 Well, welcome everyone. I'm Steve Morrison, CSIS, and we're thrilled this afternoon to be able to host this event. We were just saying a moment ago we have the Mount Rushmore of USAID Bureau of Health. So get your pictures now. We can start carving the mountain soon. And things are, this is an amazing collection of people. And it's an amazing volume that Robert and many others put together. And I hope you all have this. And Robert's going to talk about it in a moment. And then we're going to have a roundtable discussion among these distinguished individuals. And following that, we'll have a reception. We do book events a couple times a year in various topics and subtopics in global health. And never have we had a crowd as strong as this. This is really wonderful. And a real tribute to USAID and a real tribute to the quality of the book. And the celebration that's inherent here, the 50-year celebration and the decade by decade look going back. And so congratulations to everyone who put this together. Congratulations to all of you current or former USAID Bureau of Health veterans. This is just a very happy moment and a great celebration and a great way to celebrate. Catherine Bliss put a great deal of effort into this, organizing this. And thank you, Catherine. Catherine Strifel worked assiduously also pulling this all together. And there are many people within CSIS who've contributed from our staff, from our external relations staff, and from others. So thank you to all of them. I'd like to invite Robert to kick things off here. He's going to walk us through some background. So please, Robert. So good afternoon. And it's great to see so many people here. I've been asked to really just walk you through the book and let you know what's in it. It's going to be a bit of speed dating because the book has so much in it. And I've read it eight times. And every time I get inspired. So hopefully this will inspire you to pick up the book, not just look at the cover or the photographs or the quotes, but really get into the text. Because it's a great book to really refer back to and also to see what's happened over the last 50 years. Of course, none of this could have happened without a team. And I'd just like to highlight a few people. My colleague and friend, Tonya Himmelfarb, who was actually the principal author on the book, did an amazing job. And so we're really pleased that she had the time available and worked with us as we walked through various different versions. We also had a team of some of you here, actually. We're on the advisory committee. And this was 15 people who were from USAID. And I knew this book was a hit because the first time we had the advisory committee, we were supposed to go through all this logistics and how we're gonna work together and so forth. We spent the whole hour and a half just telling stories. And there's obviously a real need for people to talk about their experience at USAID and the development world in which they had lived. And so that's what this whole book is. It's a telling of the story. And I think one of the things that I have seen in my career is that as new people come in, that they need to have sort of a perspective of where they fit into the overall picture. And I was very fortunate. I've served at USAID now for 31 years. But when I came in, there were people that were my mentors and my supervisors that had been around for those 20 other years. So in some ways, I feel I have a direct connection to the 50 years of USAID. But for people coming in now, that's gonna be harder as we get older. And so we wanted this as a way to capture some of those feelings and thoughts. And we also knew that the new generation doesn't necessarily look at things and do things the way I would do. So we have the book, which is for my generation. And actually on the spine, you can see, you can put it in your bookshelf and see what it is. But we also today launched our online version of the book. It was sent out this afternoon to 55,000 people. So it's there for those who like to look at it online. And we're hoping to have this as a interactive process so that people can add to this. So this will be a living history. And we're looking at ways in which you can tell your story and create a community about the whole development process. So I probably used up most of my time already. But I would say that this is gonna be quite difficult. The first time I did this, it took me 30 minutes to do this talk, and now I have 15 minutes. So it will be a very quick view, but I do want to run you through a little bit of what's in the book to, again, to wet your appetite. So the purpose really was, as I mentioned, was to provide a historical record, also to pass down the legacy to the future generations and to showcase the evolution of development over this 50-year period. And what we tried to do is not to make this a sales job to say, USAID has done all this great work. We really have sections in the book that talk about what we've learned and also where we've made mistakes. And I think it's only substantive when you're actually honest with yourself to say that you tried some of these areas and, in fact, they didn't work. But what I think is very rewarding is to see how we have been able, over time, to take some of those lessons and move them into new programs and to make further progress. The book itself has 11 chapters, including the introduction section, and we debated a lot about how to organize it because you could do it many ways. One way is to actually have it by technical area, so we could have an aid section, we could have a malaria section, and our specialists really loved that because then all their work would be in one place and they could grab onto it. But we actually finally decided to do it by decade, more in terms of the time, decade by decade, the time horizon, so that you could see how these things interplayed with one another. So inevitably, there's going to be parts of the book that you will say, well, we were doing things in this decade, we tried to highlight certain interventions in certain decades when they were most important. So there you see the different chapters in the book. We start with, actually, the book starts in 1852, talking about when cholera was a threat for trade and the first international sanitation conference in Paris, and then it takes us through some of the activities that led up to the founding of USAID in 1961. This was an era of optimism, post World War II, a lot of stabilization, and a feeling that we could actually make a difference. And of course, this picture in the book, you see it's a broader vision. It was also a time of a lot of men. Not a single woman is in that picture. And so if you think about 50 years hence and now, we've made a lot of progress. Now, each chapter is organized. It has, what we have on the left is our indicators that were current at that time. So you can see what the world population was, the total fertility rate, maternal mortality, and so forth, and each decade we update that. We also then have a section that talks about what's going on in the world of development outside of USAID. And we have some quotes that we also put on. And as you can see in the 60s, again, a lot of optimism and I would just highlight one thing here, and that is the development field was really influenced by this idea that growth could really be the solution for countries. If you could get countries to grow, there would be a point where they would just take off and then we would be able to pack up and go home. And in fact, USAID was really established as a temporary agency. I think at the time they thought in 20 years we could solve the problems of development. And so we really never had that sort of permanency of a cabinet ministry or whatnot. But we were there to do the job, get the countries to grow and then to move on. And that influenced the way we did development in the 60s. We had a lot of hospitals, we had a lot of roads, we had a lot of infrastructure. We did a lot of things that were really hardware. And it's interesting as we see new donors coming in to development how some of these same themes are coming up in terms of the way that they're focusing their attention. But we learned that that's not sufficient to really reach the impact that we're looking at. We also, in each of the chapters, have what happened at USAID, our contribution to global health, and also we have a timeline to kind of orient you to some of the major milestones. And I would just highlight here, in 1965 the office of family planning was established or I guess was it family planning or population? Office of population was established. So close to 50 years of working in population family planning. And it was the time of the population bomb, everyone was worried about what was going to happen with the planet. And it really, this was one of the lead programs of USAID and Steve will tell us a lot more about that. Okay, so let's move a little quicker. The 1970s, this was a very important decade for development because this was after the Vietnam, a lot of frustrations about the lack of progress in terms of achieving results through this economic growth, infrastructure development approach. And Congress actually codified this in the New Directions legislation that basically specified that AID should be focusing on people-centered development. That we should not be looking at broad development changes, but we should be looking at very specific programs that really affect individuals. And we're still, I think, influenced by that direction that Congress made in the 1970s. We had, of course, a lot of optimism. Also in the 70s, the health for all by the year 2000 was a banner for many of us as we started our careers. A lot of focus on community health workers. In fact, I did my thesis on that at that time and it's interesting how this is a recurring theme coming back to community health workers now and trying to reach people at the community level. This was a time when we started utilizing a lot of our innovation and technology in the development of oral or hydration therapy at the ICDDRB in Bangladesh, a real highlight of this period, as well as some of the work in terms of developing our information sources. So the contraceptive prevalence surveys were initiated in this decade. The 1980s, it gets harder for me because I know this decade and I could talk forever about this. But this was an interesting decade because it was a reaction, again, to this broad primary healthcare focus where we were trying to achieve health for all. We're doing all this integrated programming. Everything came down to the village health worker. They were overloaded, but we didn't see the results and we also had a recession. And there was a lot of fear that we would have, that our resources were threatened by this contraction of global development. And so Jim Grant and his colleagues at UNICEF came up with this very simple version of primary healthcare, looking at selective primary healthcare, the GOBE strategy of growth monitoring oral or hydration therapy, breastfeeding and immunization, as a way to sell the program to get people interested. And Jim Grant would go up to the hill and he would say, if you give me X amount of money, I can save X number of lives. That direct translation, money equals lives saved. And that really predominated throughout this decade in terms of working. USAID played a special role in terms of expanding the use of oral or hydration therapy. We were the leaders also and helping on acute respiratory infections during that period. And we also did a lot of training. Our high mark, water mark for training was actually in 1989 when we trained over 68,000 persons in long-term training up to that point. And I think if you talk to any person in development, they'll say that one of the major contributions that AID made over those 50 years has been training people, our host country counterparts, giving them long-term training and improving the professional quality of our developing colleagues. This was also the child survival revolution, as I mentioned. And it's interesting how we're going through another revolution as we speak. The 90s. We saw a lot of reaction to some of the broader programs in terms of structural adjustment. We saw the US government reinventing itself. We went through major shock therapy in terms of closing 26 missions overseas during this period. We had a major riff where we lost 30% of our staff, direct to our staff due to this. We also saw HIV AIDS emerging and then TB becoming a renewed focus. We established the USAID TB program in 1998 with specific funding from Congress. And of course we had polio that was eradicated in Western Hemisphere. The 2000s, we moved into a new era after 9-11 where we saw that development was critical to our foreign affairs objectives. So the 3Ds, here we say, development, defense, and diplomacy. Other circles might say defense, diplomacy, and development. But the 3Ds became very, and it's very significant that development was elevated throughout this period. And it provided justification for our resources that we didn't have before, national security. And we still have that as part of our program today. We also saw major changes in the global architecture. We saw GAVI established in the year 2000. We had the global fund that was established in 2003, I believe, or two. We had PEPFAR established. Major new initiatives that really changed the whole landscape of funding from millions of dollars to billions of dollars going into global health. We had quite a number of new partners and we also looked at increasing our work on not just saving children, but also helping them thrive through our OVC program, particularly through the HIV AIDS lens. 2010, we move forward to USAID forward. We also have a recession during this period that really dampens some of our aspirations for our resources. But we really are focusing now much more on transforming ourselves with science and technology and looking at cost effectiveness, particularly how the money that we've been able to establish as a baseline can be used more efficiently. We have the call to action ending preventable child and maternal deaths, which I hope you all will be engaged on June the 25th, the second anniversary of the call to action program, which will be held here in Washington. More focus on harnessing technologies and particularly looking at graduating countries and improving the sustainability of our programs. This I've alluded to, it's pretty amazing when you look at from 1967 to today and you can see how the resources have changed over time. A lot of the resources from 2002 on were HIV AIDS resources, but we also saw increases in that period, both for malaria and even in family planning in the last several years. So we have a very different scenario and what's interesting is to think about those early days when we had so little and yet we made such big progress despite the low amount. So what's next? We have a chapter in the book that talks about the future. We have the two bold visions that's driving USAID in the future of ending preventable child and maternal deaths and creating an AIDS-free generation, responding to the economic transition of health, looking at where the money is being generated and how countries can use that money to support their programs, addressing the demographic shifts and the global disease burden, the whole new donor environment. I didn't get into any of the changes in terms of the new foundations, new actors on board. When I joined, it was really USA, WHO and UNICEF and now we have a plethora, a number of actors that are engaged in how do we work with them and then continuing to use technology and innovation. So I hope that's whetted your appetite to take the book, open it up, read it, use it. Our online version is there. We'll make sure it's interactive so that you can engage, you can share your story and we hope that this will be a contribution to the development community and we look forward to the panel which will put their personal experience along with what I've been saying here. Thank you very much. I have a conversation this afternoon about the evolution of practices and policies and understandings of global health over the past 50 years. You have had a chance to pick up a copy of the book, I hope, when you checked in downstairs. I encourage you, if you didn't have a chance too, to take one on your way out and to look through the full copy and also to check it out online and look for interactive features as they come forward. You've also had a chance to pick up a copy of the bios of our speakers that I wanna take a moment just to introduce them to you before we get started in a conversation. To my far left, Arielle Pablos-Mendez who is the Assistant Administrator of the Bureau of Global Health since the year 2011 at USAID. Next to him is Kent Hill who is currently Senior Vice President for International Program, the International Programs Group at World Vision and was the Assistant Administrator for Europe and Eurasia at USAID between 2001 and 2005 and then Assistant Administrator for Global Health from 2005 until 2009. In the middle here is Anne Peterson, currently Director of Public Health Programs at the Ponce School of Medicine and Health Sciences. She served, I believe, as the first Assistant Administrator of the Bureau of Global Health once it was elevated as a Bureau from 2001 until 2005. And to my immediate left, Steve Sinding who is currently Professor of Population and Family Health at Columbia University's Mailman School of Health. He was Director of the USAID Office of Population from 1983 to 1986 and Director of the USAID Mission in Kenya from 1986 to 1990. So taking a cue from Robert's overview of the book, let me start with you, Arielle. And ask you to, Robert has provided an overview of the evolution of some of the health, the themes and the different health programs at the agency. And so I wanted to ask you, who do you hope reads this book in the coming months and years? What do you think will surprise readers when they read about the history of the agency? What do you think people will think they know that they weren't quite sure about after all? And what do you hope readers think about or do differently once they've had a chance to read this book and consider the history of health at the institution over time? Thank you and thanks again to CSIS for the opportunity to share the book with all of you. And clearly history is a uniquely human activity. It's made by people and it's meant to be either heard or read or interacting the web by people. So the audience is the people who both made it possible and that's a large number of people, many of them in the room, those who have been in USAID, the partners we were with around here in Washington, in countries, our agency colleagues and clearly the American people because there's plenty there to be proud of. And I think that on the whole what people will find is what a rich history this has been and what an incredible progress has been made is when you put it at a decade by decade and you look at those indicators, when you zoom out history allows you to see this big picture and I think that people will appreciate how dramatic and unprecedented the gains in international development and global health these last 50 years have been. What people can take from there is on the one hand there is of course the record of that work which is always important for many more directly than others. There's also for some a catalog of lessons this things that even some of the themes that Roy was putting here decade by decade they we have echoes of those things today as there were echoes of those of the recent decades in early decades. And more importantly I also hope that many of you especially those who work in the agency can take the sense of pride and identity. History is very important in providing these to those who are linked to an enterprise and I think the book does that very well. Well thank you, let me turn to you Steve. You were director of the Office of Population in the early 1980s and then mission director toward the end of that decade. Could you, but you started at USAID in 1971 and so really we're there during a very formative period as Robert described it. Can you tell us from the beginning to the period when you left how did the agency's programs related to family planning change and evolve over that period and then thinking about that period and the period since then what do you see as the agency's greatest challenges and achievements in the areas of population and family planning and are there things that you think could have been done differently? Those are tough and very broad questions. Before I became director of the Office of Population I spent about 10 years in the field in two different field assignments so I bring to the answer to that question some perspectives from the central office but also perspectives from my experience particularly in Pakistan and the Philippines. And I think that the objective of the program when it was established in the late 60s under an earmark to the foreign assistance appropriations introduced by George H.W. Bush, a young congressman from Texas. One of the ironies of the population program is that it was intensely bipartisan at its outset and enjoyed bipartisan support up to 1980. I think a lot of its success derives from the fact that on both sides of the aisle there was strong support for this program and the money was a really important part of its success. The objective of the program was explicitly population control. We didn't use that term after 1974 when it became a term forbidden in international language but that's what it was about. It was about fertility control and reducing the population explosion that Robert referred to. That changed quite dramatically first gradually and then very rapidly. It changed, it began to change after the Bucharest Population Conference in 1974 when there was a tremendous amount of backlash from developing countries saying, we don't sign on to that concept. You in the West may want to control our population growth rates but that's not what we're about and the more you talk about that the more resistant we will be. I have to say by the way that the agency was brought kicking and screaming into the population program. Mission directors didn't want to hear about it. It was not something they wanted to go in and talk to host governments about because it was a difficult and unpopular subject in most places other than Asia, particularly Southeast Asia. But beginning really then in the mid-70s there was a sensitivity about the demographic objective which caused us to begin to soften the way we talked about and thought about the program. We still wanted to see fertility decline as a central component of the program but it was much more in the context of individual well-being, particularly health. And then came the Reagan administration and in 1984 at the Mexico City Population Conference the American delegation explicitly rejected population as a development problem. So that the demographic rationale for the AID program at that point disappeared almost entirely and we talked about population, about family planning as a social good and as a family empowerment. I think that one of the lessons that we learned through that whole era was that talking about family planning by itself, outside the context of health and education was counterproductive. And I think we also learned that wherever it was possible integrating family planning into a broader health delivery context made a lot of sense. It made it more palatable, more interesting. It just made sense to families, particularly to women, to think about family planning in the context of their own and their children's health. So those were some of the changes that occurred over the time that I was involved with the program. I was part of the first two decades, the 70s and the 80s, which in the book you call the golden era of family planning in the agency and I would say that was true. I also wanna say that if I have another minute or two one of the distinguishing characteristics of AIDS, of USAID's population program, was that it was centrally managed. It was the only sector of our development programs which was managed from a single place. The regional bureaus didn't control population programs. The office of population did and a single individual. Dr. Raymert T. Ravenholt was the person who organized and drove that program, a term that he never tired of using. And he did drive the program. I mean, as I say, the agency was resistant. Left to its own devices, the regional bureaus, many of them would simply have killed the population program. They didn't want it. They wouldn't have spent the money. They would have found ways to spend it other than for contraceptives and family planning services. Ravenholt was insistent that it had to be used for family planning. In the process, he made a lot of enemies, including the entire health establishment of the agency, which was extremely resistant to the idea of a separate population program, a categorical, vertical population program. And he made a lot of enemies in the development community, generally, by insisting that the money had to be used for family planning. It could not be used for female education and the other things that we know are important to reducing fertility. But it was that single-mindedness and the central control over the deployment of field officers and the overall shaping of the agency's response. But I think in the long run was responsible largely for its success. That would have been a very controversial statement in the 1980s. It's not so controversial today. Thank you. So moving from the topic of population and family planning to maternal and child health, and let me ask you, you were involved in collaborations with the USAID when you worked in the field in Kenya and elsewhere in sub-Saharan Africa in the 1980s and then served as the assistant administrator for global health in the early 2000s. So I wanna ask you to kind of talk about what you see as, how did the issues and approaches change over that period in maternal and child health from the 1980s when you were in the field to the 2000s when you were here in Washington ever seeing the bureau? And with the benefit of hindsight, do you think there are issues that maybe the agency should have been paying greater attention to than it was at the time? And also, thinking about PEPFAR, which was launched during the period that you were the assistant administrator, do you see or tell us a bit about the ways in which some of the lessons from the maternal and child health programs influenced the development of programs in the PEPFAR arena? Okay. Thank you very much. And again, thank you to CSIS. It's marvelous to be here. And for me to be able to speak about the work that thousands of USAID people have done to change the world is really an exciting and an honor to be able to talk about that. And I get to talk about the less controversial maternal and child health portfolio, but it really builds out of what USAID was already doing within the family planning in the PEPFAR area and the being grounded in the countries and looking at their needs. My first contact with USAID was when I was first in Africa. We were doing community health development in a large diocese, but a faith-based organization in Kenya and teaching community health workers. We got a little $25,000 grant from AID to do community-based distribution of family planning. And we were right at the interface that the book talks about between the primary health care, Alma-Ada doing a little bit of everything, to beginning to move to the more selective primary care that Robert talked about. Because when you're in community, one Africa in many places, they have a very holistic view of health. Social things are part of health and economics is part of health and diseases part of not having health. But at the same time, if you're gonna work with community health workers, they can't do everything. And some of our tribal groups were primarily illiterate. So we quickly got to the place where you're focusing on specific areas. So that field time of beginning to look at if I'm gonna make a difference in child health and maternal health, what are the fewer interventions that are going to make more difference began that verticalization. And I've been trying to reflect because that's vertical versus horizontal has been very controversial over the years. And we started with a broad mandate and make sure everybody gets the basics that they need in all the areas to very verticalized programs. And now we're talking health systems again. And I think our Congress rightfully wanted to see that we were making a difference. And in child survival, we had great opportunities to make a difference. And it's a lot easier to do it, to measure it, to see it, to prove of principle and the difference it makes in people's lives in the vertical programs. And frankly, the population program had done many things right and some things not so perfectly. And as we moved into maternal and child health, we needed that time, I think, in a more focused area to take ORS and learn how do you make it relevant to a mother? How does she really do it, know when to do it? And how do you take these programs that we've proven worked and made a difference in a pilot setting and know it'll work in a larger setting? So those decades in the 70s, 80s, 90s where we were in a more vertical disease focus, we proved we could do it. We could prove our investments in health, transformed health, and we learned how to do it at global scale. And Nepal, to be able to go out and reach the entire country to reach levels of vaccination of 80% to get ORS out there. I don't think we could have done it if we had tried to stay very broad, but being vertical has clearly also had its downside and that we've needed to now begin to look at how do we make sure that the whole system is intact. So I think we've had fabulous results within the child and maternal health. When I began in Kenya, one in four children under the age of five died in the area we were working. And the maternal or the child mortality rate has been going down and down. When I started at USAID, we still had around 11 million children dying under the age of five every year. And now we're at six. I mean, that's just absolutely phenomenal. I talked a little bit earlier today about maternal health, the other side and for a long time, if you look at the indicators, it doesn't even tell you the maternal mortality ratio for a number of years. And when it finally we're getting the numbers and it kicks in, it's really high. And we didn't think we were making much progress. In 1980, what was it, 87 when I was in Kenya, I was pregnant with my third child in Kenya. It already had a dangerous delivery and one of our staff workers' sister died in the hospital just weeks before I was to deliver. Believe me, maternal mortality was on my radar screen as something of important, thankfully, I did fine, my daughter did fine. But as we got into and I returned to AID, our progress on maternal mortality had really stagnated a little bit and we weren't making the progress and I can remember the discussion. How are we gonna jumpstart it? We're doing well in child survival. How do we begin to move forward? Should we return to things like training, traditional birth attendance? How do you get them to be skilled birth attendants? So AID taking lessons previously really worked in that area. My example is a story that's also in the book about Afghanistan. Coming in in 2001, some of the worst health indicators in the world. And quietly, USAID bringing advice to the Ministry of Health focused on maternal mortality, rural health, basic packages of services and in just six, seven, eight years, child mortality was down 23% and their measured maternal mortality ratio went from 1600 to 337. Oh my goodness, we didn't know it was possible and it wouldn't have been if we hadn't had those decades of lessons learned previously that now they were applying. So I think we did many things right. The vertical versus horizontal had its downside. I would say in hindsight, we should have thought about how do we do our results-based vertical program or disease-specific program thinking about the whole system. There are examples of how it was done well in polio eradication where they incorporated routine immunization in their polio eradication efforts. And there are examples within PEPFAR where we didn't do it so well and then where we began using the PEPFAR initiative to look at how do we make sure that the whole system is good, that we aren't just taking care of the mother who's HIV positive and not the delivering mother who's not HIV positive. So I think we've got some fabulous lessons that we've learned. When PEPFAR scaled up, that was definitely a challenge for the agency. We had so few people in our AIDS office and suddenly this huge mandate and lots of money and we had to cannibalize the expertise from the other parts of the agency. Our pop office stepped up and brought all of their expertise and commodity and supply logistics and brought it to the AIDS drug distribution. The maternal health, it was less obvious but the whole work that had been done both in maternal health and in the pop office of how to engage men in women's reproductive health issues really helped to set the stage for how do you get husbands to be willing to have their wives tested for HIV so you can do the prevention kind of thing. So in each case we got to take the lessons learned in other parts in the maternal and child and begin to play it into the challenge of scaling PEPFAR up. I will not say it was easy. I will not say that everything went smoothly but the successes there have been really awesome as well. It's wonderful to be a part of that era. Well, thank you. So you were assistant administrator from 2001 to 2005. Can't, during that same period you were assistant administrator for Europe and Eurasia. So I wanna ask you a question about the role of the regional bureaus in terms of health because we've heard a little bit about that. Just in terms of your perspectives on the role of the agency in addressing health issues in that region. But because you were in global health during the period when PEPFAR scaled up considerably and also during the period when the president's malaria initiative was launched which unlike PEPFAR was really housed right there in the bureau. I'd like to ask you to comment on that period as well and what you see is the agency's unique place in terms of PMI as well. Right, right, thanks very much. Yes, it was a unique opportunity to seek global health from a bureau perspective before I was in charge of the Global Health Bureau and that was very interesting. And I just wanna add one thing, take a moment of personal privilege if I might. The book really is wonderful but when I look out at this audience and I look at the people I know here, I can't help but note that in my entire career I don't think there's been ever a time when the quality, the professional quality and the dedication of the people I worked with was higher than at USAID. And virtually everybody here that I see that I worked with there's stories I could tell about how wonderful it was to work with them. So a lot of the success for the global health in USAID is because of personnel, the quality of the people who we were able to recruit or had the privilege of working with. I started my career with a PhD in Russian history, did not expect to be sitting here. And in fact, I was in the Cold War, I was in Moscow at a time when there were very few foreigners in Moscow. And if anybody had told me then that the United States government would be spending billions of dollars in foreign assistance to the former Soviet Union in Eastern Europe, I would have just found it almost impossible to believe let alone that I might have some role in the leadership of the distribution of that money during the period 2001 to 2005. And if you look at what we accomplished during that time in those 27 countries and in Kosovo, you remember this was essentially planned very inefficient economy. But USAID and the Global Health Bureau played a major role in developing the health systems for Armenia, Albania, Kyrgyzstan, Kazakhstan, Georgia. We didn't, we had a tougher time, frankly, in Russia and Ukraine. We had a lot more success, I think, in Eastern Europe. But we had just remarkable success in helping get those countries up and going. Or consider the fact that the highest, some of the highest abortion rates in the world were in that part of the world. But by introducing family planning to Eastern Europe in particular, the abortion rates plummeted. It was a wonderful thing. You could get agreement by conservatives and liberals alike about the wonderful impact of US foreign assistance through family planning to lower abortion rates. Or I can remember visiting Soviet, Russian then, prisons, incredibly difficult situations in terms of tuberculosis. And our assistance there made a huge difference. So I saw firsthand the impact of USAID and Global Health there. Then in terms of my five years or four or five years in the Global Health Bureau, you asked about the President's malaria initiative. That is one of the most unusual experiments that was tried. Because we'd had this wonderful success with PEPFAR, but it was, in one sense, it was a new kind of operation. You created this outside of an established agency, HHS and USAID were the principal implementers. We did about two thirds of the work. But as Ann said, it wasn't always easy. But it worked and the results were there to be seen. And when the approach was made to President Bush, that with a major expansion of money spent on malaria, you could have a huge impact on deaths. And he bought the idea and was willing to do it. The question was, how are you gonna do it? Is it gonna be like PEPFAR? Is it gonna be like MCC? We made the proposal that you could get the results that you'd gotten with PEPFAR in an established agency without creating an infrastructure that would have to be created as supported if you would give them sufficient freedom to be flexible and innovative. The National Security Council, the White House, State Department debated it and eventually they said they would try it. And key, again, was personnel. To get Admiral Tim Zimmer. It's always good to put an admiral in charge of something like this. He was wonderful. And I see in the audience here that his deputy was Mr. Naglin over here from HHS. Now, is that right? I get that. Yeah, I still have it. I see him back there. And here's the interesting thing. This was an interagency operation operated within USAID. That's a new model. And the results were spectacular and continued in right to the present time. So I think that was a good example that you could take an established agency like USAID, do something innovative and flexible and get the results. And I get PEPFAR some credit for this, in fact, because they help prove that these things could be done. And I think USAID learned some things from that. That was very good. I see a couple of former ambassadors here in the audience as well. From Uganda. And I can't remember where Ambassador Lang was, but he was in charge of avian influence. And we took on that task in that period as well. But it was the cooperation with the State Department, with HHS, with OGAC, PEPFAR, and other agencies, which I think is one of the new developments in recent years that is so exciting. Well, thank you. You've touched on the theme of interagency partnership, which has been strong. The book also really, kind of looking back to the 1980s, emphasizes one of the key themes is the importance of partnerships with a wide variety of groups, both within the government, with the NGO sector, with the faith-based organizations, and private voluntary organizations. I just wanna ask, each of you has served in the agency during different periods and on different themes. But I wanted to ask each of you to just reflect for a moment on the role of partnerships and the changing paradigm of partnerships over the years and what that means. Would you like to start? Sure. The population program was built on partnerships because we couldn't get the missions to do much outside of Asia. So you really had to work with PVOs and NGOs. And a large part of the population program was identifying organizations that had the capacity to work in countries and were willing to work in this area. I don't know that the population program sort of paved the way for public-private partnerships more broadly in the agency, but I do know that in the 70s and 80s, most foreign assistance was going in the form of bilateral agreements at the country level. The office of population had to, and the population program had to work in a different way. And so a much larger proportion of our resources were going through partnerships of that kind. One of the things that I'm proudest of from my aid career was in changing the terminology we used from intermediaries to cooperating agencies. In fact, the office of population, I personally said we're not gonna call them intermediaries anymore, we're gonna call them cooperating agencies and partners. And the cooperative agreement that is today such a fundamental part of the way the agency does business really emerged from that change in, is much more than language. It was a change in mindset about what this relationship really ought to be. The organizations we worked with hated being called intermediaries because that meant that they were mere instruments of the agency. And there was an arrogance in the way in which we managed those relationships that we had to learn our way out of. So calling them cooperating agencies and talking about the relationship as partnership really did begin to change in the 80s. And I think it spread well beyond the population program and I feel very good about that. Yeah, well I was on the recipient and as an FBO when people weren't even really talking about it but aid had a long history of working with NGOs and FBOs. And in looking for the people that could be the best instruments to work with and sometimes that was very disease specific. When I was at a, there were already like 4,000 different NGOs that the health program regularly worked with and I got to know sort of the biggest and most prominent ones with the largest program but more and more the ones on the ground that people were working with. I did have a chance to go back and look at the program. I was part of that I'd received the USAID grant when I was there in the 80s, 25 years later and it was still going. It was still doing community health worker training no longer with USAID funding but on an ongoing basis. So that idea that you really could build a local national capacity through your partnerships did really work, not all of the time. During my time at AID was again that beginning of PEPFAR and we talked about the war on AIDS and one of my mantras was we can't win this war on AIDS unless everybody is involved. It is too big, it's too sensitive, it's too broad. We need to bring all of the different partners in so there was a very concerted effort to bring in faith-based organizations who were working on the ground and were trusted in this delicate area but also to make sure that they held the quality that was needed by our accountability and our results orientation. And I had fascinating and fabulous experiences with the private sector. We sat down with oil companies and we don't usually think of those as our favorite partners but Shell, we're talking about what could we be doing together and Shell Oil, I thought they were gonna talk about how they were going to do AIDS treatment for their workers and surrounding communities and they said, well yeah, we could do that and we will do that but do you know what we're really good at? We're good at scenario planning and looking out 20 or 30 years at different levels of say, disease burden. We'll do some scenario planning for you so you can begin to look at where you should be prioritizing your impact. I never would have thought to go to them to ask for that. And so in the building of partnerships I think the most fascinating thing for me was learning how much other people could do to help you move your agenda forward. If you wanna ask them, do you wanna be part of this? What could you offer? What is your skill set that you could bring to it? And it was always more than I expected and as AID reached out to all of these partners, we spent a lot of time enabling them to figure out how to successfully get AID monies and respond to the RFAs. We had a whole spectrum of huge partners that did marvelous things. Thank you. So Ken, you are now with World Division, a faith-based organization. Can you tell us from your perspective at the agency and from your perspective now how the partnership paradigm has changed and it's important? Well, you know, I mean, they talk about the faith-based office but as a matter of fact, USAID was working with faith-based groups, at least as far back as the 80s and probably earlier than that. So I think we were already ahead of the game as far as that goes. But let me give Africa an example. If you're trying to deal with PEPFAR objectives, when you've got a situation where 40, 50, 60% the estimates, we don't know exactly what it is but an awful lot, most of the healthcare in Africa is probably distributed in some way through faith-based groups. If you were to exclude them because they're conservative or because they're religious or they're Muslim or they're Christian or something, you would be taking out of the equation the partners we have to have to succeed. Now Ann and I, during our years at Global Health Bureau, when we had to deal with the prevention strategy and we had the strategy of ABC, abstinence, be faithful and condoms, there is no sure prescription to be hated by both the left and the right all at the same time. So it was the most, one of the more unusual challenges of my life but they were right, we needed all those interventions from the involvement of conservative religious groups to folks who were involved with casual sex or they at least used condoms but it was a public health objective, we needed to do it together. And even on family planning, the great news now I think is that if you do the work right and we've done it right at USAID for a long time with a portfolio, I learned this from Jeff a lot that you can have family planning techniques that Catholics and conservatives and folks who might not use certain techniques but would use that, we would offer it all and yet you could birth space your children, you could talk about it in terms of health and you can have a big tent. So that big tent has to include faith-based groups and non-faith-based groups, it has to include as many people as possible and it's immaterial that they don't see eye to eye on all the issues. Thank you. So Arielle, over the past few years, there have been a number of important partnerships launched. I wonder if you could say a bit about the vision looking ahead, where do you see the partnership paradigm or relationship going and what will we see 20 years in the future? Well, thanks. First of all, when I arrive at USAID, I quickly learn that our implementing partners is an extended family, is more than a partnership, is some people may look at it good or bad but sometimes people have worked in the agencies, have worked in the NGO world, it's an extended family and I think that that's very important as how we do our work. If I can zoom out a little bit to address your final questions to the future, what we now see as global health used to be called tropical medicine and for the first half of last century, it was mostly missionaries and plus some author called ones, the missionaries of science, it was the time that there was Rockefeller and there was not yet W Show, there was no NIH, CDC was just beginning, so it was a different time where I think the principles and the parameters for what we saw in the second half of the century were established, were unleashed in a way and following World War II was really the moment in which things did happen and partnerships were merged in different ways, we had the allies at the time but actually it was not so easy for development, the idea of development really came to the fore as a government international institutional thing, building on the commitment that Faith Base had already established and the guidance of scientists. So there was that sort of partnership at the time, it was not called out, but it was operating and following World War II, there was the UN Reconstruction Agency, UNHRA with Marshall plans and others, they even helped the guys in the east side before the Cold War frosts and when the Cold War frosts, then partnerships begin to break in many places, all of the members of the Soviet Union did not show up at the World Health Assembly, a new organization W Show had assembly until Stalin died, but with the Cold War, the history with the capital age was shaping the space in which we were working and things changed dramatically and at the time, it was the time for big partnerships as we heard in one of the early discussions by Robert, it was pretty much W Show and UNICEF, it was the big agencies and USAID and it was that sort of partnership, that's how partnerships were construed and there were significant at the time. With the end of the Cold War, the geopolitical space changes again and with that change we, in this middle period, we had termed from tropical medicine to international health and with the end of the Cold War, we became global health and the change of name was very significant because everything changed in the 80s, 90s, everything changed and we saw an explosion of NGOs truly unprecedented, the explosion of civil society groups all over the world, we saw the emergence of many new philanthropic enterprises including Bill and Melinda Gates foundations and we saw now the possibility of working with the private sector so probably prior partnerships came to the fore in this period of global health. They were impossible in the 70s when a member of the corporate world could not set food in W Show, so there was all of that. So partnerships have evolved, the context had allowed us to see this and we have now really what Debbie Fiedler calls it's not quite an architecture of health with all the partners doing well prescribed roles but it's truly an open source anarchy as he says. With a lot of people and a lot of groups all working to the same higher purpose. We all believe health is one of those beautiful things that we all can believe in saving life in improving the well-being of people and because of that, we don't need somebody to direct you. People sort of knows what the intention is and so many new forms of partnerships are gonna take place. I believe that as we went from tropical to international health to global health, I believe the geopolitical space is changing again dramatically and that this will probably at some point somebody will write a paper calling it something else. It's gonna be a new era and just like the 70s was a period of assertiveness when countries could tell you I don't wanna do population control and then a certain is came out of the wars of independence of European colonialism coming down that what we see now is a different type of assertiveness taking place. The success of the economic development in the world means that many countries that were low income are now becoming middle income and that's creating now the space for South-South collaborations in which international institutional architecture has not quite yet grappled with and yet that is not calling for it. What will be the role of the Chinese? How will Brazil work with Africa? Those things are not yet specified but I see that big space of possibilities for those macro level partnerships to occur as the other partnerships continue to be reached and important in this period. So I would believe the most important partnership will be the partnership has been natural but now being explicit of the countries themselves, countries that will be increasingly be able to stand on their own and again, a testament of the success of these 50 years of international development. I want to point out that when we started with USAID 50 years ago and we saw that, no, Richard Cantus had life expectancy of 70, going to 80 years and the poor countries had life expectancy of 30 or 40 years and we thought that that's the way the world had been created but no. Everybody had a hard time for millennia. It was a new thing that the Richard Cantus in the last century had accomplished that status and we are now in the midst of an incredible grand convergence both in economics, in life expectancy and in so many other parameters. So this generation, the next generation will really take from, and I see many of the old generation here but I also see many of the young generation, they will see that possibility of the grand convergence between rich and poor countries. The same force that inspires us all along now seeing a bold end game. We are thinking of an A3 generation. We are thinking of any preventable challenge around the end. These are not just slogans, these things are happening and it's going to be a different world and that will mean that indeed in 20 or 30 years many of the places where we now need to support from an assistance model may no longer require assistance and many of our partners are also evolving their own business models to be working with many other sources, diversification of funding and working with the countries themselves. It's going to be an incredible period, rich in success but also different than the era of global health. Well, thank you to the panelists very much. I want to give our audience a chance to ask a round of questions that will take some questions from the audience. There are microphones because we have an audience on the web. Let me ask you to wait until, to raise your hand if you have a comment or question. Wait until a microphone is delivered to you and please say your name and your affiliation and to make a brief comment please. We'll take a few questions now. Thank you. Where are the microphones? Can you please get one over here? Please, sir, in the back. Okay. My name is Fernando Zacarias from Global Health International Advisors and I really have a very brief comment. To the audience, what you have heard is true. Okay, that's my first comment, is the truth. I have worked as a partner to USAID in the area of AIDS for about 20 years. And everything that was done and that we learned, lots of the knowledge came from the experiences of USAID with AIDScom, AIDStech, et cetera. So I saw firsthand the way in which you approach any problem of health. And here is my brief comment. What you need and what you have experience in USAID is good ideas, good leadership, good approaches, good policies and good action. And that's why you got results. I know that the audience here is mostly people from USAID but I'm a witness to what happened. And then I agree with the comments about vertical approaches and what Ariel said every time he talks he says something different. About extended family and about change. And my only message for you is that you have to have a vertical, you have to be a verticalist but you have to have a horizontal vision, spiral approach and a global concern. And my suggestion for the next step in the successful history of USAID is why don't we all concentrate on obesity for example. Not overweight but obesity and have the same approach and see if we can have the success because that's the number one problem in more and more countries. Thank you very much. We have time for one more question or comments. Is there one more? Yes please over here on the side. Thank you. Hi my name is Irene Niqua and I work with Wash Advocates. I had a question about well with Wash being critical to many of the global health interventions and overall development of any country. Is there, can any of the panelists speak to the role of like the future of Wash programming and policy because it's so interconnected with so many of the other areas. I didn't really hear much about it. And maybe can you take a brief answer? I'll do the history of Ariel to the future. When I was doing the sort of comprehensive primary care in Kenya Wash had to be part of it. I mean it just couldn't not be. And as I went through my course of career and was doing various things and came back and you know was told well Wash is over here and nutrition is over here and health is over here. I thought no no no you can't do that. In the early 2000s when the Millennium Development Goals were being put together, they did the other Millennium Development Goals and the very last ones that got ironed out in Joburg at the World Summit for Sustainable Development were the ones around the environment about the water and the sanitation goals because they are so key. So when I talk about the MDGs that are health related I always include the water and sanitation. We've had again sort of hidden away within USAID a very strong wash group that brought the not so much initially it was infrastructure. It was wells and large engineering things and some of that died with the RIF. But the behavior change, the hygiene, the household intervention, USAID it's a really seminal work on what you can do within the households that built within our sort of community orientation. So I would see it as integral. We can't get to the kind of health indicators that we thought were really important without including that very seminal part. We are very fortunate to be joined this afternoon with Ambassador Deborah Birx from the Global AIDS Coordinators Office. And Ambassador Birx I wanted to ask if you would come up and say a few words about the history and legacy and in the context of this book. Well, you have the brain trust of the origins of PEPFAR on the stage. So it's difficult for me to even say anything with Anne and Kent and Ariel here. Some of you know there's been interagency difficulties. The degree and the depth of which you all have contributed to PEPFAR stems from Anne Peterson's strong role in ensuring that USAID was always at the table. And really I have to applaud you for the amazing job you did and that very, at the birth, the very birth of PEPFAR. But we're talking about the 50 years of USAID. And you know when President Kennedy created USAID he also expanded NASA. And so made the announcement that we were going to build an agency that was going to help countries around the globe and said we're also going to the moon. Now I see a lot of young people in here and it's great that you have a lot of young people coming up with NASA and going to the moon. We had slide rules. We didn't have calculators, we didn't have computers. So at the time that he had the brilliance of the vision for USAID and you were, it was the same as going to the moon. But at the same way we only had slide rules. Yet in these 50 years, the progress is really quite extraordinary. This 70% decline in childhood deaths, 45% decline in TB mortality. The amazing increase from 10 to 15%, 50%, despite the obstacles talked about in family planning, 50% availability in this expansion is extraordinary. The eradication of smallpox, which wasn't thought to even be possible. And the work that you have done in polio is nothing less than astounding. So like NASA, you've worked in difficult places for a long time. And it's not, you know, they went to the moon but you went to some difficult places without question. My daughter does this now, you know, and she goes to Goma in South Sudan and says, oh, it's fine. And I look up and see, well the State Department says you shouldn't go there. What are you doing? But I know you have been out there and you go to these difficult places for nothing but to help others. What an altruistic, amazing, and deeply humbling piece. And so I think USAID has stood for that from the very beginning. Let's also remember, there are people in the audience, the ones who remember that we use slide rules. The ones who remember that, one of them I was sitting beside, who, well I won't make that reference really, Robert, but I do think you had a slide rule. I think we've talked about this at breakfast many times. I had the special metal one that was yellow on one side and white on the other. That was my at-home slide rule. And then I had the bamboo one that I carried around like in the purse that you would always have available in case you came up and had to do a quick equation. But there are people in this room that raised the alert about HIV because you were always looking horizontally, as described. You were in vertical programs but you were looking horizontally about what was happening. Robert was one of those people. Sent up the alert over and over again to Washington that there was a problem. And you move funds around as soon as we knew it was HIV. In 1986, started working on HIV. With the Life Initiative, you were out there at the forefront in country after country. So you not only have this incredible, proud heritage of a long-term work in global health, but you were on our front lines that really identified the HIV pandemic. And that's really extraordinary because no one else was talking about it. So thank you for your work. Thank you for your energy. Thank you for having young people too. This is just really fabulous. And thank you for this panel because this is between, these are the people who have done amazing work within the PEPFAR world. And I'm deeply grateful to all three of them. So thank you for your strong work. And thank you for being able to come by today. Thank you. So we've had some time this afternoon to think and talk about the history of USAID and the work that has taken place in the era of global health over the past five decades. I want to turn to Ariel now to take us through a little bit of a different history and also to think about some of the next steps for the future. Well, thank you. Thank you very much. And as Steve knows, because he left USAID and went to Rockefeller when I came from Rockefeller to USAID. And at Rockefeller there's a great passion for history because it's such a rich history as I alluded to early on. So I understand that history has always been important, the power of history to make sense of where we are and where we're going. When I was in WSU, I actually also initiated the global health history series. And I was just looking at talking in Geneva during the World Health Assembly with the editor of the WSU Boletting Room who runs this series with a group in England and is now the longest series of lectures. That is, who would thought the history is important? But I was clearly for the first of that and with Haven Mahler to run the first global health history seminar. And he was crowded. This was not a technical session. It was not about the latest science or a program in a country. It was just the history of our space. Very powerful. And as I said, it's continued to be found. So when I arrived, I used to do it three years ago and I arrived in the midst of the 50th anniversary of the agency. And I, this is my thing, I like history. And I couldn't have had a better person to help me understand that history than Robert Plague who was joining at the time from the Office of HIV AIDS as my DA. And I was very, very lucky to have Robert to understand that history, to make sense of that history. I understood the context, but it was so rich. And it was based on those conversations with Robert that we said, hey, we should do this. And I'm very happy and very proud that Robert leadership working with a team that did it. And this is just one little itzy, busy thing of the many things that Robert Plague has done. And if you allow me, I would just like to say that recognize Robert. Robert, as you know, 31 years with the agency, we were in Durban just last week with Debbie and the PEPFAR crowd, it's a big crowd. And it was great to have the opportunity to do the same thing, but I would like to invite you all to recognize and say thanks to Robert for the 31 years in USAID as he retires from the agency. But we're gonna be working with Robert, the extended family of Robert. And as you know, June 25th, we are gonna be celebrating the second anniversary of the call to action which builds on decades, honors the decades of work of this agency in reproductive maternal neonatal child health and put forward really that commitment and a new way of working with partners and with countries to see the end of preventable child maternal that we can do this. We have helped save more than 100 million children's lives in the last 20 years alone. So we are very close. This generation will deliver that. This history is not yet written. I see a lot of the young people that Debbie who's kind to join us has pointed out here. And it will be a lot of the young people and who will make it happen following the example of the people who made it happen before to us. So I just want to thank you and thank our panel.