 All right, well, we have a great session for you today and it is now 12.33, so I think we're gonna get started and allow people to make their way on in the next couple of minutes. My name is Aaron Kesselheim, I and Leah Rand and I jointly run this help policy and bioethics consortium, and we would like to welcome you to this, the last session of the 2021, 2022 academic year and we are thrilled to have a great lineup for you today to talk about supplying international aid. So just to run through some ground rules, there is a Q&A feature that you can see on your screen. Please click on the Q&A feature to submit questions. If you are interested in tweeting about anything you see, we use the hashtag policy ethics and you can use the chat function with any technical issues. And if you are interested in learning and being on the mailing list for next year's session, you can check us out at the bioethics, Harvard Bioethics website or at the portal website and submit your name to get on the mailing list. So the goal today is to, as always, articulate key issues in healthcare system that involve ethically challenging policies or practices, bring together experts with different perspectives and experience to consider and propose solutions and to stimulate conversation and academic study to help advance the field. So today I wanna have, I'll take the pleasure of introducing our moderator, Rebecca who is going to lead us through our conversation today and is going to introduce our expert discussants in turn. But Rebecca Weintraub is an assistant professor in the Department of Global Health and Social Medicine at Harvard Medical School and an associate physician at Brigham Women's Hospital. She is the founding director of the Global Health Delivery Project at Harvard University, which is a joint initiative of Harvard and the Brigham. She has done a lot of great work in writing, investigating delivery bottlenecks and exemplars of well-designed care delivery. And Rebecca, thank you so much for serving as our moderator today and leading us through the session. Terrific. Well, thank you so much to Aaron and Leah for having us today. There's a beautiful arc here as Aaron and Leah shared with me that Paul Farmer began this talk series in September and I hope we'll be able to root back to that discussion that began early this fall. I am going to just share a few opening comments but then quickly introduce Jim Kim who's on the line with us today. And to reframe a bit of the conversation thinking of the moment that we're in today, thinking about this notion Congress did not supply, for example, the $5 billion as expected for the COVID vaccine plan and the pattern that we'll see through the conversation with our experts today of the bottlenecks and the lessons from MDRTB, HIV, Ebola and COVID. And I think as many of us know how we confront pandemics and improving health in low-income countries require ambitious public health plans. We have three very ambitious leaders with us today. When historians have read about the COVID-19 pandemic, they will center on the rapid development of the vaccines. We know this is a once-in-a-lifetime moment that within nine months, we've been able to have now six new vaccines to use within our vaccination programs. But as anticipated, the success of these vaccines has exposed vast disparities in access and uptake. The procurement processes, the stockpiling of vaccines created the basis for these fundamental inequalities in our global distribution. And although there's wide consensus that the vaccine equity crisis must be addressed immediately, the progress has been slow and the disparities in vaccine access have grown. And the B2 variant is again revealing the persistence of the unprotected populations as we're seeing case counts rise across the globe. So today we're gonna focus on the expertise we have on the line regarding operationalizing and financing major public health programs for TB and MDRTB, HIV, AIDS and for COVID, both vaccines and treatments. And as you listen, we hope you start seeing this pattern of how leaders operationalize, adapted and iterated on the flow of the products, the information and the financing to prepare adaptive systems to meeting the needs of global populations. So I am honored to introduce Dr. Jim Young King who's been a life, a career long mentor of mine. As many of you remember, he was not made by President Obama to serve as the 12th president of the World Bank Group. And Jim quickly outlined two critical goals. Number one, to reduce extreme poverty levels to below 3% and grow the incomes of the bottom 40% of each country. And to that end, his organization lent out cash, almost $59 billion a year through its network of 189 member states. Previously, Jim served as the director of the World Health Organization's HIV AIDS Department and he led the WHO's three by five initiative, the first ever global goal for AIDS treatment. Following his service at the WHO, Kim was chair of our department of global health and social medicine at Harvard Medical School, chief of the division of global health equity at Brigham & Mowen's hospital and director of the FXB Center for Health and Human Rights at Harvard School of Public Health. He continues to serve as a vital mentor and beacon for all of our shared work and Jim's tenacity and determination has led, has created an indelible imprint on so many who are on the call today. Just to take a step back, when Jim was a resident at our hospital, Brigham & Mowen's hospital where Aaron and I both practice, he was also known for someone who pilfered the supplies from the Brigham. Surgical instruments, their economy trips, medications. He took those stocks, put them in a suitcase and brought them to Conch. And then in the mid 1990s, Jim was aware of the epidemic of multi drug resistance tuberculosis in Peru. Many experts believe that patients were simply not adhering to therapy and the World Health Organization at that time essentially declared that treating NVR TB in resource-concerning settings was not cost effective. Jim, meanwhile, was filling his suitcase with drugs, they charged to the Brigham pharmacy and he hired community health workers to help mitigate the despair of patients. Jim's tenacity paid off. They quashed the provian outbreak and gave the clarion call to alert the world that NVR TB is a problem and will continue to grow. Eventually, Jim negotiated lower prices for second line therapies and today NVR TB is standard line of care. Jim, we're so thrilled you could join us today. Thanks, Rebecca. It's a great being with you. Jim, I'm gonna start us off to take folks back because many on the line may not remember your role and what it took to move from a small scale pilot of NVR TB treatment at a time when the World Health Organization was saying it was not treatable to running NVR TB programs around the world, including your role at the Green Light Committee and innovative financing mechanisms. So if you could start walking us through that story. Sure, sure. But Rebecca, we had started working in a slum in... Can you guys hear me? Is it okay? Yeah. We had started working in a slum. It was part of a fellowship actually that I was doing at the time and we really stumbled upon this outbreak. There were 50 cases of drug resistant TB in a town of about 100,000 people and we discovered those 50 cases pretty quickly. And so, you guys probably know the rates of TB in the US is something like six per 100,000. So to have 50 per 100,000 drug resistant cases was really alarming. And so we started just asking questions. We actually didn't know in the early part of our work that the World Health Organization had said that it's not cost effective and it actively said you shouldn't do it. We didn't know that. And when we heard that, when we saw the kind of very loud, emotional, even angry reaction from WHO and the local TB program officials, we just kept poking at it because we couldn't understand what... These are people who are clearly sick with documented NBR TB. And the definition of NBR is that you at least have resistance to the two most important anti-Turkish medicines, I sniced it in Rufanthusen. And we had documented with laboratory studies in Massachusetts and we also documented that they were spreading it very nicely inside the family. So it was an outbreak, an ongoing outbreak, but the local authorities, we kind of felt they'd say, well, thank you for caring about these patients. We know they've been neglected and it's a shame, but we just don't have the resources to treat them, but thank you for trying. That's not what we heard. What we heard was, if you treat a single patient, we will kick you out of the country. And so we were saying, what is going on here? And not only were they saying that, but they were getting very strong support from Geneva and the World Health Organization. So as we dug into this, what we found was, yes, it's much harder to treat, but instead of just facing up to the fact that it's harder to treat, but because it's an airborne infectious disease and we've documented that it's in families, you've got to figure out something to do. They started coming up with all these sort of reasons why it's not an issue. They said it's not spreading from person to person, it's just non-compliance. Oh, so everybody in the family was non-compliant in exactly the same way and they have exactly the same resistance pattern. How could that be? And so it was this, it was a sense of outrage. And I think at the core of it was that the quote unquote TB community and they called themselves not the TB community, they just called themselves TB. TB was saying, who the hell are these people? If it was treatable in resource core settings, we would have done it. Who the hell do they think they are? So it was not just a lack of aspiration. It was a lack of aspiration that led to anger and fundamentally, at least at meetings anyway, the equivalent of attacks. They were saying, you guys are crazy, it's not possible. It was never possible. And by the way, the prices of the medicines are too hot. So we started making a little bit of progress and I asked one of the folks who was sort of leading the charge against MDR2B treatment. I said, well, you know, what do you think the cost of the medicines are? He says, oh, it's 30 to $50,000 per patient. And I asked him a very simple question. Well, are these medicines generic or are they still on patent? And his answer was, I don't know, right? So in my mind, this group of people had declared a death sentence on everybody in a poor country who suffers from MDR2B and they never bothered to check whether the medicines were on patent or not. And it turned out that all of them, except the quinolones at the time that were being used and not broadly, but all of them were off patent. And the reason they were used for MDR2B patients is because they were older drugs that the bugs still had some sensitivity to but they had stopped using them because the side effects were so much more severe than the drugs that were used in the regular TB treatment program. And so I had done my PhD dissertation in anthropology on the global drug industry and I immediately said, well, but you know, if they're generics and they're behaving like branded drugs, it's just because the markets are so small. And if we did a few things to get Indian and Chinese manufacturers to start making them, we could drop the prices very, very quickly. And then when I gave a presentation to the International Union of TB and Lung Disease, I gave the keynote presentation at one of the meetings. And then TB stood up and said, you're crazy. If you drop the prices, we will accuse you of creating pan-resistant strains of TB. You should not even try to drop the prices. So they went further and they said, not only should you not treat them, but you shouldn't even try to make the drugs more accessible. So we had to come up with a plan and what we did was we created the Greenlight Committee. One of our students who just finished his MPH at Yale, Raj Gupta, we sent him to Geneva succumbed by partners now. And we had no money at that time. We were running on fumes and we sent him there just to try to see if we could continue to make progress. And I said to Raj, has there ever been a time when WHO has been able to control access to drugs while at the same time lowering the price? And it turned out there had been for a minute to couple vaccines. And they were able to both lower the price and control access through something that they called the Greenlight Committee. And so we just said, hey, just take the documents that established that and we'll do the exact same thing for MBR teacher. And once we did that, then I think people started getting on more. Okay, so every time we came up with a solution they drew a new line in the sand. And this final step across the line was the Greenlight Committee. And it was just very hard for them now to say don't treat anybody, don't do anything. As this was happening, we were treating people living with HIV in Haiti. And it was just so bizarre because the exact same argument was being made about HIV drugs. And they were saying, oh, it's impossible. Bill Gates at the time said, we really care about all these HIV patients. I mean, the Gates has given so much. But along with literally everybody in the global public health world except a very small number of people who weren't saying it's impossible. And one of them luckily was Tony Fauci. They were all saying, we have to focus on prevention. We have to think about the next generation. And we just were, we were dumbfounded that we were doing it again. And it seemed like the resistance to treatment was even stronger in the HIV community than in the TB community. So a few things happened on a very specific day. I think it was January 18th of 2003, PEPFAR was announced and it just blew us away. It just, we couldn't believe that President Bush had made that kind of a commitment because not only did he talk about treating people in Africa, but he talked about a price for a full year's regiment of $350, which was only possible through generic manufacturers, literally breaking the intellectual property law by creating these generic versions. We couldn't believe that he'd said it was, and I still, President Bush's commitment to treating people in Africa is still far and away the most important thing probably that happened to Africa in the last 20 or 30 years because if he hadn't done this, if he hadn't provided leadership so that everything else that happened could have fallen into place, I don't know what would have happened to the African economy. I just, I can't imagine the fear that we had in the early 2000s, if that had continued for another 10 years, I just think the entire economy of Sub-Turban Africa would be in a complete shambles. So anyway, he made that announcement. And then everybody had to take it seriously because it came out of the president of the United States but inside Petfar in the early days, there was still this tremendous fear, how are we gonna get the prices down? What are we gonna do? How are we gonna make it go forward? And so right at that time, the other thing that happened on that day in January of 2003 was that J.W. Lee, my very good friend who's campaign for the Director General of WHO, I had run along with Paul Farmer, he was elected as the Director General and he asked me to come and I said only if we can be extremely aggressive on HIV treatment. So that's when we went and we established the target. But then the question started coming up, how are we gonna be able to get the kind of prices that we need to get in order to really scale up HIV treatment? And so what we did was within the essential medicines group at the World Health Organization, we started something called, well, it's something that they had done before for other medicines, the pre-qualification program. And what it was essentially was we borrowed drug regulators, drug regulatory authorities from a lot of mostly European and Canadian countries. And we would send them to these factories in India and China that were making antiretroviral drugs and they would quote unquote pre-qualify them, say that they would do all the things that they would normally do to determine if a drug was safe and effective. And so we started pre-qualifying these drugs and we were going directly against what the drug industry was saying. And so I had a lot of extremely tense and loud discussions with the representatives of the industry. Also, the Bush administration wasn't crazy about this and there's no way that they would have been able to just accept our own pre-qualification process. And so they were just racking their brains about what to do so that they too could get those prices because if they were gonna pay 15, 20 times more than what the global fund was paying for those drugs, they wouldn't have been able to reach their targets or get anywhere close. And so it was Mark Dible, Tommy Thompson was the secretary of health. They came up with a really brilliant solution which was basically to recreate the pre-qualification program within the FDA. So the FDA, they didn't call it pre-qualification. I don't remember what they call it, he probably knows but the FDA basically did the same thing, went and gave approval prior to the approval of those drugs on the US market. And so the only way that made it possible for the US to spend US dollars buying antiretroviral drugs from these generic manufacturers because they had been approved by the FDA but only for use in these programs, not of course for use in the US. And again, I'm sure that Prashant and Thief know much more about what happened afterwards than I did. But my understanding is that this has grown in preparation for this session, I've been reading about the access to medicines index where they're looking at the performance of various pharmaceutical companies. And while it's not perfect, it was a very interesting solution where we protected in actual property in first world markets because that's the way that you create the incentives to continue to make new HIV drugs. And luckily, new HIV drugs have continued to be made because there's enough of a patient pool in the OECD countries to make it profitable. And then quickly make those drugs available to poor people as well. So this was a great system that I think could have and perhaps should have been used in thinking about what to do with access to vaccines. In other words, the arguments over intellectual property were not really, I mean, we probably could have gotten to the very, to the specifics of just making more of these vaccines and getting them delivered more broadly without having to have had such arguments about intellectual property. And again, I've always been and I always will be more focused on access. But I really think that looking at the problem now and my understanding of COVID is that we just, we've got to really increase production and probably in developing countries. I don't think the Africans are gonna be satisfied with people saying, oh, you'll get them, we'll make them elsewhere and send them to Africa. I think the Africans are demanding that they develop some kind of production capacity and it's started. But I think there are enlightened ways of dealing with intellectual property, with innovators, with global health advocates so that we can really get on top of the task, which is to have a system where we can continue to get new vaccines out and vaccinate everyone or at least everyone who will agree to get vaccinated in the world as quickly as possible. Thank you, Jim. I mean, so many important threads there and you've just set the exact frame that we wanted for the discussion. Eager to dive into some of the specifics now, especially for folks who are attending who may not know the details of the PEPFAR's successes and how do we actually operationalize PEPFAR for and the programming for HIV and TB patients. So we're absolutely thrilled. I'm gonna pass the baton to Dr. Teep Alsamari in a moment and just wanna introduce you to her if you haven't met her previously. She is currently the Director of Science and Policy in the Office of the Surgeon General. Also a friend of many of us on the line, the Beckmerthey's second round here as Surgeon General of the United States. She served as a senior advisor for TB and HIV within the Office of the Global AIDS Coordinator and Health Diplomacy at the State Department where she led scientific guidance, policy and oversight for TB prevention and HIV testing programming in 50 PEPFAR-supported countries. Teep also served as the Chair for Code Diabetes South Africa's PEPFAR portfolios providing strategic direction for HIV and TB treatment. She previously served as a White House Fellow in the Department of Energy where she led the development implementation of the Oppenheimer Science and Engineering Leadership Program. Teep trained as the CDC Epidemic Intelligence Service Officer at the New York City Department of Health and Mental Health Hygiene and also served as a Deputy Health Officer to regularize the controller in Santa Clara County, California. Teep, so many thanks for joining us today. We'll pass the time over to you. Thanks so much, Dr. Wingtrap. It's a pleasure to be here and it's a pleasure to be on a panel with Dr. Jim Kim and speak with all of you as part of this really incredible conversation that you have. So I want to start, I'm gonna pull up my slide. All right, so I'm just going to start by telling the story of two TB patients. And the first is a patient I took care of as a medical resident at Milago Hospital in Kampala, Uganda in 2008. Five years after the launch of PEPFAR which was historic and incredibly exciting. So this was a 25-year-old patient who came in familiarly, probably to many of you with night sweats, evers and profound weight loss. He had a chest x-ray that was done in here and that showed miliary TB. He had a blood test that showed he was HIV positive and an extremely low white blood cell count. He was tested for malaria. His students were collected for AFB smear and culture and they were unsurprisingly smear positive that the cultures would take weeks to come back. He was single, he wasn't married. He had moved to Kampala from a small town to look for work and he was at the hospital with his mother who had traveled from their village to come care for him and stayed beside him throughout his stay. She'd cook for him, she slept on the floor next to his hospital cot and he had to pay for all of his tests, all of the imaging out of pocket. If he needed a blood transfusion, his mother would have to go to the blood center to pick it up, except for a handful of medications offered at the hospital pharmacy. All of his medications had to be picked up by his mother or another family member at another pharmacy and paid out of pocket. His HIV medications, however, were free. So he was started on TB meds and then sometime later, HIV medication. He was thankfully didn't develop iris. He was in the hospital for a couple of weeks and discharged home with follow-up at the outpatient HIV clinic in Kampala for his TB HIV medications. I actually never saw him again, but I hope he was able to stay on his medications. It seemed like he had good family support and perhaps a faith community he could lean on. HIV was still a death sentence for many during that time. Too many people arrived to Moago late in the course of their disease and despite everything we tried to do, the number of men and women who were not there in the morning when I returned to rounds was incredibly shocking. I mean, this is the world that Dr. Farmer and Dr. Jim Kim were faced for many years and fought to change in Haiti with their parts of the world. So all I could do was hope that when he went back to his community, he didn't face stigma, didn't fall prey to misinformation, was able to stay on his medications and tolerate the side effects to work, to become virally suppressed. And perhaps he married and perhaps he had children who were HIV negative and that he continues to thrive today. So fast forward five years later, I was a newly minted TB controller in Santa Clara County, AKA Silicon Valley, and I was responsible for overseeing the treatment and care of every TB patient in the county. And so we probably think of Silicon Valley as home to Google, Intel and other tech giants. It was not a place that you really thought about TB much but it actually had some of the highest rates of TB in the country and a couple of hundred TB cases including a handful of MDR TB cases each year. Our patients were incredibly diverse and spanned South Asian tech workers, Filipino health workers, Vietnamese refugees and migrant farm workers. I used to say that it was like doing international health without the jet lag but it also felt like living in a dickens novel. It was a place of both extreme wealth and extreme poverty. One of the patients I heard about who was reported to us from the hospital was a 36 year old migrant farm worker who didn't have health insurance and was hospitalized with several weeks of worsening cough, fever, night sweats and weight loss. That sounds probably familiar. He had an HIV test done. He had an AFB smear and culture. He was started on empiric or drug TB medications and he also had a specimen sent for a gene expert testing to the county lab. This smear was four plus and the gene expert test results came back the next day which reassuringly showed us that he did not have multi-drug resistant TB but he was HIV positive. He lived with six other migrant workers in a one bedroom apartment, had a wife and family in Northern Mexico if he hadn't seen in two years but sent money to and FaceTime with regularly because he couldn't be isolated at home. The county provided him housing at a hotel with closed ventilation until he was smear negative. He was visited by the county nurse for directly observed therapy. Each day, groceries were delivered once a week and he was seen by a county doctor, sometimes me for his TB HIV care. As he improved, his DOT was switched to FaceTime and that allowed him greater flexibility. He had done much of his work outdoors but we also evaluated and offered treatment to his coworkers who had commuted to the farm with him. All in all, the county nurse interviewed, tested and referred about 15 people who had close contact with him and thankfully none of them developed active TB. It took six weeks for his smear and smear to convert to smear negative but at that point he'd lost his job but once he was smear negative, he found another job, found an apartment with more friends and the county nurse gave him gift cards so he could purchase a bicycle to commute to work. He continued to do DOT with FaceTime and get treatment. He ultimately finished nine months of TB treatment and HIV care by the end his white cap has improved if our load was down and he'd return to a healthy weight. He paid nothing out of pocket. Why do I start with these stories? I tell them because they're remarkably different yet similar and what Petfar looks today is actually much more similar to how we cared with my patient in Silicon Valley than what caring for TB HIV patients was like in Uganda in 2008. We are much closer to that vision that Hall Farmer and Jim can had that no matter where you are in the world you can get the same quality of care. We're not there yet but what we're getting there and we've come an incredibly long way and I just wanted to just point out one other similarity that ties to some of the work that I do now in the Office of the Surgeon General and what we talk about which is when we go upstream to think about that sense of loneliness that both of these patients had and how that might have played a role in them seeking a sex worker and what the role of lack of education and opportunity might have driven young women to become female sex workers. We'll come back to that. So, Hall Farmer was started in 2003 and it was thanks to Dr. Kim and many other advocates around the world to that this was launched and it has been one of the most successful applications of global health community in history. The goal being to end the HIV epidemic by accelerating treatment and prevention efforts around the world. It's truly historic. As you'll see, I won't go through the numbers here except that about 20 countries have nearly reached academic control. There's nearly three million babies that have been formed HIV free. There are nearly 19 million people around the world including men, women and children who are on life-saving antiretroviral treatment. And so it's truly unprecedented. And the budget of PAPFAR, you can tell this is a photograph from South Africa that I was really struck by and kind of reassuring that there's a sale on tombstones that it is not a big market anymore. So the PAPFAR's budget is about $6 billion and operates in more than 50 countries. The funding is allocated mostly as bilateral commitments with country governments and an epidemic that looks different across countries. How do you do that exactly? So I found this interview with Dr. Farmer where he once said without the staff, stuff, space and systems, how can you do good work in a medical wasteland, a clinical desert? I don't think you can. So I'll try to walk you through a little bit of how PAPFAR makes sure that we have the staff, the stuff, the space and the systems in place to care for patients in a data-driven and targeted way to end the HIV epidemic. So the program is now in its 19th year and has evolved over time. It's been led by different global AIDS ambassadors who focused on different priorities. And I won't cover the history of PAPFAR and I won't be able to describe to you all the different parts of the program, but I want to give you a sense of how this financing is operationalized. So I'll walk you through the program at a 30,000 foot level to show you how someone might come through wherever they are. And the first thing that Dr. Kim pointed out is we need ambitious goals and targets to align our efforts and this orients and guides everything we do. The current goals are set by UNAIDS that we reach what are called the 95, 95, 95 goals by 2030. That is 95% of people who are HIV positive know their status 95% of them are on treatment and 95% who are on treatment are virally suppressed. And that is the definition of epidemic control. So about 20 countries, PAPFAR-supported countries across the world have achieved that and it's really truly astonishing. However, YTB is the leading killer of people living with HIV worldwide and prior to COVID-19 with the leading infectious disease killer worldwide as well. As Dr. Kim and Dr. Farmer knew, well, TB is a complex disease clinically but it is also a social disease and one that is treatable and curable. Nonetheless, for too many people, it's a death sentence if protected and treated too late. So because of that, I'm gonna come back to this because of that every patient who's diagnosed with HIV around the world through PAPFAR is going to be screened and in the United States will be screened for TB and every patient who's even suspected of having TB is going to be tested for HIV. But PAPFAR, like our colleagues at WHO, Global Fund and Harvard, we care about TB. We know that in order to save lives for HIV, we need to think about and treat TB. So this is a quote from Dick Sheson and Jonathan Gola that Johns Hopkins really highlighting the importance of TB preventative therapy for BLHIV in its reduction of mortality. So it offered TB preventative therapy as a nearly 40% reduction in mortality. And so in 2018, then Ambassador Burks set ambitious targets that we would treat all BLHIV who were eligible with TB prevention therapy. So how did we do that? Well, we started with this magnificent tome called the Country Operational Plan Guidance which this year is nearly 800 pages and that guidance lays out a strategic vision for the upcoming program year. Minimum program requirements that every country is expected to achieve and meet as well as technical guidance across prevention and treatment priorities. The COP guidance is essentially a blueprint for how we would like programs to operate and plan for the upcoming year. It includes, it outlines preferred treatments for HIV and TB including specifying INH or 3-HP or TB prevention therapy and different HIV drug regimens for adults, for children, for women who are childbearing as well as TB diagnostics and diagnostic tests for HIV. So all of that, what that does and eludes to something very important that I think Dr. Kim talked about which is it sets a signal to the market and as not only is PAPR a buyer of these goods but the guidance inevitably serves as a signal to the market to pharmaceuticals and diagnostic manufacturers about what kinds of investments will be made and where the future of PAPR investments and global fund investments and country investments will go. And that hopefully helps drive down prices which is critical for sustainability. The technical guidance is often aligned with WHO guidance but not always. And it differs for a variety of different reasons we won't get into. However, we don't, when we set this guidance we don't do it alone. It's a critical partnership with UNAIDS, with UNITADE, with Global Fund and other donors to really think about what targets we're setting, what precedent we're setting and to collaborate and coordinate in the procurement and implementation of supply of countries and how they end up in countries. So the COP guidance sets the policy, the strategy and the technical direction. This signals what will be purchased and what will be operationalized. This requires we align country level policies with COP guidance, implementing partner, standard operating procedures, laboratory networks have to be in place and people, crucially people are trained in or retrained on new policies, procedures, changes in data entry, diagnostics, interpretation of diagnostic tests, supply chain forecasting, distribution and transportation pathways for medications and laboratory tests. And of course that everyone from the physicians to the laboratory staff, to the community health workers are informed, trained and retained. And they are also trusted. And I think it's something that you were talking about a little bit more. All of this has to be done to make sure that wherever a patient shows up in the country they ultimately have access to same services and treatments. We go back to the patient group presented with cough and fever. The first step is that clinical triage. Recognize this as a patient who might have TB. And if they might have TB, then they need HIV testing. Does the clinic have a gene expert or TB lamb? Are there enough tests? Are the tests easy to use and interpret? Is there a clear algorithm for clinicians on what to do next? On this slide you can see some of that of just how we think about that as we're operationalizing. This is specifically for TB preventative treatment. And this is a little bit more detail on some of these and just the planning and monitoring that is involved. And just wanted to give you a glimpse. Don't need to read the details of this, but this is really a sort of the case definitions for the data entry that's required. And that's collected down to the clinic level. And every clinic that's supported by PAPR collects data that's recorded on a quarterly basis back up to headquarters here in Washington, DC through the implementing partners. So here I just wanted to show you a little bit of that data which is the number of patients who are on antiretroviral treatment who have been screened for TB symptoms over time. And that just to from FY 2017 through the end of fiscal year 21, which was September 30th, we've had overall programmatic improvements that among 19 million people were seeing more and more regularly screened for TB symptoms to make sure that even when they're on HIV treatment that they're not relapsing. So in order to do this, I think we have to ask ourselves a lot of questions not just about the supplies and the resources and the systems, it's also about the people or the healthcare workers and the healthcare providers kind and empathetic. Here's their persistent stigma against HIV or sex workers or men who have sex with men and we call key populations. How does this change the care a patient receives and how they perceive their care and their willingness to stay on medications? If they experience stigma, will they simply decide to go home? A community health worker will be assigned to them to follow up and check in and also check in who else is in their household? Do they have a spouse? Do they have children? How can we test them without disclosing their status without their permission? There are systems and structures and services and people who have to be woven together to both keep the individual patient at the center while also keeping in mind the population level goals. So here I just wanted to show you, which was really incredible, Uganda had a 100 day campaign to treat 100,000 people with TB preventative therapy. Just wanted to sort of suspect the importance of leadership in addition to those ambitious goals that has to be there in order to operationalize on those goals. And this shows you, you know, we had hoped to treat all PLHIV with TB preventative therapy by the end of 2020. We reached about half that target at the end of FY21, about over 8 million people who are on HIV, anti-retroviral treatment have completed TB preventative therapy, which is truly incredible. So it's, when it says like, what has made Papar such a success? And it just goes back, it's not just the strategic direction and ambitious goals, but that each year the targets that are set for each country across sub-populations, across geographies and regions. And that, how far also operates within a larger and broader system societies and cultures and partners that sometimes have competing and sometimes complimentary priorities. I'm just gonna walk you through a couple of quick slides to give you a feel of some of the data that we look at, which is, this is about the type of diagnostic tests used across countries. And you'll see that the dark purple color is gene expert and more and more countries of greater proportion of samples are being sent for gene expert, just like the patient in Silicon Valley. I'm just gonna scale up. Please, I won't go into this, the LF-LAM. And then this is just the last data slide. I wanted to highlight that a little bit of the impact of COVID-19 on reaching some of the targets and the reporting of TB that's been impacted because of COVID-19. I wanted to just bring us back to a couple of questions and this takeaway for me with Papar, that is, if you want to go fast, go alone. And if you want to go far, you need to go together. And so some of the questions that I just thought to end the discussion is, ultimately Papar is built on partnership and partnership, not just within US government agencies but with ministries of health and country governments and multilateral banks and global funds and WHO, implementing partners for local and international and civil society. But one of the questions I had is, how do we avoid this sort of, the potential of global health imperialism? How do we balance respect for sovereignty and autonomy if country policies and operational programming are not aligned with Papar cop guidance or policy priorities? For some countries, HIV is not as much of a priority as malaria, nutrition or childhood education or poverty. How do we reconcile these investments? Is partnership truly possible in countries where there's a greater dependency on Papar funding for essential services? There's an essential role of diplomacy and leading science and evidence. And what is the fundamental difference between influence versus coercion? And what lessons can we learn in the United States from health systems in low and middle income countries or from Papar? And we have humility to recognize that we too have lessons to learn from the innovations that are being deployed abroad. So Papar investments have also been foundational for COVID response and are not siloed from other health system improvements. The same health workers who treat HIV also treat malaria, malnutrition and provide vaccines. So as we approach epidemic control in so many countries, when HIV starts to look more like a chronic disease which has its own challenges, how do we adapt our programming and approach to be holistic, integrated and human centered rather than disease centered? How does this change how we allocate and prioritize resources? And then what do we need to do differently to think about sustainability? How do we plan and prepare and ensure that countries are able to be successful when Papar, the president's emergency plan after 19 years may leave the country when they reach epidemic control? The country governments have to be able to afford the humans and the staff and the stuff and the systems and be able to maintain it. And then how do we go upstream to address the structural violence that Dr. Farmer called out so powerfully? How far now has prevention programs that include treatment for TB, but also pre-exposure coflexus, cervical cancer, a program that supports orphans and vulnerable children and their families, a program that focuses on HIV prevention among adolescent and young adolescent, young girls? How do we prioritize allocations for health services and clinical prevention while at the same time investing and addressing the root causes, like poverty and education and community loneliness? So I obviously don't have the answers to all these questions, but I highlighted some of the challenges and some of the opportunities and some of the ways we can go from setting a vision for the kind of world we want to live in, keeping in mind the inherent dignity and a sense of possibility for a full, thriving and healthy life for all, wherever they live. So we are capable of doing an incredible amount and we need the ambition, the targets and to work together to build the foundation to them. So many thanks, Teep, for sharing your thoughts and reflections and your expertise as a clinician and to someone who's actually operationalized these programs. We're going to transition. There's so many dimensions here. I wish I had a 3D diagram as we think about the relationships between obviously Jim, the cornerstones of what you set up, Teep, your operational expertise and then translating that into the day-to-day supply chains of these countries. If we don't have product reliability, it's very difficult, those of us who are clinicians to actually then diagnose, treat, prevent these diseases that we mentioned. And I am eager to kind of share and introduce my very close colleague, Dr. Prashant Yadav who has been over 15 years of the person that I call when I don't understand the mechanisms or the flows of how products are entering the country, the information that's needed to procure, allocate and verify product delivery and the flow of financing that's needed to invest in robust and resilient supply chains. Prashant is a senior fellow at the Center for Global Development and an affiliate professor of technology and operations management at NCOD. And his work has focused on improving healthcare supply chains and designing those with social benefits. And over the last 15 years, Prashant's worked with almost every country, government and global organization to improve their supply chains. He has served as a strategy leader for supply chain at the Bill and Melinda Gates Foundation. He's been chair of Market Dynamics Advisor Group of the Global Fund. He also served as the co-chair of procurement and supply chain management for the Royal Back Malaria Partnership and commissioner of Atlanta Commission on Essential Medicines. Prashant's been invited for expert testimony on issues related to supply chains in the United States Congress, legislative bodies and he is an active teacher in our courses across the medical school and the school of public health. Prashant, thank you so much for joining us. Thank you, Rebecca for that kind introduction. And when I heard Jim describe the work with HIV and MBRTB, I feel I'm an infant in the world of global health delivery, procurement, medicine access. But what is encouraging, I remain in gratitude to Jim for having supported me both personally in my career and lots of other encouraging activities that have helped me. But I think one thing that stood out or two things that stood out from Jim's comments. One is that we have made significant progress on some aspects from the times of three by five or the green light committee. But structurally, we have not made progress on a number of things. And what I wanna do in a set of short remarks is say, where for new health technologies, whether it is new vaccines for COVID or it is oral antivirals for COVID or some other new technologies such as the use of NGS for pathogen genomic sequencing, we are still in a world where we say a health technology when it becomes available and we can see it has immense value for the care provider and the patient. We still seem to ask the question that is the deployment infrastructure in developing countries ready to deploy this health technology? And I have gone back and forth in terms of is that even the right question to keep asking or is it incumbent on all of us to say if there is a health technology which can benefit the patient is useful and important for the provider and the health system, then it is for us to build that deployment infrastructure and not say that this deployment infrastructure doesn't exist. And that's where some of the divergence and debate continues. For example, at the start of the COVID pandemic, we had, we here is the collective of global organizations who were working hard to provide vaccine access to countries around the world. A big question was what portfolio of vaccines should we put in place contract, advanced contract purchase for resource limited settings or for what we use, what we're still calling as the 92 advanced market commitment countries from Gavi or Covax. So in making those portfolio decisions, we still go back and say, well, this new nucleic acid vaccine technology, we don't think it's ready to be deployed in many of the countries in the world. And I think it's a flawed decision for two reasons. One is many of the things that Jim highlighted, I think they're still true. We can make that infrastructure happen if we make a concerted set of efforts. The second is that information about the use of a health technology reveals over time. So we know that for most stability studies or stability studies more generally, they come out after technology has been out for some time and they give us an opportunity to use that technology in more settings than where we originally assumed it could be usable. So let's not be in the business of making technology choice decisions for low income or lower middle income countries based on some architecture which we set up in Geneva, Washington DC, Seattle, London, wherever in the world such decisions have been historically made and continue to be made. Those decisions should rest with the managers of health systems and it's our job to provide them both the tools to make those decisions and a choice architecture which allows them to truly make a choice from the technologies that are available. I think that part remains to be an important deficiency in the current architecture for supplying development assistance for health. That deficiency has still not yet been resolved and requires considered action by a group of people to get that right. Then I think Jim mentioned the access to medicines index and I've been there executive committee since the very start. And I think one interesting thing that has come out of that work is the amount of attention that companies are now starting to give to resource limited settings and not writing them off as this is not an area where we can supply an expert machine or this is not an area where we can supply an NGS machine. That has changed dramatically and using instruments that are in a way respecting what a company has to, the constraints within which a company has to work such as private investors, private capital market, short planning horizons. Can we insert things within those systems and structures which can incentivize companies to think about a deployment strategy, a product handoff strategy that is not just limited to saying, if I'm a global life sciences company my job finishes when I hand over the products to a global super national agency and thereafter it is for them to get the product out to the patients but a company starts more actively getting involved in being partners in developing the infrastructure that is required to get the technology to the patients and I think that will also bring a lot more private capital to solve infrastructure problems that we face in particular in supply chains in Africa and in regions where infrastructure supply chain remains weak. Then I think it's the question of tiered pricing and voluntary licenses and generic manufacturing, right? I mean, we know that tiered pricing, the ability to tier prices to meet the ability to pay off a given country or a given population subgroup is a tool that we learned from HIV AIDS and we have also learned that it is actually a very useful tool, companies can use it. How exactly to determine the tiers who all should be at the table when you think about the tiers and tiered pricing? Is it a decision that a company makes unilaterally for countries? Is it a decision that occurs in active collaboration with super national and national entities? Those are still pending questions which we haven't found clear answers to. I think we've seen with oral antivirals the number of voluntary licenses that pharmaceutical companies have provided but the voluntary licenses in itself is not sufficient to improve access. There is still a regulatory pathway. There is still a deployment of supply chain pathway which all need to be worked in before they will become widely available. A personal story I cite is my parents who live in New Delhi, India. My father has had cardiovascular disease for many years. I'm just a portfolio patient. Earlier this year he had COVID and the ID physician who was treating him was asking me, so what do people in your professional network recommend? And I would very quickly jump to the idea that yes, we have this new oral antiviral called Paxilivin. Remarkably efficacious, say, why don't you put him on that? And his response was, well, but we don't have that yet in India. It's not registered, it's not available. So should you really care about putting him on Paxilivin, you should fly with Paxilivin as suitcase, right? So this reminds me of a conversation or the few instances in which I was able to sit and chat about my work with Dr. Paul Farmer. He would say all of the work that you're describing in improving supply chains and market shaping through the global fund and all of the agencies, it's all good, but don't lose sight of the fact that in the end the supply chain is about getting a health technology or a product to a patient and a provider. And at that level, it should be agnostic where, which channel and through what global structure and architecture the product came from, start your work there instead of starting your work at the level of the global and supranational entities. And I think that has stayed with me and I've gone back and reflected and rethought some of the ways I do my work on supply chains. But the reason I'm bringing that up is in the pandemic, we had a question of new manufacturing sites for vaccines. And again, vaccines are not like oral antivirals, they're not small molecules, they're not as easy to make as the HIV drugs were, the complex biologics and not just the infrastructure but the people, the clinical staff, the analytical chemists and the CMC staff needed to make complex vaccines is much harder. Nevertheless, we have to create a system where they can be manufactured in regions which currently do not manufacture vaccines. And this is not about intellectual property. This is a question about resilience and equity. And in thinking about resilience and equity, I think we, I bring up this question of, as a society, if we think having new sites that can manufacture health technologies and it could be vaccines, it could be new lateral flow tests, it could be oral antivirals, if there are new sites in Africa which can be set up to manufacture the new health technologies that we would need. Are we as society going to benefit from the resilience that it provides to our supply chain? We are then saved from many potential disruption risks. And if we think that society benefits from this resilience, then society should be willing to pay a premium for this resilience, similar to the premium that we pay oftentimes for innovation. When we are thinking about what is the right price to pay for a medicine to an innovative company versus a generic company, we say, well, we should pay a slight premium for innovation because some of this money is going to go into further research or further development work which will lead to new innovative health technologies coming out. So is there an equivalent or a counterpart of this which could be a resilience premium? And would we all be willing to pay that because the new manufacturing sites will not be able to compete with the Uber efficient sites that exist for making such technologies in India and China at the moment? Let's be very candid and honest about that. A site in Western India that makes one billion or one and a half billion doses of a certain vaccine, the efficiency they have is not what we can replicate at new sites in Africa. So we have to be ready to pay a resilience premium. And then it comes to whether paying a resilience premium is best value for money from ethics and equity. I certainly agree and would say, yes, it is. The moment you start adding lenses of economic value for money or cost effectiveness, then the answers become slightly fuzzy. So I think that's where we need to build a more compelling case so that overall we don't remain stuck in this cycle that, oh, because we don't have the supply chains and the deployment infrastructure for the latest health technology, therefore we cannot deploy them at the moment in developing countries. So let's wait and first build the deployment of architecture and infrastructure and that'll take us a decade and then we'll go back to thinking about access. That's not the scenarios we wanna continue working with. If you wanna change that, then I think we need a serious rethink of how we do this and who makes those decisions. And the examples that keep coming back to us such as test and treat for oral antivirals, right? I mean, the fact that one of the oral antivirals has somewhat complex drug drug interactions that even when we think about the channels and sites through which we will administer Pax Lovett or other antivirals, even in the US we think this is complicated. But then when we talk about doing the same people often ask the question, well, if this will be available at the health posts or the lowest level health facility in a low income country or at a little pharmacy in India who is gonna think about the drug drug interactions? We will not be able to deploy this product for its intended use, right? So that's once again an area where we've got to come together and think about the tools about the tools that come with digital technology today that can be very rapidly deployed which can bring the divergence that exists between clinical providers in a rural part of a low income country and clinical providers at Harvard Medical School. We can bring that together through the use of some digital tools. Again, there is a lot of work that has happened through PEPFAR on this. There is a lot of work that has happened in the deployment of technology such as GeneXpert which has given us the chance to use them for alternative use cases. But also I think sometimes we forget when we are thinking about a new health technology that what we are intending to use today for may not just be the only use. The future use may surprise us. GeneXpert is a perfect example. But if you were to think about GeneXpert only from the standpoint of MDR-TB or drug susceptibility testing for TB, some people would conclude it's not a cost-effective technology to deploy in medium burden countries. But then when you think about what else could have happened and what else has happened with that platform today, that is remarkable and that's not what is typically captured in that cost-effectiveness. So I think I'll pause here but I wanna end by saying one thing which I wanna repeat and emphasize again, deployment and supply chain infrastructure should not come in the way of us saying this health technology is not usable in some settings of the world because the infrastructure there doesn't allow us to deploy it. Thank you. Prashant, thank you so much for your clear and consistent voice in this realm. And we think about the expectation setting. Jim, I'm about to pose a question to you. Oh, great, I'm hoping you can join us back. So we think about the complexity of reliability, trust, resilience, and the breakdown of trust in the midst of the pandemic, the communication lags. What is needed now to rebuild institutional trust? We need these institutions, the World Health Organization, the World Bank, the CDC to operationalize at a different speed for the next pandemic. What is your guidance to the next generation of leaders? Well, Rebecca, I have no guidance in the sense that it was really painful watching this happen right in front of me. Early on, it was really just lack of aspiration. I mean, we were seeing state health authorities saying, we can't do contact tracing, we can't, some of it was very real based on the lack of availability of testing, but there were states that had zero cases that came out and said, we can't possibly engage in the traditional of public health response. And there were also voices in academia that were saying things like, this is moving too fast, we can't possibly mount a public health response, we just have to wait until herd immunity kicks in. And these voices from academia had a huge impact on places like the UK early on Sweden. And I think that we're seeing the full complexity of it because in China, where they had a very aggressive public health response, they're now struggling with how to unwind from that particular response and to open up their economy more and do it in a way that makes sense. So there's nothing easy about it, but I think on the one hand, I think there were just really, I would agree that the public health system in the United States wasn't set up to have the kind of response that was needed. But just again, it was crazy how quickly the public health authorities gave up. And so what I was hoping is that after $7 trillion of basically fiscal stimulus, that we would have a really good conversation about, okay, so now what do we need to invest to make sure that we're prepared to respond next time? And what we're seeing is just once again, one of the things that I kept saying when I was at the World Bank was just, we've got to stop these cycles of panic, neglect, panic, neglect, panic, neglect. And even while the pandemic is still going on, we've moved into neglect at a leadership level. So for people who are looking at getting involved in these things at a level of a major organization, the UN, PEPFAR, I have to just stress again and it seems reductionistic, but it's really not. Leadership is just so critical. And what did we learn from PEPFAR? It's, I would argue that after smallpox eradication, PEPFAR and the HIV treatment response is one of the most incredible success stories that we have in global public health. And I can guarantee you that the key, the key to all of it was President Bush. The fact that President Bush, if you were gonna tell Mark Dible or Tony Fauci that they couldn't do something, you knew that they could go directly to President Bush and then it would happen. So I just, I think you need strong leadership, frankly from the Oval Office. When I was at the bank, we tried, when we had President Obama, Angela Merkel, and people like Justin Trudeau and Macron, there was a really nice group of people and we were thinking about, oh, now what do we do? We really, they were critical in getting the climate change agreement over the line. And if that group had been in power during COVID and the pandemic, one, they had a really good relationship with each other. They would have been on the phone, they would have tried to figure it out. The absence of the U.S. from any leadership role in responding to the pandemic was just disastrous. I mean, it was the worst possible thing that could happen because what we've seen is that without strong U.S. leadership, and I don't wanna be too U.S. centric, but I'm just telling you that if my experience over the years and being in every G7 and G20 leaders meeting for seven years, that if there's strong leadership from the U.S., amazing things can happen. And the other part of it is if there's just complete abdication of leadership role from the part of the U.S., that's disastrous. And then there's all this range in between of what you can get. There's no sort of simple thing that I can say for us to do, but just, you've gotta pay attention to who we elect in leadership roles in not only of countries, but in these institutions. And if there is strong leadership from the White House, from the Oval Office, I think we could make this move even now at this stage of the pandemic. And I know a lot of people are saying that because PEPFAR has been so successful, could PEPFAR be a launching point to tackle all of the complex issues, everything from managing intellectual property to supply chain to the relationships that PEPFAR has built all around the world. I think that's a great idea. So if you have the right leaders in the right positions, fantastic things can happen, but a lack of it just, you know, makes it impossible. Thank you, Jim. Teeba, I'd love to pose almost the same, really the same question to you being, sitting both with your HHS head on, your experience with PEPFAR and this relationship between reliability of the product and then trust in the institution. How would you answer? It's such a great question. Huge question. And I think it is a question that we all need to be asking ourselves, this question about trust and what's happened. And I think the evolution of the COVID-19 pandemic of the misinformation, the politicization of science, it's actually, I had right before the pandemic started, I had just finished reading and the band played on about the very beginning of the HIV epidemic. And there are so many parallels the sort of disbelief, the stigmatization of certain demographic groups, the lack of prioritization because it was affecting certain people and not others. So there are so many parallels there, but the bigger question, and I think, yes, we need, and there's an excellent study by Tom Bulicki in the Lancet, and it was published, I think a couple of months ago that you're probably all familiar with around this question of trust and how trust interpersonal trust and trust in institutions across different countries was correlated with COVID-19 mortality. There's probably a lot of confounding factors in that related to like the homogeneity of populations and whatnot, but it's very compelling and it brings us back to this question. So I mean, I think I agree with Jim that, the leadership at the top matters at the same time, it's this fire hose versus drought mentality that we take for public health investments. It's either we throw all the dollars, that the system actually really has, finds it very difficult to absorb when you throw all the dollars in at the same time because you haven't created a system, you haven't created the foundation, you don't have the people and that takes time and that takes building trust and capacity at a local level. And I think that's what PEPFAR does. It is the leadership at the top, but it sees it through all the way across down to the community and guess that buying and that investment and I think when we think about that, both with PEPFAR and the United States, it's that lack of investment at the community level with faith groups, with like, who are those trusted messengers that people can turn to? I think that's become eroded in our society and that's very challenging. And it varies across countries. I heard, I think Raj, Punjabi or I told Guwande mentioned on a call a few weeks ago that they were hearing about these programs in Uganda where they were actually, they were not having the same problem with misinformation as we did in the United States. They had a different foundation across that they had invested in it. They had invested in those community groups. So I made the last thought, which again, I don't think I've like fully answered your question, but my last thought is, I think in order to get that leadership buy-in, I think we also need to deepen our understanding of what public health is because even now, even after this historic pandemic, I think there's a profound misunderstanding of the role of public health in our lives as a government and as institutions. And so I think articulating that and helping funders at the political level, truly understand that and the interrelatedness of public health problems that they're not siloed is really critical. We'll stop there. But Rebecca, can I jump in just to follow up on some of the things that you said? You know, one of the ways that I think we develop trust in Massachusetts and you may know that we started a major contact tracing program in Massachusetts is that we recruited people from all of the different communities. We had people who spoke all of the different languages and what we found this in every place that we've worked is that not everyone is gonna trust a physician or a public health specialist, but they usually will trust their neighbors. And so the contact tracing program, I think led to a lot of great information about how the virus was moving in Massachusetts. But the other thing is, I think it really reduced the distance that people in the community had to the system itself because the contact tracers did everything from getting people access to tests to actually doing the contact tracing. But also what we found is that some of the families that had to be isolated and quarantined, they weren't able to buy diapers. And so we had a system that we had implemented in every partners in health project where we had people specifically making sure that they had the food and the very basic stuff as it were that they needed in order to be able to go through isolation or quarantine. So I think one of the ways that we can build trust is to do what we did. And now I think people are talking about perhaps even in Paul's name, having a kind of national accompaniment program. Now, at the World Bank Group, we have studied this so extensively and we call them either conditional or unconditional cash transfer programs. And the reason they were studied so extensively at the bank is because ideologically, the old timers at the bank were completely against it. Now you'd think giving poor people money is a pretty rational thing to do but it wasn't and the argument was no, no, no, you can't do that, you can't do that well. So like 50 studies later, the bank concluded that not only a conditional cash program, transfer programs really helpful for the poor in ending their poverty, but it led to better public outcomes or led to better educational outcomes and it provided local fiscal stimulus because these people spent the money and other people did better. Andrew Yang, his whole universal basic income came actually from his reading of the bank papers, right? And so one of the ways to think about improving in the spirit of fall is accompaniment, that by putting money directly into a community, you give them jobs, you stimulate the local economy, you have improved public health outcomes and you're not relying on communities to trust big institutions, you're asking them to trust their neighbors. Thank you, Jim Prashant. I was gonna add something to what Jim said. So one is, I think if we look at development assistance for health and compare it to the amount of money that goes as remittances and then we take the proportion of the remittances that are used by the beneficiary of the remittance that goes into health needs, that number is quite significant. I think according to some estimates, it's bigger than all of our spending on development assistance for health. And that is a somewhat social network driven cash transfer. It's not conditional. And there is immense amount of trust in between the party who's sending that money. So when we think about supplying international aid effectively as the title of this seminar, I think the sender of the remittance and the receiver of this remittance have a very strongly established trust. We don't build on to that and say, what can be done so that the health networks that the recipient uses are well structured, provide the kind of healthcare that we all are seeking. Also, some of that money goes into things which are for infectious diseases, some is going to chronic diseases and so on. So I think that's one part which is remittances and health and that intersection that when diagram remains an unexplored area, we ought to do more there. The second is there are a lot of young innovators who have come up in the field of healthcare delivery. They are funded by private capital, they are funded by venture capital, they are funded by philanthropic grants. And these are people who are closest to the community, they are solving real problems using technology and new business models. And in doing so, they have the trust of the community because they start small, they start from the bottom up, they don't have an established structure in the big capitals of the world. And we still haven't figured out how does PEPFAR work with young, small innovators? How does the global fund work with small innovators who are relatively small nascent companies but are doing exceptionally well in terms of the service they provide, in terms of the patient care they give or the medicines they provide and so on. So that's the second part. And a third is trust in global institutions is weaker, but trust in regional institutions has grown. And I think thanks to the work of the World Bank and Jim's leadership, the Africa CDC is one exemplar now where we see there is a much greater amount of trust in things that come out of Africa CDC, whether it is about the use of non-pharmaceutical interventions of what types or it is about what kind of health technologies will be procured for member states of the African community. So I think when we think about trust, we also have to ask the question that the role of regional institutions in creating greater trust in the international aid supply delivery system has been underappreciated in the past, has been under invested in the past with the exception of Africa CDC and the World Bank's investments in it. And that is something we ought to take much more seriously in our next phase. Thank you. Thank you all. I cannot believe we're almost at the end of the hour and there's so many threads here that I'm not gonna be able to weave together in 60 seconds. But I'm gonna try just a few quick takeaways and we'll also send the audience there's a whole few papers that I've gotten mentioned that I'm pleased to send as a follow-up. First, I just wanted to remind ourselves kind of the start of this hour and Aaron, I'm sure you'll tie us back to the first talk in the series that the power of these global programs that we're talking about change the trajectories of lives. They alter the power dynamics between families, as Tee mentioned, the social networks, as Prashant reminded us, and the economy of a continent of Africa, as Jim reported. And without a durable system in place, we are in this panic-neglect cycle which leads to further inequities. The second is that we've seen this powerful signal that we actually can send to the market to summon generic drug manufacturers to ensure supplies are there. We can measure the right things and the three by five initiative is one of those beacons of time where we needed a metric both of volume and speed. And our interdependency is clear. Our supply chains are fragmented and then when we strengthen these systems, we actually mitigate the disruptions not only for healthcare but for all other products and services within the market. So the answers today have been incomplete but I think it's the questions, Erin that we hope will kind of bring in, bring forth to the community that has joined us today. When we think of the lack of aspiration and how we have eroded trust, how we promote, in a sense, greater expectation, greater equity and a more adaptable health system for all. Jim and Prashant Nadeep, thank you so much for joining us. I'm gonna pass the time to Erin. No, thank you all. I was gonna say the same thing. Thank you so much for a really great discussion. Thanks, Rebecca, for organizing this so well and for Jim and Thieve and Prashant for your great comments today. And yeah, I do think it is very special to be able to end the session this year with this given where we started as well with Paul and talking about some of these issues in the first of these sessions. And learning from experts like yourselves and hearing what went on and hearing the sort of like lessons that you draw from those experiences and how you're applying those kinds of lessons to current issues is, I think, something that is inspirational for all of us to try to take out there. So once again, thank you so much. Thanks to everybody for joining us this year. We will start this series back up again in September. So check out your inboxes and I hope everybody has a great afternoon.