 of thought. Let's try and do this as a conversation around big questions and big ideas. And let's try to bring in some of Larry's closest friends and allies over the years who could help in this celebration in a kind of deliberate, interactive, brisk discussion. And so Larry agreed to that and has enlisted Tony Fauci who you all know as the leader since 84 of NIAID and another, you know, a really huge presence in our lives in all matters pertaining to global health. And we'll be joined in a few minutes Tim Evans from the World Bank as the third party to this. So the way we're going to go about doing our business here this afternoon, we're going to run up to 430, no later than 430, we may even sort of trail off, we'll see how things go. We're going to open up with Larry saying a few words about this work. It's the culmination of many years of effort. It's not just the only large, comprehensive, definitive, encyclopedic, analytic work. He's actually done this in a bunch of other areas over the course of his career. I wanted to have him just offer a few quick reflections from his chair around the genesis, the experience of building the book and what it taught him, what came out of it. And then we'll morph from there into our discussion. And our discussion is going to be structured around two big questions that are very future-oriented, each of them very much trying to get us thinking about the future. And the first one is going to be what is the single biggest challenge or problem that we need to keep our focus upon looking ahead over the next five to ten years? What will that be and why? And we've got an international law expert. We have Tony as a person coming at this from the perspective of someone involved deeply in the science, research, development of technologies. Tim Evans, someone whose life is really centered in the science of delivery and implementing programs and organizing large international organizations to be effective in that. So we'll begin with that first question and then we'll morph from there into what do we believe the biggest idea will be over this same period that will spur innovation and change the calculus in this world. So welcome. Thank you all for being with us. You have the biographies, the short bios. On our speakers, I'm not going to go into great detail. And Larry, Tony, and Tim are all familiar to all of you as close friends and folks that we call upon constantly in debating any dimension of global health. So Larry, congratulations. Thank you, Steve. It's a great occasion and floor is yours. Tell us a bit about the board. It is a great occasion and I just wanted to start, Steve, by thanking you and CSIS for doing this. There's no place like this in Washington in America and you've built something incredible. And Tony is also a long, long time friend. So I feel like I'm surrounded by friends, but more than that I'm surrounded by two of my heroes that have worked so hard in global health. I mean, there is no book on global health law and global health governance and we tend to think of law as just an esoteric field. But in fact, the legal instruments, the governance of global health is really critical. Think about the Framework Convention on Tobacco Control or just think about Ebola. The WHO declared a public health emergency of international concern that was under formal law under the international health regulations and it invoked various powers and the like. But what really drew me to this book was the idea of two global health narratives are operating out there. One is what you hear from the really great thinkers in global health in the Gates Foundation and USAID, the WHO. And that's a story of remarkable progress in global health where we are now with some incredible achievements through the Millennium Development Goals soon to be the Sustainable Development Goals. And that's a true narrative. There's no question about it. If you look at age, child maternal health, malaria, tuberculosis, we've done very, very well. But I also have done civil society, social mobilization work around a Framework Convention for Global Health. So I've talked to people on the ground and their experience is completely different. It's a different narrative. And theirs is a narrative of deep impoverishment. It's a narrative that you can see in West Africa today, quite frankly, of, as Steve was saying, food insecurity, human rights violations, Ebola. And either even for a whole variety of other treat, other conditions, people are afraid to go to the hospital. And so we really are facing a crisis there. And that's what I hear. And it turns out that both global health narratives are right. You have improvements in global health, but those improvements aren't equitable across the board. And equity and justice is a really major theme in this book. And so basically I ask three basic questions, and then I'll move on. The first question is, you know, what would a perfect state of global health look like? That is, if we could imagine something what we would aspire to, what would it be? And for that, I really try to place a premium on public health, population based health services, disease prevention, and control as being really important. Things like that we don't think of as global health, but it is. Nutritious food, clean air, sanitation, hygiene, vector control. All of those things make life much more livable. And then the second question is, what would global health with justice look like? And the third is, how we would get there. Now if you do manage to pick up my book from outside, I think that the best part of it is, and the best advice I got from Harvard, they said, don't get somebody like Bloomberg or Bill Gates to write you forward. Nobody cares what they think. Think of something else. And so I did. And what we have in the beginning are global health narratives, their stories from children around the world in their own words. It's really powerful if I had time, I would read you one. But I think it's really important for us to really capture that idea of what it's like to live in a poor country filled with injury and disease. So thank you very much, Steve. And without further ado, we can get on to the important part. Great. Thank you. Thank you so much. I didn't mention at the outset that we're going to, in the course of the discussion, we're going to open things up and hear from you. So please think about your comments and questions as we move through this dialogue. And we'll get to you quickly, and I promise. Larry, do you want to begin by offering a few minutes of thoughts about the most important problem that you see, the most important challenge? Hi, Tim. Come on up. Hi, Steven. Hi, Tim. How are you? We're just getting rolling here. Tim Evans from the World Bank. Welcome. Thank you. Cheers. Great to see you. So, Larry, why don't you kick things off for the few minutes around? What is the biggest challenge that we face looking ahead over the next five to ten years? I think the biggest challenge really is equity and justice. I'm in this kind of tobacco guru listserv, just very, very small, and they argue with one another the great tobacco zealots in the world. And I don't know how I got part of it, but I was. And they talk about end games in tobacco. End games are very popular. You can see with AIDS, getting to zero, you can get it with all of these other areas. And so I decided to not be diffident, so I asked them an ethical question. I said, suppose you could get to the end game in tobacco, which means that you have a prevalence rate of five percent or less. But you still have the mentally ill, the poor, the working class with relatively high rates. Would that be ethically acceptable to you? Every single zealot said yes. It was acceptable because the main goal was health improvement. But I think that our biggest goal is health improvement with justice. Trying to look and make the world a place where it doesn't matter if you were born in Kampala or New York. It doesn't matter if you're a male or a female or a child or an adult if you're sick or if you're healthy, disabled or not. What matters is that you have equal opportunity to live in the conditions which are healthy. If I may, just one thing that really struck me. I came back while I was doing the last chapter of the book from a very typical Sub-Saharan African city. And I came back and I realized that I really wasn't feeling well. I didn't have malaria or anything like that. But I just, my throat was bad from all the fumes. My tummy was a little bit bad. I just didn't feel good. And I realized when I came back from any of these lower income countries, I didn't quite feel right. But I thought I'm in Oslo, feeling great. Berkeley, nice. And that told me something that where you live makes a lot of difference. And it wasn't the doctors I could see. It was the environment in which I live and which people live every day of their lives. Thank you. Tony. Okay. Thank you, Steve. So what I picked out is the single biggest challenge or problem for the next five or 10 years is one that is certainly not new or creative, but it is very, very real. And it really has to do a bit with what I am as an infectious disease person and dealing with the problem, as I'll state it, is the disparities in health in the developing versus the developed world, which relates very much to the justice that Larry was talking about. But I'm particularly involved in this right now with what I've been doing over the last couple of months in the arena of Ebola. And let me just take my two and a half minutes that I have left to go over that with you because I always talk about disparities in health. You talk about malaria, you talk about malnutrition, lack of clean water, all of the things that are related to countries that are not resource rich or put a different way that are limited in their resources related to health. And I've been doing this for a very long time, but the thing that has impressed me like nothing else is what I've experienced over the last couple of months with Ebola. Some of you may have heard me in the media say that, of course, I always get asked the question, should we be worried about Ebola here? And the answer is, well, somebody's going to get on a plane from West Africa, wind up in Washington or New York or Paris or London. They're going to be well on the plane or not. Get here, get sick, go into an emergency room, get sick, maybe die and infect a nurse or a doctor and then everybody will realize it's Ebola. There will be isolation, the proper kinds of precautions and then the outbreak would end there. In West Africa, we're dealing with a situation where we're seeing an exponential increase in cases, 3,000 plus now with 1,500 deaths and the projections of it going to 10,000 of cases is not hyperbole because the curb is now exponential. And the reason that that's happening is because of the disparity in health care capability. That is the only reason that's happening because you can't have infection control. There's no infrastructure for isolation. There's no infrastructure for quarantine done properly. And there's no real infrastructure for the contact tracing. So if there were those first two or three cases that were in the United States, it would be very frightening to everyone. It would be all over the newspapers, but it would stop just the way the 23-24 outbreaks prior to the current one stop. So as I was getting prepared to give my three minutes of what I think the greatest challenge is and we'll get to how we can address that challenge, is just that there would not be Ebola epidemic that might devastate countries if there weren't absolutely stunning disparities of health in the West African countries compared to our country. So I'll stop there. Steven, we'll take it on later. Thank you. Tim. So great. This is going to be a bit of a repetitive theme here. There may be some selection bias that's at work. Let me first apologize for being late. It was something called Ebola that is consuming many of us who are either directly or indirectly involved in the response. And I don't think today there's a greater challenge because I think it is symbolic and indicative of those vast disparities that continue and which not only threaten the countries and their economies and their stability and security, but has certainly made it clear that the West African context is increasingly shaky with respect to containment of Ebola and the rest of the continent and therefore the rest of the world with respect to feeling some sense of what's involved. But I wanted to first begin by saying congratulations to Larry. I don't know Larry as well as many of you do, but from a distance I've always felt he's been just a massive leader in really practicing what he writes about so eloquently. And that's really bringing the discipline of law to global health and I feel that this book, which I haven't read yet, but I'll give it a glowing endorsement based on your reputation. But congratulations. I'm delighted to be here. I was going to say having wasted two of my three minutes now or at least spent them on more important things, add my two cents on this. And to me the biggest challenge is inequality or inequity and it's essentially both between countries and within countries. The fact that you have major, major gaps in life expectancy and health achievement in this country with all the means that it has to me is an assault on a fundamental sense of justice. But I think it is also one that civilization needs to move increasingly to valuing all lives equally no matter where they're based. And I think that ethical principle really needs to be much more fundamentally ingrained in everything we do. The challenge of that I think is multifactorial and I think we'll have more time to chat about what are the points of entry to begin to really allow that principle to manifest itself in a meaningful way. I would say, however, that relative to where we were 20 years ago, there has been a massive mobilization in something called global health or around global health which has multiple manifestations which I think embodies to a significant extent this sense of impatience and intolerance of global inequities and health. And I am personally very encouraged that we're moving. But when we look at the Ebola crisis today it's clear that we could move an awful lot faster and I think we have to look at how it is we can do that. Thank you. When Ebola first came to our attention earlier in the spring and the initial response was that this didn't look that different from other things and then as we moved into April, May, June and perceptions began to change, there was a certain confidence in the ability at that time to still use the tools we have to address this and there was a recognition that the inequities, the infrastructural gaps were feeding this along with distrust, mobility, speed of transmission that was happening. But inequity was recognized as a fundamental part of this and a huge gap globally in West Africa. But I don't sense that people made the leap from that to say that the inequities of that kind were more than a normative consideration, that they were more than something to lament as a reality of life and work normatively to fix versus saying they are something that is both normative and ethical in what we face. But it's also something that strikes at national interests and security considerations in a way that would motivate people to see inequities as something that require much more aggressive action. And today when you look at what's happened in this exponential leap over the last six weeks, one of the stunning things to me is that it's not registered as a security issue, it's not been brought to the UN Security Council. It's competing against some pretty formidable other geopolitical crises of which there are no fewer than three major ones at work today, so the field is very crowded. But when you all raised these issues of inequities and all referenced the Ebola crisis in West Africa as a very poignant and really excruciating example to witness in our lifetimes against a backdrop of dramatic gains that have been made in the last years, how do you make the case? How do you make the security case? How do you make the national interest case now that these inequities are ones that have to be addressed? Because I think we're still struggling today as this crisis unfolds. We're still struggling to figure out how to make that argument at the higher levels of government. Not just ours, but many other governments. Larry? Well, I think you're very insightful, Steve. You raise a lot of important questions. Undoubtedly this is a geostrategic security issue. You have a whole region that is destabilized. Ebola is first and foremost a health crisis, but it's also travel's been cut off, food security, employment, the economy, productivity. All of that is down, it's focused on a whole region of the world. There's been international spread. The WHO has already invoked the international health regulations as a public health emergency, and yet WHO, as you say, has just been basically left to itself with the US government and others, but not at that higher UN level that I think that we need. So I think it is clearly a security issue, but I really worry about it. I think my worst fear is that this could be another Haiti, where it mobilizes a huge, it hasn't yet, but hopefully it will, a huge humanitarian response. But then when the humanitarian response gets up and leaves, the same conditions on the ground exist. You still have the fragile health systems. You still have enormous deficits in doctors, nurses, midwives. Already there, places like Sierra Leone and Gnay, Liberia, have something like one-twentieth of what they would need in terms of health workforce, and yet they've lost a lot of doctors and nurses to Ebola. So what's going to happen when we do contain it? We will eventually. And then we move on to the next thing. I mean, looking at Tim, I mean, this is a development issue, as well as a security issue, and it is an infectious disease issue turning. So that is my biggest fear. Well, getting back to the point that you make about security, this, you said, when is it going to be recognized as a security issue? Soon. And it's going to be recognized soon because if you look at the curves and the projections of mathematical modeling, you know, when you have 3,000 people infected and 1,500 die, that's a humanitarian issue. It's compounded by the fact that people who don't have Ebola don't go to the hospitals because they're afraid. So as many people are dying from bleeding ulcers and automobile accidents and the need for care at birth and they don't have it because they're just not going to the hospital. So that's really compounding it. But it'll become a security issue when you look at the model of go from 3,000 to tens of thousands and then governments start collapsing and things and then all of a sudden it's going to be a security problem. I remember back in the mid to early part of the AIDS epidemic. In fact, it wasn't that early. It was into it when we became very clear that in the developing world, particularly in Sub-Saharan Africa, that there were militaries of different countries of strategic interest that had 30 to 35 percent of their people were infected. And I remember because I went with then Secretary of State Colin Powell to the United Nations special session on AIDS and UNGAS and he for the first time articulated that he considered this a serious security problem. And then all of a sudden everything opened up and people began to consider that. So Steve, I think it's going to happen and it's going to happen reasonably soon if you look at the curves of where it's going exponentially. Tim? Really two sets of points. One is sort of how do you make the case? And I think that on that front, the weakest link in the chain is one that is a threat to us all globally. And in 2005 when WHO passed the revision of the international health regulations, all countries were supposed to become IHR compliant by 2012. And anybody who had ever seen any experience in a low income or even a middle income country after every country signed up to that knew that there wasn't a snowball's chance in a hot place for that to actually happen because the investments weren't being made. And the problem with the threat as the stimulus is when it disappears, when SARS disappeared, when H5N1 disappeared, when H1N1 didn't amount to the crisis that people thought it would, that countries did not make those basic investments in that core infrastructure. And lo and behold, when you have something like this and you have nowhere near the infrastructure that you need, then you don't have that ability, which is not a complex ability to really snuff this out before it becomes essentially endemic. So you need to, the rationale for investment needs to be strong, but it has to go beyond the immediate threat. It has to look at the return on investment from investments in health. And here we've got just tons of evidence. Larry Summers, Commission on Investing in Health came out and showed that this is one of the best investments that can be made with respect to economic growth in the economy. And so ministers of finance, and this is a job for the bank, really need to understand that these sorts of investments are not only ones to help people live and survive, but they're ones which make abundant sense in terms of prosperity and economic growth. Having said that, in addition to mobilizing, as Larry said, hopefully the commensurate level of the response, and I'd like to make it clear that we are about 25 to 30% of the mobilization necessary against the WHO roadmap of 490 million. And we have not heard from the UN senior coordinator, David Nabarro, in terms of what's required above the immediate health response to respond to the crisis. So the price tag will go up. And so there is a long way to go with respect to the immediate response. The challenge is that it needs to happen tomorrow, not in three weeks. And I was listening to the president of MSF at the UN this morning, and she said we need a search force capacity, which is paramilitary in character. And she was saying the biohazard force that many countries have has to be deployed in this epidemic if we're going to see the rate of response necessary to get on top of it. Now this is coming from the institution that has cared for two-thirds of all of the cases to date in West Africa, MSF. So I think their sense of the urgency of that mobilization is critical. But assuming we can do that, and that's a big assumption, and I think I'm making a big point of that because I think all of you in the room, in addition to us on the panel, have a responsibility to try and make sure that that requisite mobilization takes place. But the aftermath is critical. And here we need to begin thinking about the investment not only in the health infrastructure, but particularly in the health infrastructure that is going to make sure that we don't have a repeat of this, not only in West Africa and in the three affected countries, but in others. And that's why we designated half of our $200 million response to building the medium to longer term public health infrastructure that we think would be necessary to equip countries to have a longer term sustainable capacity to respond to these sorts of challenges. Thank you. Someone had mentioned earlier this was a bit of a Katrina moment. When you think about where we are with Ebola, you think about the moment at the end of the 90s when you approached the UN special session on AIDS. When you think about the shock that was felt with Katrina, when you think about perhaps some other things where the methods, the institutions that came to the table initially in good faith and with considerable courage like MSF, International Rescue Committee, others find themselves washed out in a way, washed over, not washed out, but washed over and now making this case for the dire need for the introduction at a much higher level of new capacities that have been absent. In a way it's a considerable reflection on how the global health institutions, WHO itself, is falling short in this period considerably and the way in which our own efforts have, of national, local governments our own, I mean we have 75 or 80 CDC personnel on the ground, probably 35 AID personnel and it's becoming increasingly imperative to simply protect them. I mean it's becoming much more difficult than that. So we are at this watershed moment where the disparities, the ethical considerations, the gaps in institutional capacities are now at the forefront. I hope you're right Tony, that the security reality comes home forcefully and registers at the level of world leadership because that has been missing. Over the course of this summer there was not engagement by world statesmen in this issue of the kind you would have expected when you looked at the implosion across multiple sectors that was unfolding in August, July and August in West Africa. Let's shift to a more positive outlook. What do you think, and let's go back to Larry, what do you think the big idea will be, the most promising idea of the next five to ten years that could guide and drive innovation and raise hope and change the calculus of the way that we go about doing business in global health? Yeah, it's a good question and when you mentioned Katrina and Tony and I were talking about that, if this is a Katrina moment the question is who is FEMA, that is who has dropped the ball on this. And I think there are some really good candidates that we might point to. So what are the big ideas? I mean I'll build off what Tim said about we have international law through the international health regulations, 172 countries signed on to the international health regulations. It requires both countries to build capacity and the international community and WHO to help them build capacity. Nothing's happened or very little has happened and we haven't even begun to meet those standards. Even the WHO's own independent commission on functioning of the international health regulations following the H1N1 pandemic were highly critical and they recommended even then in 2011 a surge capacity. Nobody did anything about it. So what is the answer? I mean I think one of them is the Feinberg report to get that standing surge capacity so that we can go in and up with health workers as Tony said really nip these things in the bud. But the bigger idea I've got a paper coming out on Thursday in the Lancet where I propose a health systems fund based upon the Ebola crisis which would have two components. One have this emergency component, a surge capacity if you will with a standing contingency fund that could be mobilized, an international fund that could be mobilized and should be mobilized. And if that had happened perhaps the WHO would have had an incentive to declare a global health emergency much earlier than they did. It was five months after the first international spread of Ebola, international spread before they called the global health emergency and I think that's just waiting too long, it rattled out of control but if there was a reason to call it early with this surge capacity I think they would have done it. The second thing is the longer term health systems fund. I think that this would be a multi-billion dollar investment so I realize that I'm asking a lot. But it's not really that much. People tell me well you can't do it. Well we did it for AIDS, we've got PEPFAR, we've got the global fund and quite justifiably but now you have so many WHO, many others calling for universal health coverage, health system strengthening, Jim Kim at the bank has come on board with that but we have no mechanism to do it. We don't have international law because nobody, everybody ignores it. We don't have a dedicated fund. We can't leave this to charity. I think the whole global health aid model is corrupt and bankrupt. Aid assumes that you have a wealthy good doer, philanthropist that will at their discretion give money and that you have a needy recipient wanting a handout. That's not global health justice. What global health justice is and what it requires is to have mutual obligations. States themselves, even poor states should give a certain percentage of their national budgets to the health sector as African heads of state promised but never delivered and at the same time it's very clear that in West Africa and many, many other parts of the world the health systems are broken. They don't have the capacity. We need an international fund to do that. I think it's simple, it's doable and it would make a world of difference not just for this crisis but going forward for the future. I think that's our greatest hope. Thank you, Tony. Whenever I talk about ideas I have to apologize to my non-communicable diseases friends because I'm an infectious disease person. I recognize that there are other diseases besides infectious disease. In case any of you think I've lost sight of that I haven't. Having said that as an infectious disease person let me stick with that now that I've given that apologia. One thing that isn't new because it's been established a little while ago within the last year that I think if it were in full effect would have had a major impact because when I'm sitting down thinking and people ask me all the time what could we do to alleviate or perhaps completely neutralize this disparity that I was speaking about. That's a decades long job if you're talking about the issue of economies and how you can build them up and get countries to be self-sufficient. But there is one idea that was implemented in a policy or an agenda that I think some of the people in this room may be aware of that if it were fully operational it may actually have had an impact on the eruption of this outbreak and it's called the global health security agenda. The global health security agenda was established for three fundamental objectives in mind. One was spurred by the recent interest in antimicrobial resistance and how that's a worldwide issue and you can't just tackle it in the United States. The other was the issue of biodefense because of the fact that there could be people with nefarious motives that might unleash a microbe upon us and the other one was the ever present perpetual challenge of emerging and reemerging infectious diseases. The global health security agenda because it was predicated on the concept that global health is intimately joined to security apropos of you're asking me the question when is this going to be taken up as a security issue and it had nine objectives in three major divisions prevent avoidable epidemics, detect threats early and respond readily and effectively and if you look at that I don't want to take your time to go through all of the objectives within those three buckets but if they were even marginally in place we may not be in the situation we are right now with Ebola getting that back to that as our index example. Particularly the area that includes an interconnected global network of emergency operations centers and we how long it took to get an emergency operations center that could essentially handle what's going on in West Africa was something that if you had this in place it would have been hitting the ground running. So that's my three minutes my idea is the global health security agenda implement the agenda. This was launched in February, snowy day in mid February and has gone through several meetings outside the United States to further test. But it was US led. It was US led with 27 other countries and this is a very I think timely point that Tony is making because on September 26th is when the summit will occur here in Washington at a much higher level to try and test the how forthcoming and what level of commitment and you know for the USG one of the problems has been of course finding making the case and then matching that with funding to make it operational. And when you say take that idea and make it operational right now that idea is at 40 or 45 million dollars per year which means it's an idea that's being tested not made operational and perhaps this moment in a positive way this crisis that we face and the fact that this new initiative is struggling to get off the ground with White House backing and the like might be able to bring this to the next stage where real money and real political will is applied to that. Yes Stephen, as a banker let me just build on that in terms of real money. One of the things that we've noticed in being involved in the response since we put some money into the pot is just how difficult it is to mobilize the resources. And you know WHO has made clear some indication they started at 100 million they're now at a half a billion and we know that that's likely to double probably when David Tomorrow gives us his estimates on what's the minimum response needed to get on top of this and preserve you know the livelihoods of those the affected countries and however the sobering and humbling reality is we do not have a good health security fund. We're contingent on a very antiquated sort of no-bless oblige let's hope that we can make a case of severity to those that have money and that they will ante up in a way which is commensurate with the need and timely. And so I think part of the thinking that we've had at the bank is that one of the lessons coming out of this is that for the future we really have to develop some form of health security fund. And the reason that is so important is something that Tony Lake the Executive Director of UNICEF said the other day in discussing with this with the UN Deputy Secretary General he said you know the world has to wake up and realize that viruses can be as deadly or more deadly than bullets and bombs. And what he was pointing to was that the UN as a set of affiliated institutions all with their specialties is virtually impotent when it comes to mounting the critical response to a health crisis unlike a tsunami. In the tsunami that we had in Ache almost a decade ago there were warships looking for survivors off the islands there from all donated you know volunteers were moving in from all over the world right. But in this situation where there's a bug that's lethal nobody's coming. The UN mill put out a call to 53 countries for volunteers. They had one response out of 53 countries. So it gives you a sense of how poorly equipped. So I think the investment side of this such that we can mobilize the requisite resources and deploy them quickly is absolutely essential and I don't think we're anywhere close to this and WHO is chronically underfunded has been for decades and so everybody has an expectation that WHO should be and they are the go to agency to give us advice on what to do and how to respond. But they have no financial mobilization capability as we've seen in this setting. So I think that's the first part of the response. The second is I'd like to push it into building the development agenda because if countries move systematically towards universal health coverage in which they got adequate financing for provision of all of their citizens of access to essential basic care with requisite investments in those key dimensions of global public good dimensions of public health we would have a capacity to respond in countries to this such that we'd be much less dependent on an international response of huge magnitude. So I think that this investment which could be equivalent to Larry your idea of the health systems fund but really focusing on building the strength and integrity of those systems in a developmental sense for the longer term is the best prevention that we can prescribe. Thank you. Let's open things up and invite some comments and questions and so please put your hand up. There's folks with microphones and we'll bundle together a series of comments and questions. There's one here. There's a hand up. Just please put your hands up and we'll get everyone in the first round but we'll get several. Let's start with you right there. Thank you. I'm Laura Hemeke from InterHealth International. This is all music to my ears. Especially I mean I think a lot of us are struggling with not wanting to build on the Ebola outbreak as an opportunity at the same time it really is an opportunity to stop talk about health systems strengthening in a different way. And I love the idea of a fund and thinking about pull together. That's my question is we talked about the financial limitations of WHO. What I'm thinking about what are the limitations in general around global health governance and really what structure WHO has other limitations in addition to not having I think significant funding. How would any of you envision strengthening global health governance so that we're able to both respond to emergencies but also continue the long term investments in health systems strengthening. Thank you. Let's hold on that for a moment. We have a hand over here. Do we have other. Do we have just one microphone we have two. Sahil could you come over here please. Please introduce yourself and yeah I'm Corneliza Morogi. I'm a medical officer. I'm stationed at USIS. I was stationed in Iraq about a year ago and I let me share with you my experience and about some of the shortcomings about when you wanted to do global health and global engagement. So when I get my orders to go my order said you're going to be advisor to the Iraqi Surgeon General. Check. I go on the ground. The commanding general said you know your priority is to take care of our forces. If you have time you deal with the infrastructure building of the Iraqi security forces. So I noticed that we don't have a doctrine to engage other nations. Then a week later I got a phone call from the Ministry of Interior telling me they have 19,000 MPTs from this current conflict another 30,000 from the Iraqi Iranian war. Can you help us. Okay. So I go back to my boss and said they need help. He said this is Ministry of Interior. This is State Department. Not Department of Defense. Well authority to engage is not there. And to make this story then I come back call my Surgeon General here. I tell her this is what we have. We don't have a policy to engage. The bottom line I put it together. Any global health engagement. We need the doctrine to engage. When is the authority to engage. I need with a policy to engage. If we combine all three you will have sustainability. And that's where I see the issue is. All the things that you gentlemen mentioned are very important. But how do we implement that? Like United States now has more than a hundred security assistance agreement with countries. If you channel global health in that context then you have a program where sustainability issues, capacity building, education and transferable of knowledge from this great nation and many other nations to more developed countries. We don't have to wait for a crisis to mobilize all these equitable assets for a place. I think if you there are more more sustainable efforts like like a lot of issues can be solved. That has been my experience actually. Thank you. Thank you. Down in front here sir. So help. My name is Jerome. I'm a global health co-fellow with UNAID's deciliaison office. I also took a class with Larry in University of Melbourne in international health law. I have two or three questions. The first is. Please give us one question. All right one. Well the first is. Is this. No first yeah. Sorry the first and last is. Is this the first time that we're in this sort of situation. I mean this is not the first Ebola outbreak. And also most of these countries have countries neighboring them with which they share similar conditions and GDP that have contained this Ebola virus before. Shouldn't we be perhaps learning from these countries rather than you know taking an international up bottom approach. Thank you. Thank you very much. Let's take one more. Yes right here ma'am. Thank you. We'll get to we'll do another round. I assure you. Yes please. Hello I'm Adriana Blanco. I'm the regional advisor on tobacco control in the Pan American Health Organization. Congratulations. And as you make your. Exceptions that you know that noncommunicable diseases exist. I would like to hear a little more. The analysis of the noncommunicable diseases because it's not it's not seen as an emergency. But we know that we skill in so many people and I see too much emphasis in health system. But what do you think is the role of health global law health global law in the determinant. The health determines the social determinants of health. And many other thing when we are not facing viruses but we are facing huge economic enterprises in the world that have a huge power in the level where legislation can be done. So can we can confront that that is not a virus. But it's really deadly. Thank you very much. Who'd like to jump in first. We've got several issues on well I I'd like to answer the gentleman's question about since we've contained Ebola infections in other outbreaks. Why can't we learn from that and apply it here. Well that's a really good question because it's it gets asked frequently. So in 1976 Ebola was first isolated in outbreaks that were almost simultaneous in Zaire former Zaire and Sudan. Since then there have been about 24 almost two dozen outbreaks over the years ranging in size from two people to the last second biggest one was in Uganda in 2000 that had about 425 people. The issue with all of those was that for the most part they were in geographically restricted small village type settings where it was not easy but relatively less difficult to get isolation contact tracing because when you're in a village and the village is pretty isolated the contacts are not necessarily that widespread like there was a an outbreak in in 1995 in Uganda and Kirkwick where it was a serious outbreak but those people are not likely going to get on the plane and go to London the next day. What you have in the current situation is you have multiple countries with porous borders and it's gotten into the cities and that's the critical problem that it gets exponentially more difficult as you get more and more people like if you look at one one contact tracing you might have 90 to 100 people in a city whereas a contact trace in a small village may be three people. So the mechanisms of what you want to do a similar the magnitude is is amplified extraordinarily so and the longer it goes without containing it and the more exponential it gets then the paradigms of previous outbreaks are no longer meaningful. It's a different ball game. Yeah well I think Tony has has answered that question. I think I just wanted to agree with the issue on raised by the Colonel on how to implement is is is not simply just do it. It's actually more complex than that and it's worth you know some of the articulation that you provided. I won't try and improve on that but I think attention on how to implement is absolutely fundamental in all these things there's a lot that we can learn. The other point I respond to is the NCDs where I think part of what's going to define the effectiveness and is defining the effectiveness of national responses is the global mobilization and I'll give you one anecdote. I went to Mexico to attend a meeting on the prevention of overweight, obesity, and diabetes and at that meeting I learned about Mexico's NCD policy which they had enacted about three months earlier and they launched the policy with the head of Coca-Cola Mexico on the stage and part of the policy was a major value added tax on all sugar drinks. So I said to the Minister of Health I said how on earth did you get you know the big beverage industry to agree to be part of this and they said well it wasn't that easy and I said well tell me more and they said initially it was lobby against and they were going to beat us but then we looked to the European Union and there was a directive on non-communical diseases that all the beverage companies had signed up to including Coca-Cola and so they drew on this EU directive brought it to Mexico and said if you're able to sign on to a directive in Europe why aren't you able to sign on to a similar directive in Mexico and that was what mobilized the beverage industry in Mexico to sign on. They realized that by having a double standard they would look and suffer in the public's eye enormously and so I'm using that as an anecdote because you say oh what is the value of a EU directive I mean geez that's Brussels bureaucracy oh god what is that but here is a case of the value others can use this not only in the EU and this arguably made a big change in the boldness of a strategy to tackle the sorts of challenge that you're identifying so I think this was what I would call soft law and and I think that one can use both hard and soft Joseph Nye's sort of theory of diplomacy not everything has to have teeth and sanctions some things by association by precedent can be very influential in changing behavior I'm not suggesting that's the only way but I think that we have an instrumentation and I think that when it comes to moving forward in global health part of what's going to determine our effectiveness collectively is our ability to think creatively about how to draw on these instruments not just a one-size-fits-all not just a framework convention on tobacco control and tobacco you know consumption is beat but rather a range which are understanding of what works in different contexts and recognition that there's rarely a one-size-fits-all for any problem the kernels point about how do you get the authority to engage how do you get the policy and the authority to engage that is one of the fundamental questions on the table today when we're talking about Ebola and we're talking about deployment of exceptional capacities that are military and character to address something that is beyond the scope of humanitarian organizations now and I my I guess my response would be that only happens when there's a strategic decision taken by political leadership and those to streets strategic decisions have not been taken so you put a request out to 53 countries wasn't 53 you put a request out to 53 you get one back you're gonna get deep resistance to jumping in first into this particular situation until it's matured into a higher level on the quest your own question around why didn't we learn from this from past cases there were 24 or 25 or previous cases I think it's important to to point out that they and Tony's explained this that this case in West Africa pushed us into the unknown very rapidly when it jumped from one to three when it jumped to the coastal cases when the numbers began to take off when it it did things that we had not seen before on a scale of speed of ferocity and we were slowed we were slow to get it and we were slow to come around to where it was going to take us into this next phase there's and and I think we in some ways and naturally fall back on go to the things that worked in the past and double that effort or try be disciplined and persevere well those that's true up to a point but in this case we're at this very difficult moment of saying it has not worked and the point about governance of the global health institutions is I think of a similar kind of logic that WHO and the way the WHO is guided and governed is not risen to this not fit this situation and that's a very good segue to what I was going to address the WHO issue and a little bit the NCD issue I mean WHO is is is such a wonderful promise I mean it was it was the first UN agency in in a world where I I when I wrote the book it occurred to me that in this 1947 to 49 period there were three monumental things that happened the UN Charter the WHO Constitution and the Universal Declaration of Human Rights all of which talk about the right to health what happened with WHO and this is a story that we need to learn from because Tim mentioned that WHO has chronic budget shortages I was there when Margaret Chan announced mass staff layoffs and things and and people were just so incredibly disheartened the way they've dealt with Ebola I mean they're basically have a they're a begging bowl that they're going around trying to get money for it's not the way to do business the WHO not only has a chronic shortage but it actually does not control two-thirds of its budget what organization could exist when it had no control over two-thirds of its budget because these are dedicated funds by donors for things that are worthwhile like polio eradication and so forth but nonetheless WHO can't do anything about it this has to change before WHO can even begin to rip to meet its potential and and and govern the way that that I would we would like to see it there there ought to be assessed dues proper dues and that will transition to things like universal health coverage non-communicable diseases and the like we've been talking about a global health emergency of infectious diseases but it's across the board and it's not just what's prominent in the news it's not just AIDS it's not just malaria or it's not polio eradication it's cancer it's heart disease and things that people never talk about it's mental health it's injuries just go to the developing world and see the level of devastating injuries nobody talks about it and if you look at the global burden of disease and you compare that to the WHO budget it's a complete mismatch we don't devote almost very few resources to NCDs to mental health injuries it is a sad situation it's reversible if we but we need that political will let's take another round of questions let's start over on this side yes down here and then the two hands yours and keep let's take these three folks here hi my name is for us a diki I'm a law student at Howard University some of you mentioned about funds like the you know global health fund or dr. Fauci mentioned about the emergency kind of fund what I was thinking about like the ideas of having a pool of money for these for such problems has been around for some time you know for things like the health impact fund the global fund itself for HIV AIDS I guess I'm going back to a comment over here about the governance around it like if there's several different types of funds that people are thinking about doesn't it go back to something like a bank like the World Bank where there's funding going on to several organizations or sorry several different priorities I'm I wonder if there's if you can talk the professor Gostin about the governance around such funds in in plural and what are the main challenges why has this idea been around for a long time other than finance finance yes but like can you put some cloth onto onto this these ideas of funds thank you thank you I just why don't you hand the mic over there and then a couple rows in front yes thanks Steven excellent presentation it's somebody everybody involved in global health should hear about you mentioned about the backdrop of Ebola against the NCDs and all the infectious diseases people are dying of against that is the backdrop of a lack of capacity that you mentioned the who could do this would you not suggest that we have extraordinary capabilities here matching those capabilities with the fund to be able to strengthen a broad range of skill sets could be part of the solution but my question really deals with given the weak governance in places like Liberia Sierra Leone and Guinea how do you compel governments that are weak perhaps ribbon with corruption to be able to develop the rules-based based framework the legal framework that can underpin access to primary care public health and access to basic surgical capabilities thank you ma'am right here take two more comments and questions right here Joe thank you thank you my name is Jeannie Whitwood voice of Vietnamese Americans thank you for the presentation I like to focus on the law of the global health law and I like to bring up the point of justice and the national governance and also the international governance seems to be the key I follow up with the question just asked before how do you help to build the capacity for the national government to build up governance to deliver a credible health care system in the country and also internationally is there a way that you can look into to oversight the justice for example Vietnam is near China and many young Vietnamese men have been lured into China to sell the kidneys without any education without any follow-up without any understanding a guarantee that when they come and donate the kidney that they had proper surgery down to them no infections afterward and what after they come home three months afterward have significant infections and the other kidney fell and what would happen to them and their family when the whole village near the borders had that happened to them that whole village is devastating and the government did not seem to know nobody seemed to care so that's something that I think significantly it hasn't been brought up but it truly is the legal system the failure from the national governance the legal system in many different aspects so I would call upon you to pay attention to that not just that case but many other case including vaccinations bed toxic drugs being put into the market and being sold for much cheaper price thank you thank you thank you right here thank you gentlemen most illuminating my name is Mindy riser I'm vice president of an NGO called global peace services USA my question has to do with the the fewer overuse of experimental drugs the media certainly latched on to that I would like you to comment on what kind of protocols you think can be developed to deal with this equitably and obviously there's a limitation of supply and there are priorities but how do you determine the priorities and what countries and what people should be on the priority list thank you let's take one more comment right here and then we'll come back to our thank you my name is Aviva I'm a PhD student in healthcare policy so when you talk about Ebola it very much reminds me SARS so when SARS outbreak happened I was in a high school that's right besides the Infection Hospital hosts all the first and all cases SARS cases in Guangzhou so I remember every day I went to school I thought okay I might be died tomorrow but my school teachers won't lower their standards and my classmates won't stop learning so I have to work hard even if I died tomorrow so I think no people find strength from they're actually from people around them so I'm very I care and I wonder how how are people in West Africa doing what they're thinking what how they are they fighting against this disease and how the international organizations are helping them more than curing the disease thank you very much thank you Tony you want to start with some of the protocol issues yeah so yeah the question about the drugs and vaccines a major major misperception is that there are effective drugs that have been given selectively to a few people and not to others the drugs that are in question have never shown to be a safe or even effective and when the drugs were given the two Z map monoclonal antibodies to the two Americans who came to Emory there was a lot of press how they miraculously got better there's no scientific evidence whatsoever that there was any difference that was made by that drug also receiving the drug was a Spanish priest who died also receiving the drug was one of three of Liberian health care providers who died so I think that misperception needs to be clarified when you have experimental drugs even though emotionally you want to get something to someone who has no other hope you've got to at least understand that they need to be safe now the difference between a drug and a vaccine is another thing that people don't understand when someone is dying from a very serious disease and you have a drug that's in the very experimental stage you want to make that available to them as quickly as you possibly can it's easy if there is a limited amount of drug you can do anything from a lottery you can do a clinical trial you could randomize it you can do whatever it's different than when you have a whole bunch of drug and only white people are getting it and West African blacks are not that's not the situation because there's no there's no drug that's actually been shown to be effective vaccines are a different story vaccines the paramount thing is safety because you're not giving a vaccine to someone who's desperately ill who needs something you're giving a vaccine to a normal healthy person and the big important principle is first do no harm when you're giving it to a normal person so right now the only vaccine that has ever been given to a human for this right now in the context of the epidemic is the first dose that we gave to our patient up at Bethesda at about 10 25 this morning it's the first time that that vaccine has ever gone in to a human so the first thing you do is you find out if it's safe if it's safe and it induces the response you wanted to then you have an interesting tension do you immediately distribute it or do you try and distribute it within the context of a clinical trial and that's what you struggle with to do the ethically sound thing but the main goal of all of this is to get it to the Africans who need it but you understand none of them have been proven to be effective Tim would you like to talk about how you engage and persuade governments to make the investments yeah wish so a couple points because I think it raised it also draws on this issue of selling of organs first is in every country in the world people do care about their health and if the public sector is absent then markets will form and unregulated markets in health are a very bad idea that doesn't mean that the private sector has no role it's just that the private sector needs to be regulated if there were no regulations on the way that drugs are produced we would have anarchy chaos and unparalleled levels of harm when the principle is to do no harm or to do as little harm as possible to do as much good regulation matters so the case of organ sale in Vietnam is a classic failure of public provision of dialysis for people who need it in perhaps this case China if the market is if the demand for dialysis or kidney replacement is so great and that there is a market for harvesting organs which is illegal and dangerous and as you you know very eloquently described terrible for the communities that are affected then the best prescription there is to have an adequately funded publicly accessible health system where the private sector can play a role but in the context of that bigger chapeau so this gets back then to Keith's overall question which is first your citizens wanted if you're a smart politician you're going to move in that direction and what we're seeing with respect to universal health coverage is many low-income country politicians are saying when we talk to our constituents they want to have access to care and they want the whole shebang they're not saying we only want access to HIV treatment we also want to have access to hypertension treatment high blood pressure treatment because we're getting old and we have high blood pressure right and they can read they can write their link to the internet right so those expectations drive secondly if we think about that then the structure of systems the institutional capacity to deliver is absolutely fundamental and health systems are complex and I think what we've learned over time is that creating that institutional capacity is not simply the Nike expression just do it right we can learn a lot about how to set up financing systems we can learn a lot about how to deliver infectious disease services appropriately respond to epidemics and also change behaviors in the context of lifestyles and chronic disease risks but we have to learn much more systematically and be able to support those countries in moving in that direction so both from the demand and supply side I think that's part of what we need to move forward there was a very poignant question I think posed by the doctoral student from China lives through SARS about how are people thinking and responding how are the people that are on the ground living with this how are they thinking and responding today in West Africa Larry what would you say what would your answer be to that well it would be somewhat similar to Tim's is that I really think there's a universal aspiration for health that everybody yearns for it and it's just I think quite remarkable when you have people on the ground they may have signs of Ebola they might have heart disease they might have just been in a traffic crash and there's nowhere to turn the hospital systems collapsed they're fearful and so I think that the human spirit there's nothing more that they want more than health I mean it's what your mother told you if you have health you have everything and I think that that is that is a truism that we we tend to forget now a lot of the questions were about how do you get there and this is what my book is all about it's about regulation it's about governance it's about global governance but it's also about national governance which is what we were asked about so how what do you do about these things these are these are when you have these are at least two of the three most affected states are post-conflict states they are they're very fragile the people have lost trust in their government to a large extent and I think that's unacceptable I think that what we need is to have the rule of law both nationally and internationally and people have told me and of course it's true that it WHO or with health you can't have a health police but there are ways to govern we govern trade through the WTO the World Trade Organization we have an adjudication we have rules and norms that countries abide by I don't see why it would not be possible to do that with health both at the national level issues like corruption transparency accountability all of those things are really critical issues and I think that from a health perspective they make they can make all the difference for good health and as I say that that's basically what the book is about to try to find a way to bring that kind of well-governed society for the purposes of health Tony do you have any thoughts based on you yeah I think the situation I agree with everything that Larry and Tim said but I think what you experienced in China with SARS is is different than what's going on right now and the people in West Africa are have a perfect storm of conditions against them they're frightened they're terrified they come from a background of oppression where they don't trust authority the nature of the disease is that you need to cooperate with the health providers by getting into isolation by getting contact tracing they perceive that if you go into the hospital you die so they do exactly what you're not supposed to do they take the sick person they bring it into the home and they infect everyone in the home they don't cooperate with contact tracing because they're afraid of the stigma so the situation is so different I mean people were frightened of SARS back in China and in countries in the Far East but you were within a pretty good infrastructure of health where your teacher was able to tell you to listen study and everything will be all right that is totally different from the situation where it's terror and fear that's going on right now in West Africa it's really a horrible situation that they're in we've gotten to the close here and I know some of us have to have to be off for further discussions in other parts of town around this many of these same issues here so I think we want to close I'd just like to ask our three speakers to leave us with just a quick parting thought we start with Tim and close with Larry and point point as point your comment really to this audience this is in a Washington based audience what is the message you want this audience to take away looking to the to this next phase we've spent a lot of time on Ebola we don't need to make it centered on that but we've talked about big challenges we've talked about big ideas that can get gravitate people's energies that can channel people's thoughts and energies what's the Tim what's your last word of advice to this to this audience here well I'm not sure I have any advice but other than perhaps to say that I think there the realities the world that we live in are such that we increasingly need to think about global health is intimately linked to our health locally and I think that means that we not only have to be concerned with the issues that confront us directly and approximately close to our neighborhoods but we also have to be as concerned about the conditions elsewhere because we're increasingly interconnected and therefore our role to try and make sure we move towards that principle of valuing equally the lives wherever they may be lived is extremely important value to see embodied in in all forms of governance local through the global thank you I guess my comment would be that to this as you say this Washington DC sophisticated audiences because something might seem insurmountable don't give up it really can be done just because something has not been done doesn't mean it cannot be done I reflect often back in 2002 when everyone thought that Africa would would just be the fall off the face of the earth with HIV AIDS and the PEPFAR program was put together and people were saying you could never ever get Africans to take medicines you'd never get them to be able to you know incorporate into their into their lives a daily medication that could save them or prevention and then PEPFAR came along and has completely transformed the lives of millions of people throughout the world so global health and and addressing the disparities is something that's going to take a long time but if you use the PEPFAR example I think we should just be encouraged that it is possible thank you Larry this is a celebration of your work and your career so you get the last word thank you I'll pick up on Tony is his wisdom is always a good place to pick up on I saw you know I've been working with civil society on a framework convention on global health and some days I get up and I'm just so inspired but more and more days I get up and I just say it's overwhelming it's useless but I tell myself what you just said Tony never give up we actually can do it and maybe we'll just end at it with a great writer Camus in the plague who base I'm paraphrasing but basically he's he says pathogens just come and come and come at us and yet when the next one comes it seems to we were surprised we don't you know why are we surprised why do we jump from crisis to crisis from Haiti to the tsunami to SARS to Ebola isn't it obvious it to me it's obvious we know how to make a population healthy it's affordable it's doable so let's just do it thank you all for joining us I want to thank our three speakers and I particularly want to congratulate Larry on this terrific new work so please join me thank you