research level. Where it gets really expensive and where we need to understand who's going to use it, that it's really wanted, is at the phase three trials. And while some of them are less expensive and other are really expensive, so that's an order of magnitude. I think what makes the difference is that people are informed and there's been discussions on what it is they want. This week, one of the decadent vaccines teams is in Namibia as part of their consultative process to understand what it is they need at a country level, listening not just Namibia, but the nearby countries in terms of being ready to introduce a vaccine, what is it that would actually help them? And they're looking for some help in things that may be technical assistance, that may be preparing for launching into a campaign. It was very, it was very personally gratifying, I have to say, to be in Burkina Faso last year for the launch of the MnNJ vaccine, which I'd been involved with the CDC and WHO teams in writing a proposal to this Gates Foundation prior to my joining the Foundation. And watch it go from a concept of partnership, potentially with pharma, to one in which it became a very sort of complicated partnership engaging not only CDC, WHO and PATH and NGO, but developing country manufacturer. And you can shrink 10 years of work, well nine years of work on that, to a launch in which rather than hitting the 99% of the population from H1 through 29 in 10 days, Burkina Faso did it in eight. And they did it with massive mobilization of the national resources and healthcare workers, but with 10,000 volunteers, it was done. And that is because that disease really matters to them because of the annual epidemics that they get. And I think that that prioritization needs to happen, particularly at the phase three level and with an eye towards not only what vaccines are needed, where have we done the right work to create the information base on what diseases are important, but also what Mark LaForce did for that project, which say the countries want it, but it has to cost less than 50 cents. And that forced a massive restructuring to actually be able to reach that goal for a single component conjugate vaccine. So I remain extremely optimistic. And impatient. And I am also impatient. Yeah, I'll try to touch on maybe two aspects of the four or five questions that we didn't hear as much on. And the one is in the next five years, I'm also very optimistic and I was thrilled to see that the Gavi funding coming through with the meeting that I believe with donors was held in June, including the US government being a strong supporter of Gavi. And I believe and I know Helen will be up here soon. I believe Gavi has about $7 billion in order to implement immunization programs over the coming years. And I am a big fan of what Gavi has accomplished. And I've seen firsthand, I sat on the board of Gavi representing the industry for a few years. And I saw firsthand how the efforts of Gavi were leading to tremendous uptake of vaccines, whereas historically it would have taken 15, 20 years to get an innovative new vaccine into the developing world after it was launched in high income markets like the US. Gavi has brought that down to a couple of years and it's just great to see with pneumococcal, the new vaccines now coming out because of the advanced market commitment, it will be even quicker. And so I'm real bullish on the delivery side of what we can accomplish in the next five years. I'll admit I'm more nervous on the R&D side and there are many government organizations that are subject to funding reductions because of the budget situation. You've heard Tony mention could happen to NIH. I know Nelson Michaels here, the MHRP or military program which funds important vaccine development work for HIV. You heard about the DOD labs. Certainly CDC could be part of that. We don't know what will come out of this USAID which is an important donor, certainly to AIDS vaccine research in our organization as well as capacity development in the developing world which supports vaccine trials. And so what we have to do is make sure that we're not short-sighted, that we keep the end game in mind and go after that holy grail. And I know it's difficult to fund both the delivery and the R&D for the ultimate solutions at the same time but I think we just have to find a way to really do both. And the last thing I'll mention is the question on industry involvement in the Decade of Vaccines Initiative. The initiative has been going on now for several months. We have Lauren Lombin who will be up here who's leading one of the task teams. I've been involved as has a few others who have had industry experience and the decision of the steering committee was to get through the initial phase including people who had industry experience but weren't currently sitting in roles in the industry and then to go to a broad consultative phase not only with the industry but many other key stakeholders and that is now where the initiative is over the coming months and I know many discussions are taking place to make sure there's industry input because I'm a big believer that to have solutions that will work you need to get the industry engaged and make sure you're coming at it in a way which is going to align with their decision making and incentive processes and then I think we'll be able to accomplish what we're setting out to do. If I could just add to that just a couple days ago I sat with the five CEOs from the other R&D vaccine manufacturing companies and we signed a commitment to support the decade of the vaccines and we'll be coming out with our own statement of what that support will look like and how we can do our part to step up and contribute to the success of the effort so I don't have specifics to give you today but we are certainly committed. Thank you. This has been a rich and wonderful discussion. Please join me in thanking our speakers. Thank you.