 Before we get started, I want to offer special thanks to my colleague, Katie Peck, who put the event together. And I also want to offer special thanks to Ted Trimble from the National Cancer Institute who brought this idea forward initially a number of weeks ago, which we were thrilled at the chance to pull this event together. So thank you, Ted. And I also want to thank our speakers who are with us here today, Dr. Harold Varmus, the Director of the National Cancer Institute, Nobel Laureate, former head of National Institutes of Health, former President, CEO of Sloan Kettering. Thank you, Harold, for being with us. Ambassador Sally Cowell, a good friend, a longstanding friend of mine and of CSIS, who is the head of Senior Vice President for Global Health at the American Cancer Society and has worked at senior positions in a multitude of diplomatic and public health institutions over the years and is a remarkably accomplished leader, both as a diplomat and global health expert. Sally, thank you for being with us today. Tom Boyke, senior fellow at the Council on Foreign Relations, also a longstanding friend of CSIS who just completed at the end of 2014 a groundbreaking task force on NCDs, on non-communicable diseases, which we'll hear more about today. And Tom, thank you so much for joining us. We're going to take this conversation in a couple of different ways. We're going to open with one round of comments, introductory remarks. We'll start with Harold and Sally, Tom, to talk about two things really in the opening segment. One is how their respective institutions are looking at this whole question around global cancer and what do we need to know about the way they look at this and the things that have been undertaken in recent years in order to raise the profile and be more effective and impactful in this area. And then as part of that, to talk about the tools that exist today that are accessible and affordable and impactful that are ready-made that perhaps with a little bit more energy and attention could be brought forward in a more effective fashion. So we'll go through one round of conversations to open things up along those lines. Then we'll move into a second segment, which is thinking more long-term and more strategically around forging coalitions. How do you build a coalition long-term? How do you set a long-term research and development agenda? How do you begin campaigns that are priority campaigns? These sort of things. Because across these institutions, all of those topics, the coalition building, the R&D agenda, the campaigns are part of their everyday and long-term work. So thank you. Harold, why don't you kick things off for us? Thank you, Steve. And I wanted to begin by making a brief remark about the historical significance of what we're doing here today on World Cancer Day from the perspective of somebody who's getting long in the tooth and remembers a time when this would not have happened. So when I was a medical student in the 60s, I was interested in global health, but I was interested in what we then called tropical disease, and that meant neglected tropical diseases, tuberculosis, other infectious diseases, perinatal deaths. And it wouldn't have occurred to any of us to think about cancer in that context. And now, of course, the world is very different. People are living much longer lives in poor countries and lower-middle-income countries. They are more susceptible to non-communicable diseases. We've had appreciable gains in control of infectious disease. And the focus has definitely shifted, as you'll hear. But even in the 60s, when I was more mesmerized by infectious disease in poor countries and not thinking about chronic disease, even then, the national cancer, too, was already involved in studying cancer in poor countries, in particular in Uganda, where Dennis Burkett had discovered Burkett's lymphoma, had displayed one of the first beneficial effects of chemotherapy by using cytoxin to dramatically improve the health of kids with this horrific disease, where they discovered Epstein-Barr virus demonstrating that studying cancers in poor countries can be beneficial to the rest of the world. So many principles were laid down then, and despite the political ebbs and flows in Uganda, the institute in Makarari, at Makarari University, that was established in the 60s, survived. And to this day, does important work on a variety of, especially, virus-associated cancers that are abundant in Uganda. So many of the principles that underlie my own organization's commitment to fostering better control of cancer in poor countries was laid down in those early days. When I came to the NCI about five years ago, it was immediately apparent from looking at our current portfolio that we have a lot of investments in global health in various parts of the world, epidemiology, clinical trials, and other things. But the effort was not well focused, not well organized, and we created a center for global health as headed by Ted Trimble, who apparently provided the spark of the idea for this conversation. And what we tried to do is to recognize, first of all, that we ought to have a template for thinking about controlling cancer in different countries. And then we need to be sensitive to the fact that of the almost 200 countries throughout the world, the capacities, the financial commitment, the personnel, the nature of cancer in each country is very different. Mantra is not one disease. It's a multitude of diseases which differ in frequency every place we look. So our mantra in approaching efforts to study cancer, which is what NIH does is to do research, and has been to list with respect to every country what needs to be done. That begins with saying, what is the problem? Developing registries, learning to identify epidemiological problems that need to be solved to understand the cause of developments in a certain cancer, and leading to the development of a national cancer plan in which a nation decides how much to commit to trying to control cancer in various ways based on what resources are available for doing it and what cancers are afflicting their population. So at that point, the national cancer plan needs to build heavily on developing an agenda of cost-effective pursuits, those that basically pluck the low-hanging fruit. That often begins with the recognition that many cancers have an infectious origin. And for some of those, we have vaccines like the human apulomavirus vaccine, hepatitis B vaccine, that many of the factors that predispose to cancer are also factors that predispose to other chronic diseases. Number one on that list by far is tobacco use. And I'm sure as everybody in this room knows, tobacco use is out of control in many countries around the world. As people develop wealth, they often advertise that by taking up tobacco use, which can be expensive. And controlling tobacco, which is used by as many as 50 to 60 percent of males in many countries around the world and an increasing number of women, is the number one factor in trying to control cancer in poor countries. A third set of factors have to do with behaviors like overeating and getting exercise. And we try to contribute in planning to reduce cancer rates, which can be reduced. Incidents can be reduced by as much as 50 percent in many countries. We then look at health systems and think, what can we do to improve screening for catching cancers early? Improving hospital resources so that this myth that cancer is simply too difficult to treat, too expensive to treat, can be overcome. So things as simple as easy surgeries, as I mentioned, screening, especially for colorectal oropharyngeal and a few other cancers, very important things to implement. Not terribly expensive. And then there are drugs, many drugs that are very effective for certain cancers can be afforded. And the fourth element here is controlling symptoms. We call it palliative care, which is especially important at the end of life. No one in the world should be dying of cancer in an excruciating fashion. Finally, in thinking about all this, we have to consider how we mobilize resources because especially at this time in the history of NIH, we can't do everything ourselves. And we find that our cancer centers around the country, they're 68, are very responsive to the idea of helping with this global battle. We provide supplementary funding and modest amounts that gets leveraged to make our cancer centers paired with cancer centers in poor countries. We try to take advantage of the enthusiasm of young faculty and students, trainees, for this battle. And we try to convince people who make policy that there are advantages to doing what we're hoping will get done. To this end, I think it's very important to be setting goals, to be thinking about disease priorities and recognizing that there's a change in the approach to global health. And I hope that in today's discussion we get into some of the ways in which we can not only make the decisions about what to pursue, but find the tools for doing that. Thank you, Harold. Sarah, Sally. Thank you. My name actually is Sarah, but thank you. And thanks for inviting me here today on World Cancer Day. The theme of this year's world, you know, these years all have themes and the theme of this one is not beyond us. And I think that's actually a very good theme because it's, to me it says that there are a number of immediately deployable tools, as Dr. Varmus has said, I could just say I'm in and quit here. But don't. We know what to do. We have things at our fingertips that we could deploy that don't cost very much money, that would make a significant and almost immediate difference in the global cancer burden. So I stand up and cheer when I hear it's not beyond us. This is a slogan we heard in a different form in 2008 when somebody said yes, we can. Yes we can. We can do something about cancer. And so in this first part I think what Steve wanted us to talk about was some of the best buys. And I think Dr. Varmus has already mentioned most of them that we at the American Cancer Society are also working on. We are in some ways the civil society equivalent to the National Cancer Institute and we work very closely with the National Cancer Institute with its global center also with the World Health Organization and its regional affiliates such as PAHO in this region of the world because we won't do this alone. This needs to be an all of society approach and an all of government approach if we're going to make any kind of a difference. What we're trying to do globally is an extension of what the American Cancer Society does domestically. We're driven by our domestic mission which is really to, we're committed to preventing cancer to saving lives to diminishing suffering and to mobilizing a global network. Here in the United States we have about four million volunteers who work in virtually every community in the United States to promote survivorship, to promote early detection, to promote prevention. And we want to extend what we do in the United States to vulnerable communities abroad. We know how to save lives and we know what works. So we just have to apply what we already know. And we feel at the American Cancer Society that it's beyond that it's also our moral obligation to do so because it is not only the fact that people are living long enough to become burdened with these non-communicable diseases and that's a triumph to a certain extent of public health that we now use, lose fewer people to childhood diseases and fewer people to HIV and AIDS so that they live longer and they live long enough to become burdened with things like cancer. But it's not that benign. The moral obligation is that we are also exporting our Western lifestyle whether that's tobacco or diet or physical inactivity. So since we have exported that lifestyle it's about time we exported our knowledge about cancer control too. And we have some good lessons. The United States which has 11% of the world's cancer incidents has about 50% of the world's cancer survivors. So we have learned certain things and all of them may not be applicable everywhere and that's why we try to focus on countries where we think we can make the most difference because the policy environment is conducive. There may be a national cancer plan. It may be a democracy where we can help build these civil society forces that urge their governments to do more about communicable diseases. And it's also on certain kinds of cancers. Cancers where there are very good ways to prevent them such as tobacco, not using tobacco or where there are very good, ineffective and inexpensive ways to screen and treat for those cancers such as cervical cancer. So we're focused right now on trying to make a difference in a number of countries. Kenya, Uganda, Ethiopia are big focus countries for us this year. Also India, the birth of disease in India. And we're focused on cancers like cervical cancer. And also as Dr. Varmas mentioned, the notion of palliative care. The fact that 85% of all pain medications in the world are used by just 7% of the world's population is a huge equity gap which we know we have the tools and we've already been able to roll out those tools to a number of countries. And we've seen that within a period of two or three years a difference can be made. So that's what we're focusing on right now, tobacco, women's cancer, cervical cancer, but also not ignoring breast cancer, recognizing that breast cancer is at a very early age. And we had a very good forum yesterday at the Pan American Health Organization on breast cancer in low and middle income countries. So breast cancer, and it's an interesting curve as countries become richer, breast cancer incidence goes up and cervical cancer incidence tends to go down. So we can't bury our head in the sands and forget that breast cancer isn't rising also very quickly. So I'll stop there and we'll come back on a second round to talk about some other things. Thank you. Tom. Great. That's a bit about your work. Well, it's a pleasure to be here on World Cancer Day. It's always nice to be at CSIS and work with Steve. So I'm glad to have this opportunity and it's a pleasure to be on the stage with Sally and Harold. I'll start with my remarks just telling you about a task force. We recently pulled together a group of experts across a variety of fields. Global health, trade, development, national security at the Council on Foreign Relations. Task forces are a signature initiative that the Council does. They're typically led by former presidents or secretaries of states or individuals of that stature. This is our first devoted to global health. And I point that out to tell you how the seriousness with which we view non-communal diseases and what's happening in low and middle income countries. The way we were able to pull together a group like this, and it's not, it's leading people in global health, but not people who had spoken out about NCDs before, people like, or at least not in low and middle income countries or were known for doing so. Former health secretaries and heads of CDC and Surgeon General, those types of individuals. And we were able to pull them together by telling them they could say no to the question that we had to ask, which is, are non-communal diseases such as cancer a problem in low and middle income countries? Is this an area in which, if it is a problem, is an area in which the U.S. has a national interest? There are lots of global problems. They're not all the U.S.'s job to solve. If it is an area in which the U.S. has a national interest, what could be done about it? Both in the short term and in the longer term. And the way we approach this is we took a very data-driven take on this. Chris Murray, who as many of you may know, leads the Institute of Health Metrics and Evaluation, was kind enough to be on the task force, and we worked extensively with them in looking at, what does this look like in low and middle income countries? And what we found are non-communal diseases like cancer are increasing faster, younger, and having much worse outcomes than in high income settings. Just to throw some numbers behind that, the rate of deaths from non-communal diseases in low and middle income countries has increased 53 percent since 1990. That's significantly faster than the rate of population growth. If you look at particular cancers, the burden from breast cancer in sub-Saharan Africa in most countries has increased over 100 percent since 1990. If you look at lung cancer, depending on the country, it's 50 to 70 percent since 1990. So very, very fast. It's not just a fast increase, it's a rising in very young populations. 80 percent or more of the burden of non-communal diseases in sub-Saharan African countries in South Asia is happening in populations under 60. So we took a stricter definition of prematurity than the WHO uses, because it thought we'd get the point across to people what this looks like. And we looked at populations 59 or younger. And what we found again, 80 percent of the burden, that's 8 million deaths, 59 and younger from non-communal diseases in 2013 alone, to give you a sense. Because these diseases are largely chronic and people are sick longer and they're sick younger and they have worse outcomes as enormous economic impact. World Economic Forum has estimated it will, non-communal diseases will extract $21 trillion in economic costs by 2030. That's roughly the economic output of all low and middle income countries in a single year. The other thing we identify in this group is that this isn't being driven by byproducts of success. I think most people are not merely. Most people assume this is driven by our success in cutting infectious diseases. Incomes are rising in low and middle income countries. People are adopting perhaps unhealthy lifestyles. And what we found is in low income countries, the rate of increase of non-communal diseases is 300 percent faster than the rate of infection, decline in infectious diseases. In lower middle income countries, it's a third faster. Rates of obesity, physical inactivity in low and low and lower middle income countries are still really low. What's driving it? Same thing that is driving other global health problems. Poverty, lack of health spending, a dramatic expansion of urbanization, depending on which cancers you're talking about or which health conditions you're talking about. These are the drivers in these settings, more than just simply a byproduct of success. So why should the U.S. care? This is bad. I love the slogan, not beyond us, because I think you can read it two ways. It's not beyond us just in terms of its solutions, but it's also not beyond us as a global health problem. It's here now. But why is it the U.S.'s problem to solve? And I think most people, probably nobody in this room, but most people assume most of what we do in global health is about protecting U.S. citizens from direct health threats. And the vast majority of what we invest in in global health is not about preventing a disease, an emerging infectious disease from coming here. It's about HIV or poor maternal newborn and child health. It's about malaria and the prevalence of these conditions in Malawi have nothing to do with the prevalence of these conditions in the United States. What we did is we looked at the 49 countries where the U.S. spends $5 million or more annually in global health aid and asked, what are people getting sick from prematurely and what are they dying from? And what we found is non-communicable diseases represent premature mortality, just premature mortality, 59 or younger, three and a half times the rate of premature deaths in HIV in the same countries the U.S. has invested in. They represent almost twice as many deaths as HIV, malaria, and TB combined in the same countries we invest in. So if we invest in these countries because we care about the welfare of these governments, these countries, these people, the same reason to exist to invest in cancer prevention and treatment in low and middle income countries. This brings us to the last area. So this is a problem. It's a problem the U.S. should care about. What can we do about it? And some here I will of course echo some of the areas that Harold and Sally rightly identified. We looked at three buckets. The first are things that are shovel-ready now. And on the cancer side, tobacco control. Tobacco works in poor countries. It works in wealthy countries. It's cost-effective. In many cases, it's revenue-generating. But it is not an area in which we have invested sufficiently both in the U.S. government as well as internationally. It's an area that deserves much more investment. Lung cancer is the leading cause of death from cancer in low and middle income countries. 70% of lung cancer is driven by tobacco use. We can do more. We talked about some of the vaccinations, prevention, HPV, hepatitis B. These all fall in categories of tools we have now. You can extend them to low and middle income countries without adoption. The second category is talking about some of the areas that both Harold and Sally mentioned is we've made enormous progress cutting premature mortality from varieties of cancer, particularly breast cancer drop. Premature mortality has dropped to third, I think, since 1990. Or death rates, rather, has dropped to third since 1990 from breast cancer. In the United States, other high-income countries have had that success as well. Whether you're talking about stomach cancer, testicular cancer, childhood cancers, we've made an enormous amount of progress, but these have by and large not been extended to low and middle income countries. And with a bit of investment on some of these diagnostic tools and treatment measures, perhaps they could be. But it's an area where NCI is doing good work now, but we need a lot more investment than there is currently. And the last area that we talked about are areas where the U.S. and low and middle income countries can learn a lot from one another. The U.S., as was pointed out, is an early adopter of the NCD problem. And certainly we have a lot to learn on cost-effective chronic care and other measures. And that's what this task force came up with around cancer in low and middle income countries. I hope that's helpful. Thank you. Thank you very much. I do think it would be useful to delve a little bit more into the whole question of why is it so difficult to make the case with respect to cancer? We've had a presidential strategy and study. We've had many other things that we've heard about here. We've heard Tom talk about the nature of the threat, how the threat is conveyed and understood. There's certain mythology around too expensive or too difficult. There's the complexity of the field. There's multitude of different diseases or interventions that we're talking about. But it would be useful to hear you say a little bit more about your reflections on why it's difficult and what does that imply in terms of forward-leaning strategies looking ahead? Well, if some parts of it are difficult, other parts are not. I do think that the U.S. public is prepared to support these efforts. Some years ago, I wrote a report with Tom Pickering for the Institute of Medicine on this topic and the U.S. Investment in Global Health. What does it mean? Why should we do it? Part of the argument is that we are pretty good humanitarians in whole. There are exceptions to that. But on the whole, we do a pretty good job in responding to need. And I agree with Tom. This is not just about defending our country from threats of infectious disease or being concerned about sending our workers to third-world countries where we have investments. We do care, just from a humanitarian perspective, that countries be healthier than they are. And we also recognize the other element here, which is that the world in general is more secure if people are not being battered by diseases, especially diseases that occur at a fairly early age in life. And I actually applaud the idea of the Council taking 60 as a year to emphasize the life expectancy. The WHO has tended to favor 70, but this idea of everyone dies. And if you don't frame the question in a way that avoids the fact that eventually everybody dies or something, you make a much better case for advancing our cause here. But I think the problem is that cancer is enormously difficult to think about. Lots of different cancers, different causes, different ways to approach control. And what I think we've tried to do, and I think the Council's report does the same thing, is to focus on some areas where things are now achievable. I'm just reiterating what everyone said by pointing out that the tobacco control is way up among them. And dealing with vaccination becomes a little more complicated because the cost of Taplomavirus vaccine by the unwillingness of countries to make the investments in certain vaccine programs, but those are very effective too. They just don't have immediate consequences. So I think one of the things I hope comes across from today's discussion here and many other places is that there is a list of things that are currently ready to be used, are not all that expensive, not all that difficult, and can make a large impact. The final point I'd make is that it's important that we recognize that every country is different and the countries have to do this job in large part on their own, that we need to bring the expertise, guidance, and encourage each of these countries to develop their own program, use their own citizens and their own resources ultimately to get some measure of control of cancer in their countries because we're just not in a position at this point to bring in the arms that are required to prevent and treat cancers in the way that is appropriate to all those countries. Some of this really involves partner countries making this a top priority in their dialogue with us bilaterally, right? Some of this is the demand side of this. Some of it is also getting the private sector engaged because the private sector is so vitally important to all of us. Sally? Yeah, I mean I'm actually fairly encouraged that we may be approaching a tipping point. I hope we're approaching a tipping point in which cancer and other non-communicable diseases take their rightful place in terms of the world's attention, and I'm talking about low and middle income countries in those countries and in the rest of the world because as we've heard from Tom and others and the Institute of IMHE and University of Washington demonstrated conclusively a couple of years ago that the greatest burden of disease in virtually every low and middle income country now, they are non-communicable diseases, they are cancer and yet our funding, I think both our funding as the United States and our funding in multilateral institutions has not shifted along with that shifting burden of disease. We are a very generous country as you point out, Harold. We are a very humanitarian country. We do invest with the largest single funder of global health at about $9 billion, and that's not the money that's by and large going to the National Cancer Institutes or the things that we do at home. That's PEPFAR. But that's essentially PEPFAR, and there you have it. And of course, having been one of the founders of UNAIDS working with Peter Piat and others, I guess maybe we're the victims of our own success. We got it shifted that way because it was a tremendous crisis and we were able, but I shouldn't say we were able, I should say that sort of by mobilizing the grassroots both in developed countries and developing countries, we were able to escalate this problem to the point where it got the attention of the funders around the world and the policy makers around the world. What I'm encouraged about is that an organization like the Council on Foreign Relations would devote its first task force on health issue to non-communicable diseases. I see that as the beginning of a shift. I think it's also necessary that we shift at the top and at the same time things come up from underneath. That's why we're trying to, in the American Cancer Society, mobilize our 4 million volunteers and others to be doing more in their own communities to see that the world cannot forever exist in a place where we are the only island of hope surrounded by a sea of despair. We need to invest in others. We need to tell our congressmen that perhaps of our 9 billion dollars in allocation for global health, it's no longer appropriate that 85% of that, 90% of that, 95% of that should go to infectious diseases and maternal health when really the biggest burden of disease is elsewhere. So I think we need to, I would of course like to see more funding for global health because I think it's important to our stability and security as a world as well as our own economic progress. You mentioned the private sector. The private sector of course is counting on its growth and development being the growth of healthy economically active populations in low and middle income countries. If they're devastated by non-communicable diseases dying at an earlier age, not productive members of their own societies and not consumers for our product, then that promise will not be there. So in that sense, I think non-communicable diseases are every bit as devastating to the world and to us as communicable diseases. That distinction is really a distinction without a difference I think. They are undermining the fabric of society in these countries when women are dying of cervical cancer at age 30 and 40 and 50. First of all, we may have already invested in them because we are trying to save them from getting HIV or dying from AIDS because we've made medicines available so they don't die of AIDS. Do we want to lose these same women to cervical cancer for not investing any resources in that? There's still a loss to the productive workforce of their countries and there's still a loss in terms of being consumers for our products. So I think the case is certainly there. We've made it, I think, or are making it at the top level. Through our volunteer efforts and others, there's a wonderful survey also just released by an NGO called Orogia World and it's a survey of 10,000 women and the effect of NCDs on them. And they're women in countries from Afghanistan to the United States and each one of them talks about what has happened because of non-communicable diseases in her own life that she's caring for parents, she's caring for her husband, she's running a household. Up to 25% of her household income is now going toward the care of either herself with a chronic disease or family members with a chronic disease. So the investments that we have made, we shouldn't put at risk by now not reaching out and making this next investment. It does sometimes, I must say, shock me when I see how interested the Congress can get in Ebola. I know Steve's just come back from an Ebola trip and I'm aware of the fact that it's an important emerging issue but the number of people who have died from cancer just in the few months that we have been talking about the Ebola outbreak is far, far more devastating to those societies. So I agree there probably won't be a global front for cancer although some people are beginning to talk about it but I think through empowering civil societies in countries themselves to ask their own governments to step up to the plate and do more and invest more and by generous countries like the United States investing in these things we will begin to make a difference. Thank you. Let's talk a little bit more about strategy. I would like Tom to talk a bit about tobacco and about the framework convention and trade issues and the convention's been around for a decade. The progress has flattened significantly so you've all indicated this is a top-line priority in an area where you have a consensus around a convention but you've got a sort of static situation. How do we get out of that strategically? How do you imagine in the next several years getting to a better place than in five years saying, well, we're still stuck? Great. I'm going to answer that question but I want to put some numbers behind what Sally just said about the disparity of funding. It's one issue we looked at in the task force and we looked at what does the U.S. spend per disability adjusted life year lost to various causes in low and middle-income countries and what that works out to is for HIV we spend $47 per dally. For malaria we spend $5 per dally. For tuberculosis we spend $1.80 per dally. For poor maternal newborn and child health we spend $1.50 per dally and for NCDs we spend $0.02. We did a fairly thorough assessment of U.S. global health spending and $10 million out of our budget of $8.4 billion goes to non-communicable diseases. That's very low. I think this in part happens because people have looked at this issue globally. We think we understand cancer in low and middle-income countries because we know people who have cancer here, your spouse, your parent, your grandparent. I think one of the problems with looking at this issue globally is we fail to recognize what's happening in low and middle-income countries and that's part of the reason why we focused on them. I think part of HIV is idiosyncratic in a whole variety of ways in terms of why it launched. One thing that was very effective about that was the recognition that we were productively addressing a problem here but other countries were not able to do so and we could do something about it. I think the same is true on tobacco and I think it's true on cancer issues. We've made enormous progress here. Tobacco use prevalence has dropped from 42% in 1960 to 18% now. In the U.S. it has been red states, blue states alike have used tobacco taxes which has helped generate that. It's generated funding for other things which I think is fine. We've had advertising, ban, smoke-free public places, all things that could be, have been successfully implemented in lower middle-income countries but have not been. I think in terms of supporting this I think we need to ramp up our support to tobacco control in the U.S. Currently the CDC spends I think the last budget I saw was something in the area of around $3 million on its international tobacco control. That money actually comes through the CDC foundation and funded by Bloomberg. That's great. That's not a problem either but this could be something that could be certainly increased but other areas as well we lack technical capacity or low middle-income countries lack technical capacity around tobacco tax enforcement and collection. That's something certainly that we have good experience in. Product regulation we have good experience in there. One of the things we call for in the task force, I'll mention two on tobacco is a trust fund at the World Bank to support low-income countries looking to start up their tobacco control programs. World Bank currently has one now on pharmaceutical regulation which has been quite successful. This is something that we've recommended should be done for tobacco and that would provide some funding to do that. It could be relatively modest but the World Bank and the IMF are trying to do more support of low-middle-income countries looking to adopt these policies. The other is our trade policy. I'm formerly from USTR on these issues. We had a number of people on the task force, both Republicans and Democrats that were former trade officials and one recommendation that I'm happy to convey is the task force was unanimous that trade negotiations currently ongoing, US trade negotiations currently ongoing should exclude from dispute resolution tobacco control measures provided under the framework dimension of tobacco control as well as under US law. And that was not something particularly controversial for this task force and I think it's something that could be done. Thank you, Harold. Just to respond briefly to what Tom just said and something Sally just said, just to get a little dialogue going among us because we're all lecturing from the podium here and I'm guilty as anybody. But first of all, with respect to tobacco control, one other element here is tobacco control research. For the last few years, I've been co-hosting a gathering of cancer research funders around the world and we found that most of those funding organizations don't support any real research on tobacco control and under the leadership of Cancer Research UK with the NCI's help with the two biggest funders of tobacco control research. We're trying to develop a framework for other cancer funders around the world to think more deeply about these problems and to learn how to adapt tobacco control measures of which there are many as Tom pointed out that are suitable to each country. Some countries are not going to tax their citizens for tobacco use and the variety of tobacco use in different parts of the world is really remarkable. You go to Turkey, as Marine knows or to Indonesia and you see all the kinds of tobacco use that require different kinds of control measures. The second thing is a caution about making simple arithmetic comparisons of what we spend on different diseases. I don't think it's healthy to talk about Ebola versus cancer. Ebola was an amazing threat and ripped through a country and destroyed the world's economy overnight and we need, when that happens, the world needs to consolidate its efforts to control an infection that could be devastating to the world's population. I think, obviously, the numbers, I'm used to comparing numbers of dollars we devote to research on HIV to many other diseases. This is a slippery slope and I think in many ways George W. Bush deserves a lot of credit for starting PEPFAR and really coping with a disease that was devastating Africa. Populations were falling, economies were deteriorating and this program, which was expensive, I think set a standard for how we can bring strong science-based health tools to poor countries and reverse a trend. Before PEPFAR happened, we were like 16, something like that, the list of countries that were trying to provide international assistance for public health and it changed attitudes in a major way. It is shameful that the numbers we now have heard about for chronic diseases are so low, but I don't think in adjusting the balance, I think we have to recognize that some infectious diseases are just going to be immediate threats of contagion that are going to require more resources and certain other things. Thank you. Why don't we go ahead and open the floor to some comments and questions and please be very succinct. Limit yourself to one comment or question and identify yourself. What we'll do is we'll bundle together three or four at a time and then come back to our speakers. Lois, right here, Joe. Hi, my name is Lois Pace with the Liz Strong Foundation. Many thanks to Steve and CSIS for this event and thanks to each of the panelists for your remarks. I want to come back to making the case and specifically the response to that case. And so this is yet another really powerful report instead of recommendations that builds on some of the other types of reports we've seen before like IHME or out of World Economic Forum. And so I'm wondering and specifically for Tom, but anyone can respond how the people who matter are reacting to this. There are a number of strong recommendations that have been put forth, but what I want to know is what people on the Hill are saying, what people within the administration are saying they will do as a result and how we can really move the needle so that funding and other resources really shift in the way that we need them to. Lois, just right here. Yes. Ben Anderson, Fred Hutchinson Cancer Research Center in Seattle. An observation and brief question. The observation is that NCDs and cancer is different from infectious diseases in that it requires the building of capacity. You can't just get a vaccine to the country. So this requires policymakers in country to build hospital systems and capacity. How do you convince policymakers to be diverting their resources to this area of building infrastructure in ways that they can understand, particularly when policymakers are often not physicians or often not scientists and have other priorities in mind. Thank you. Ben, over here. Joe. Ann Nelson. I could talk for two hours, but I'll keep it to a small point. I'm a pathologist. I work at the Joint Pathology Center and I've been working a lot with Dr. Trimble on a project to improve pathology. In the U.S. there is one pathologist per 15,000 people. In Africa there is less than one pathologist per million people. Eight countries have none and less than 25% of people who need a diagnostic biopsy get one. We just got through doing a two-year survey, which I'm going to present at their World Cancer Day. But I think our group of pathologists is called African Strategies for Advancing Pathology because it has to occur in Africa with the African pathologist and governments. But our single goal is no treatment without a diagnosis. Thank you. Fred, another hand. Michael, right here. Right here. Hi, Mark Miller from Fogarty NIH. Tobacco seems to be a low-hanging fruit, but there is an issue about the short-term benefits of the economic vested interests versus the long-term benefits of disease prevention. And how do you get past the issues of good governance and accountability in government, whereas short-term commercial interests frequently play into practice with large tobacco industries in many of these countries, putting pressure on short-term ministers of health, even to the point of some cynicism in the Czech Republic a number of years ago made a comment that it's more cost-effective to let people smoke so they don't have to pay pensions. So it brings up issues, though, of governance in many of these countries wherever you would like to work. Thank you. Tom, there was, I think, Lois' question was really directed initially at you, although I think the broader question around how do you motivate those in the administration and the Hill to take up this agenda in a new and different way applies to all of you, but you want to lead on? Sure. So as we do with all our Task Force reports, we're doing a set of briefings. We will brief executive branch agencies, congressional staff as well as members foreign diplomatic corps. I think in terms of the reaction that I get so far, the report just came out in December, so this is an ongoing process, is people are surprised. Particularly when you look at the case studies of what this looks like in the same countries, I think most people view this, again, as a unfortunate byproduct of success, happening really in only wealthier countries and something that might happen in lower middle income countries down the line. I think people are really surprised by the data. So we've gotten a favorable reaction so far. I think it's going to be a process in terms of reframing this issue as one, again, about inequity. That's really not very different from the case that exists on a whole variety of global health issues. I agree on the direct threats from infectious diseases, but by and large not where our money goes. The money the U.S. devotes to emerging infectious diseases is relatively low. The vast majority of what we invest are to more chronic infectious disease problems. Infrastructure doing thing I would say here is we in many countries operate the largest chronic care platform through the PEPFAR program in the countries that operate. I don't want to oversell the possibility of integration because I think there are real challenges but there have been successful pilots in some areas, particularly cervical cancer is a good one. Where you might be able to leverage that infrastructure in a cost effective manner and I think there's some real possibility. On the economic vested interests I think it's a challenge for countries that have a state owned tobacco monopoly. I think it's true for some. And making it more apparent what the cost is I think also as more countries, and I'm a little more hopeful on the progress that has occurred on international tobacco control in recent years, particularly with the funding that has come in through Bloomberg philanthropy which I should also note funded this task force as well as the Gates Foundation which is funded tobacco control in Africa. I think there has been a bit more progress than we've seen previously. Harold. Just one or two comments. First, with respect to PEPFAR I really agree strongly that the PEPFAR facilities that have been created could be stepping stones to using those platforms for other kinds of things. What some people don't know is the PEPFAR program has been cut dramatically at financial level and the current ambassador running the program Deborah Ricks is struggling with a $1 billion 20% cut in her budget which makes these efforts to extend the influence of PEPFAR facilities in a dramatic way. I'd say in response not to the specific report but to the general interest in cancer in developing countries that I'm seeing a surprising degree of response in a community, a scientific community that's afflicted by flat actually declining budgets in constant dollars our cancer centers are enthusiastic about getting engaged. The students we hear from are very enthusiastic that many societies not just the ACS which has a long standing interest here but surgical societies, other medical societies have recognized that this in some ways is the greatest global threat in the incidence of mortality of cancer in poor countries and that they've got to get adapted to the idea that what we're producing to benefit Americans has got to be shared with the other parts of the world. Well just briefly I mean to Ben's comment about the necessity to build the infrastructure I really think that's true and I think it needs to really be the health system that gets built at the end of the day. It's not that I think we shouldn't confront threats like Ebola which come up suddenly and have to be dealt with that's true but when I see now all these hospitals that were supposedly built for Ebola but Ebola is diminishing or has moved on I think we should be building health systems and not necessarily purpose-built health facilities and that's where I think we should be investing. I also think it's really important that we be looking to the UN and the UN institutions and the post Millennium Development Goals they were set in place in 2000 and they talk about specifically cutting the rate of HIV AIDS in half and talking about maternal and child health. Of course there's no mention whatsoever of not. Of course that's about to be the whole process is being reactivated now. The whole process is being reactivated because the Millennium Development Goals expire this year and there is a whole process going on to say well what replaces them and I think it's there are a lot of things working in New York and in Geneva and other places and I think it's important that there be some goals there have been some goals set for what we want to do about non-communicable. And goals that are more specific than what was said in a couple of years ago when the UN had its first meeting of non-communicable diseases. Which was an important milestone in 2011 and in 2014 they did kind of a review and actually quite a lot had happened. I mean there were a lot of cancer registries were being established and there were NCD plans in place in a number of countries but of course now the important thing is to do them to really get it done. So I think we need to be investing some attention in this too. That's part of putting it on the world's agenda and keeping it on the world's agenda. Just one comment in terms of trade and tobacco I think it's really important that the task force bipartisan group sort of with unanimous on the fact that tobacco should be a carb-out in trade agreements. We also did some polling of our grassroots connections in the United States and we asked people through a survey and these were Republicans and Democrats, red states and blue states is it important that public health be a part of trade agreements? And if you recall the first trade agreement that ever had anything besides trade in was NAFTA and that talked about environmental standards and trade labor standards. Now our grassroots group is saying public health is more important than either one of those things. So I think there is hope and I think through these trade agreements the president getting fast-track authority and then the Pacific treaty that they're planning to negotiate and the one with the European Union. It's really an important time to send both a signal and to make a difference in the ability of tobacco companies which they are doing by the way of absolutely going after countries large and small from Australia to Uganda and threatening to bring them to court over issues such as plain packaging which those countries are trying to do in order to promote a decrease in particularly in young people taking up smoking. So I think that's a very important issue. The one thing I wanted just to say on tobacco and trade in this report, the reason why we were able to come up with a unanimous consensus, I'm a former trade negotiator very pro-trades many of the people in the task force were. What's unusual about tobacco is there's a binding international convention requiring these policies every TPP member other than the U.S. has ratified and is seated to that treaty. There's also an executive order issued by President Clinton that the U.S. will not promote tobacco use internationally. That executive order remains in effect. It is the only consumer product that when used as directed kills you. There is no healthy use of tobacco. And it was very easy for the task force on those grounds given its burden, given its legal status, to say that tobacco is different and deserves to be treated as such in their trade negotiations. Can I just make one comment about the comment about pathology? I don't know if I omitted it in my opening remarks, but I meant to say something about the importance of pathology to be sure that when we try to figure out what the problem is in each country we know what the diagnoses really are and I totally agree with the scant attention that has been given to the importance of pathology especially in developing countries and it is critical to the whole nature of combating cancer. But I would like to take the discussion one step further and point out that there are new technologies that can help make pathology more readily available and that those technologies are actually of broader use in global health and that is using mobile technology and electronic communication for example to try to solve if you can section a tumor or a mass in a poor country and you don't have somebody on hand to make the diagnosis you can use telemedicine to have somebody who is sitting at Thana Farber or Sloan Kettering to help with the diagnosis. I think that notion of using mobile communication to improve health outcomes especially in chronic disease is extremely important to go back to the Birkenblum FOMA problem in Uganda the cure rates in Uganda still remain very low under 50% whereas in the US the same disease is almost always cured and one of the reasons we lose a lot of patients is they go back to their village and don't use the electronic phones that they have to alert physicians that they need further therapy that the HUDCH has been very involved in trying to bring the HUDCH is now basically the major partner with the Uganda Cancer Institute and they're working hard to make these communications devices a better tool throughout the Uganda. Please use the microphone then Ann. The WHO big cancer report that just came out and it's actually discussed pathology that's true, right John? Well, that's not my problem I mean it's not my problem but it's not my responsibility we're discussing it as you know Let's take another round of questions Keith Martin and then up front here on this side and then we'll get two folks on that side Keith. Thank you Steve and congratulations Tom and Ambassador Khaled we know we don't have a knowledge problem we have an implementation problem and the interesting thing is the structures we're talking about whether it's the public health primary care or access to surgery the failure to invest in these are political decisions but there's also a confluence between the ID and the NCDs coming together because that structure is needed to deal with both of them. My question is to all of you in your experience what are some of the political opportunities we have to work with countries and LMICs to work with them to invest in the public health primary care and surgical access they need to combat both NCDs and IDs. Thank you. Thank you just in front of you there Keith Thank you Lisa Stevens from the NCI Center for Global Health so I want to bring some of the comments together about the amount of money that the US spends on global health the comments about PEPFAR with the reduced budget for PEPFAR how it does provide an infrastructure that we could utilize mention the pink ribbon red ribbon initiative and just say that I think in this instance we may be our own worst enemies in that across the US government we would like to collaborate and like to build on that infrastructure but with the reduced budget you know who directs the focus of what those facilities are going to be used for is problematic and bring it into the discussion about this UN fund for NCDs because absent some additional funding Yes over here Yes please. Good morning my name is Tatiana Soldak I represent organization resource and policy exchange I have question about collaboration between NCI and USAD because I see this as a problem on the field like for example USAD issues request for proposal or request for application and supports HIV programs in many country however if you will include an integrate cancer program for example cervical cancer they will never consider this seriously so I think that it's a misinformation that cancer even can be included into you know comprehensive HIV package Thank you. Thank you. Yes right behind Thank you. Barney Marugan at development finance international we're consulting firm that bridges business and development so my question is actually about access to treatment so I think it's very promising that we're now seeing a lot of low and middle income countries have national cancer plans but by and large they really focus on prevention and screening and a lot of the discussion here is focused on tobacco control so I was wondering if you could talk a little bit more about how to expand access to treatment that's affordable and effective including perhaps mentioning some of the new breakthrough therapies around immunotherapy for cancer which as we know is extremely expensive even in this country. Thank you. So I have a question around what political opportunities exist to invest it's a question about how do you cope with reduced budgets a question around the NCI USAID collaborations and then the issue about how to expand real access I might say a couple of things in response to these heterogeneous questions just with respect to USAID there has been a fair amount of exchange I've been down to USAID to lecture on this topic Ambassador Shaw has been to the NIH they have their very high level priorities we are more than prepared to try to coordinate our work with them when I go to poor countries people I meet on the ground almost always from USAID or from CDC and there's a good constructive relationship with respect to what they just choose to fund they have their own grand challenges program and I think Ambassador Shaw would say that they'd be willing to work with us their resources are limited they've chosen to focus on certain things and that's where it stands I don't think it's an acrimonious relationship but I agree that there is the potential for greater synergy than currently exists well let me just say again to the heterogeneous questions pick out a few points that may have some commonality and I think one of them is that we need to get better figures around cost of things what does it actually cost we say oh these are low cost these are able to be done we asked ourselves we're working in a coalition with others called the cervical cancer action group and so we convened this we in one of the meetings decided that an important thing to do would be to figure out what it would cost we say it's perfectly preventable disease what would it cost so we went to the Harvard School of Public Health and we have a report that will be coming out within the next couple of weeks about what would the cost be for vaccinating every 10 year old girl in the world and we're not yet talking about boys in the world in general but if we vaccinate eventually but if we vaccinate we have after all we have a vaccine you know and it varies of course in cost very importantly GAVI last week had its replenishment exercise in Berlin fully funded at 7.5 billion dollars a billion dollars of that coming from the United States GAVI a couple of years ago decided that HPV should be included that's only for the very poorest countries only for the GAVI eligible countries nonetheless at full funding for GAVI GAVI will step up and be offering vaccine in more countries through demonstration projects and eventually national projects but our question was what would it cost if you vaccinated every 10 year old girl and if you screened every woman at least twice in her lifetime between the ages of 30 and 49 what's the global cost because I think we began to get lots of money allocated for HIV when we could put some cost figures on it so as I said the top line seems to be and of course it varies tremendously whether you're screening with pap smears or you're screening with VIA which is a low cost of some what variable results but certainly can be effective in many settings what does it cost to have the GAVI price for vaccine versus the PAHO price which is a negotiated price versus another price is it two doses or three doses so lots of variables but the cost is about 3 billion dollars a year over 10 years now that's not beyond us so I think as we get to looking at some of these issues how do we have access to life saving measures we need to know the cost and we're beginning to get that cost let me just build on your comment to address one question that was raised back here that seemed to imply that the issue now is implementation not knowing more things and I think that's not a fair assessment that there are a lot of more things we need to know some of them just have to do with how best to do implementation I think implementation science which can be a somewhat fuzzy area is actually got its merits and we need to be doing more to ensure that we know how to take what we do know and make it more accessible but I think your discussion of HPV vaccine is a good case in point there is evidence that even one dose of the vaccine rather than two or three may be useful and we're now organizing a trial to test that idea moreover it isn't as though there's one HPV vaccine the vaccine itself is evolving Merck is about we like to get approval for it's non-strain vaccine and what will happen to the price of the two and four strain vaccines after that is very much open to questions so there are opportunities here to make the vaccine a lot cheaper not just because patents expire which they eventually will but because now will it be fair to give to a woman in a poor country a vaccine somewhat obsolete in the US because a more sophisticated vaccine has been produced here that's an open question but it seems to me that a vaccine that protects against 70% of cervical cancer is better than nothing and Merck has just licensed it to Brazil by the way so Brazil will be producing the non-available but they will be producing their own so I think these are let me just say one thing about treatment I mean certainly we've all been talking about prevention and certainly prevention is terribly important we've talked about treatment we will not treat our way out of this epidemic but I think we cannot ignore treatment and again looking at the pragmatic things we've been working on our building out sort of what we've learned about how we get pain relief drugs out to learn more and taking also advantage of what has been done in HIV to get HIV drugs out what are the barriers in the supply chains what's already there, what could be there what could be there sooner rather than later and what could be there at an affordable cost so I think if there is no treatment AIDS is now less stigmatized in Africa than cancer because there are drugs for AIDS and there are virtually no drugs for cancer so it's very important I think to have treatment options and that should certainly also include radiotherapy and surgery and I said it won't happen everywhere and they won't always be the most sophisticated but I think to begin to push these barriers back is the way to promote more screening and earlier detection and therefore treatments that can actually work I'll just throw in a couple of things on the budget question tied to PEPFAR and whether we are shooting ourselves in the foot I think the problem with that platform as we move forward is if it continues to be disease focus HIV focus as the burden in these countries shift you're going to see more cutting of funding one of the things we did out of this task force report is a group of us myself Zika Manuel, Donna Shalala, Tommy Thompson, David Satcher and Eric Hoosby did a piece in the Lancet calling for a shift in the approach to U.S. global health towards an outcome-based approach to be more demand-driven than supply-driven not just the diseases and interventions we want to put out there but responding to what the actual health needs are in the countries that we want to invest in and I think shifting the way we think about global health in that manner would be helpful in terms of maintaining U.S. commitment on these issues that are tied to a very precious set of infectious diseases and as the burden shifts it will be hard to sustain so I think that's important in terms of health systems everyone will say and I certainly agree that health systems need to be built in these countries particularly when you and it's in the report I won't get into the numbers but the disparities of health spending in low and middle income countries versus wealthy countries is spectacular all the governments of sub-Saharan Africa spend as much as the government of Poland on health and that gives you a sense of what difference is we are talking about in terms of health system it's not just pathology those kinds of numbers exist on virtually everything I continue to believe though that in terms of from a donor perspective or international intervention it does need to be diagonal you need to tie it to a intervention people can understand I think that is the way to build health systems on the issue of treatment access I think it's important that we extend access to these treatments but I do worry sometimes that our treatment access debates end up on a very small set of interventions that are patented as opposed to a recognition of how much is lacking in these countries in terms of accessibility of treatments and the entire debate is eaten up about patents and access to medicines which doesn't mean it's not an issue but we have to talk about the broader health needs in these countries and I fear we don't spend enough time talking about all the other off-patent treatment which is enormous the available tools that aren't getting to these countries either before we run out of time I want to ask our speakers to address the issues the controversies around vaccine use this week we've had the controversy around measles Senator Rand Paul, Governor Christie in this same week we have field trials beginning historic field trials beginning in Liberia on the Ebola vaccine backed by NIH GSK and others with two vaccines and a third to begin in Sierra Leone also historic soon so we're in a particularly important moment as a country with respect to this and these controversies are very live Harold, what can you tell us about the trust and confidence the trust and confidence that we need to have moving ahead we're talking about hepatitis B we're talking about HPV I think it's important in having these discussions to consider what the vaccines are intended to do and what kinds of diseases are being confronted because having a vaccine in hand to confront an immediate threat to the world's health like Ebola or another emerging infection is very different from dealing with a disease that's been around a long time like measles where the hole that we've created by allowing people to neglect vaccinating kids who are then going to be part of the commons when they go to school and we're creating the kind of Disneyland event that we just came through is very very different and there are two issues on the table most obviously one is informing and persuading people that vaccination is a worthwhile thing I'm concerned when I see relatively little dissemination of reports like the one just produced by the president's cancer panel for the NCI and the president on vaccination and the use of papillomavirus vaccine where the uptake in this country is deplorably low lower even than in Gavi countries it's striking to me how a country like Rwanda which does qualify for Gavi has vaccinated over 80% of its girls and in Mexico they now have a government endorsed program for vaccination for all 5th grade girls I just think that the role of civil society in developing policies that make sense for the whole population need to be stronger I'm not sure that I can add very much on to that debate it you know it's just again going back to the days of working more intensively on HIV that was the holy grail if only we had a vaccine if we just had a vaccine and here we have had an HPV vaccine for some time and HPV for 6 or 7 years 2 of them in fact more coming on the market our own rate in the United States is only about 32% vaccinated and of course in many countries it's not on the radar screen at all so I think we need to keep beating that drum that when we have vaccines they are clearly life saving and they should be employed and they can be employed the Copenhagen consensus has just come out with a report showing that HPV vaccine is as cost effective as other interventions for young women and girls and even at its full price so clearly we should start yet we have brought the disease under some control but we're just not going to get rid of this disease unless we have vaccination and the experience with other vaccines does make one worry that even if we had a vaccine would it actually get used at the levels that are required to put an end to this international infection the one thing I'll say quickly on this is I thought it was great but it was heartened by the speed with which the clarifications were issued by the two likely candidates who had made comments yesterday and because I do think the worst thing that could happen if the vaccine debate was not didn't already lack a scientific basis if this were to be politicized and seen as a big government issue that would be a real shame so I was glad to see the fast of the vaccination from both of those candidates on the Ebola side because I think there's been a lot of reports in the press that it was a scandal that a Ebola vaccine or the drugs hadn't been moved forward before and I think one of the things that becomes clear from what's happening now is it's very well two things one we are talking about a disease that in 40 years prior to this outbreak it's really hard for us and people second it's really hard to develop these things in the absence of an outbreak and I did not find it particularly scandalous that it didn't move forward it would have been great if there was more investment in these areas but I think what you're seeing now is hopefully calms down some of the rhetoric around that let me just as you support that statement with a couple of facts that most people don't know which is that NIH supported investigators to develop a vaccine since the late 90's and indeed the vaccine research center at NIH had a candidate vaccine and for the reasons Tom's bringing up A, there had been very few deaths almost all the disease had been confined to certain local villages and moreover while we were all talking about Ebola how about Marburg, how about Lassa fever I mean it's not the only lethal virus out there that could cause pandemonium so making a decision ramp up, get then these viruses need to be the vaccines would need to be tested very hard to test the vaccine in a clinical population if there's not an outbreak indeed one of the things we're all watching carefully is whether the very welcome decline in Ebola in West Africa at the moment is going to allow the current vaccination trials to reach their desired end point we've gotten to the end of our time here now this has been extraordinarily rich and interesting please join me in thanking our three speakers special thanks to Travis Hopkins for pulling this together thank you Travis