 And I want to say thanks to all of you for coming. We're delighted to have you here. This is our opportunity to release the most recent or current of our series of studies that we've been trying to engage in on America's national security interests in good global health. I mean, it's what this is about, is trying to find a way where America can make a contribution in the world that we need for ourselves, and frankly, the world needs. And to play that very constructive and helpful role. And I'm very pleased that we've been able to continue to draw on the expertise of these two gentlemen here, Bill Fallon and Jim Peake, remarkable leaders in their own right when they were in service, and now continue to be remarkable leaders in, I don't how you guys get really paid. I know I don't pay you, but it doesn't keep them from volunteering with their remarkable capabilities to advance good things in the world. And I'm very, very grateful to both of you for doing that. This, of course, this is a project that's now looking at the Mekong Delta. And the very serious health issues. This is undervalued and underappreciated in the American policy landscape. And it needs the attention. It needs to, frankly, be a significant focus for us. Again, these are, in many often cases, poor people with desperate need for care that they cannot get themselves. And the international community has a very strong interest in helping to bring solutions to this problem. It's both selfless and self-centered for us to want to do that. It'll be important for our health. And, of course, America's standing in the world is always better when we really reach out and help other people with problems that they have. And so it's the spirit of this project. You will find, you all have a copy of the report. And I said to the authors, it's blessedly brief, which is nice. We don't need to make you read lots and lots of words if you get the main point. And I think it's vividly conveyed in a very handsome, concise, taught report and monograph. And we're gonna get into that today. And I'm very grateful that they've donated so much of their time to make it happen. We've got very real issues in this region. There's resistant malaria. We've got pandemic threats in the region. Vulnerable populations, especially women and girls. Vulnerable populations in this region. And these are issues that need to be addressed. And we're really grateful that they're here to do that and that you're here to be a part of it. Let me just say there's some people that were, in addition to these, these gentlemen who are very instrumental in helping with this. Admiral Cullinson, who is the former deputy surgeon general, played a heroic role in getting this. And I appreciate that very much, Admiral. Thank you for what you did with us. Chris Daniel, who's a retired captain, physician from the United States Navy. Chris, thank you for leading this effort. Lindsay Hammergren. Lindsay's out organizing right now. So Lindsay, thank you. You've been a real champion for all of this. And I wanna say special thanks to Murray Hebert. Murray is a recent practitioner of healthcare. He had appendicitis last week, but he's up here walking around and he's pretty good. And if we can take care of Murray, we ought to be able to take care of everybody in the Maycong River Delta, I think. So, okay, let's see what we can do. So I'll just say thank you to all of you for a very important additional step, a step that we all need to take. And let me turn to the co-chairs of the project and you guys take it from here. Thank you very much, ladies and gentlemen. Dr. Hammer, thanks very much for a number of things. First, for the kind introduction. Jim Peek and I, I think I'll speak for, try to speak for both of us. And we're honored to be here and to continue an association with CSIS because of the wonderful example and leadership that Dr. Hammery and his team demonstrate on a daily basis. And for my part, this particular avenue, if you would, of global health, I think is particularly interesting and very, very important because one of the things that I learned after many years of working in the field or so to speak, or on the seas, was that security means a lot more than just the traditional state-to-state interactions that I grew up in as a youngster. And over the years I've come to believe that it's much more personal and close to individuals and one of the key underpinnings of that is the personal health and welfare of people around the world. If you're not in good health and you're concerned about just existing day-to-day because of health or health-related issues, it creates an uncertainty and an instability and insecurity that leads to other much more complex and dangerous things. So it's very fundamental. And another one of my strongly held convictions is that you attack challenging problems from both the top and the bottom. We need good leadership, we need initiative, we need resources, John Hamery and his gang here certainly give us a good example of that, but we need people on the ground in the field to actually work on the issues if we're gonna make progress. And thanks for all of you being here today to listen to us and to hopefully not be shy, which I know you won't be about offering your suggestions and good ideas. So as we looked at this issue, there's a continuum here. I was privileged to be part of a Global Health study a couple of years back and Jim has also engaged in several opportunities here at CSIS to further thinking along this line and see what resources might be matched up against the challenges out there. I saw certainly from my time in Paycom as the commander out there that we had tremendous capabilities that we had not only in the military, but in other aspects of US capability, government and commercial and surveillance. And I thought to myself that it would be tremendously helpful if we could figure out a way to get people to cooperate in a more useful manner to look at the challenges and look at the resources and then figure out who and what and what the organization is best suited to tackle them. So there are lots of needs, but certainly no small number of people that are willing to help, but getting all this harnessed in a useful way was a real challenge. The other thing that I saw was that we had an opportunity to use one of those major military capabilities while I was out there in the form of one of our big hospital ships. And as we got this thing spun up, of course there was resistance back here in Washington. Imagine that first question, of course who's gonna pay for this and went on and on and then who's gonna staff it and then it became very, very interesting that there were people clamoring to be part of that staffing. And in fact we had a wonderful, overwhelming number of folks here who were willing to step up. But on the down range side of things, there were many folks who had raised their hands and said, can you send that asset here? And so it was very, very useful and I'm happy to see that continues, but one of the lessons from this endeavor was that there wasn't a whole lot of what I would call staying power from these kinds of things. And in fact that's very, very true of most of our military capabilities. We have a lot of things we can do very quickly. We can bring relief rapidly and we can figure out how to do logistics very well. But we can't stick around forever. And if these things are gonna be effective, they need to be long term. And so that's one of the motivations for this particular exercise was to think about not only what could be done, but how it could be done and exactly where we would spend the effort. So it's back to this, the key question for us is how do we pull together the resources and leverage the different interests and capabilities to actually make a difference? A long-term difference on the ground, not just to help somebody feel better today, but to actually improve the long-term health. So how do we go about it? First of all, our experience was that we need to think about it, we need to gather up a group of people that are experts in this field that have tremendous amount of experience. And we've been very, very blessed to have many of those folks on the team that thought through this. And then gathering information, what is it we need to know? What are the facts on the ground that we need to take into consideration? And then come up with a plan. We can deviate from the plan, but we've gotta have some framework for figuring out what we do, how we do it. And so that's what effort was spent doing. And then another question would be lots of needs all over the world. Is there something that makes sense in a particular area that would address certainly the needs, the capabilities that could be brought to bear, and then the other things that are always lurking in the background that serve to either motivate people to jump on board and be part of the solution or on the negative side to cause them to shy away and say, you know, this is too complex, too hard, too many sticky fingers or whatever the issue is. So without boring you, Southeast Asia seemed a very, very appropriate target for our efforts. The needs are certainly there. We have seen some outreach in the recent past to work in this area. And there's some wonderful opportunities in and around the Mekong River Valley in this day and age that we thought would help pull in some of these other factors. And one of them is, frankly, China. We in the US side have been looking for ways to try to get China engaged in activities that would be helpful in the world, not competitive, but complimentary to things that we might be doing. And is there a venue and is there an idea that we could kind of come to agreement on and move forward? And so that's a big potential play in this area. US government, US military capabilities, interesting. Certainly, but how many other things are out there in the private world and how many individuals are out there doing? The answer is lots. And so the challenge is to come up with a coherent plan that we could hopefully get folks to buy in. And that's one of the reasons you've been invited here today is to have you hopefully understand what it is we're proposing. We would hope to agree and get your support and then to help us carry this into execution as we move forward. It seemed to me that one of the critical pieces that had to be put in line for this effort to be successful was the active help from my former command out there in Honolulu, US Pacific Command. And the reason why is that PAYCOM has an enduring presence for many decades in the region and it touches every one of the countries out there. It also touches back here in Washington, most of the institutions. And if we had any chance of being successful, we need not only the assent of Pacific Command, but the active participation of the leadership there and then the staff people that would help to facilitate carrying this thing out. And so I was really, really happy to have the team go out there and to get the support from the commander and the rest of the people out there. The last thing that I would highlight and I think we need to talk about this, I'd encourage your inputs, is that if this is going to work, it's going to require very, very good integration of efforts, particularly back here in Washington. So the White House supporting it, and so this is an initiative that we are proposing that might be taken forward by the president himself as he reaches out into Asia later on this year. We certainly need support from the cabinet secretaries from Defense and State and others and then other non-DOD organizations around town, linking that through the State Department and down through our country teams and our ambassadors, and then of course the various military folks on the ground. So getting all of these folks to sign up, to support this initiative and to actively help us to move forward is a key objective. So thanks for the opportunity to be with you. I appreciate the opportunity to work with Dr. Peek and the other folks who are wonderfully kind in donating their time, Chris, for hot-showing this thing and seeing it through and dealing with a couple old farts like us who never seem to be able to make meeting times and the usual nonsense. But so, Jim, I turn it over to you for your thoughts. Thank you very much. First, I'd also just like to add my thanks to CSIS and to the team. Chance to work with Admiral Fallon here is always fun. And as I look out of the audience, I see a number of the folks in the audience who participated in our variety of deliberative meetings about this and in addition to the team that's on the front row. And I wanted to thank you all as well for your participation. My approach on this is from a guy that spent most of his life in the military and the military medical side. And when you realize the stake in global health is just fundamental to our mission of taking care of the soldier, sailor, airman, and Marines because we never know where we're gonna wind up sending them. This is more than an academic exercise and it's why for more than 50 years, both the Navy and the Army have had a research laboratory presence in the Southeast Asia region. In fact, we were part of a study that looked at that and talked about their contributions to readiness, the contributions to scientific advancement in general. As an example, the HIV vaccine that y'all have heard about would not have had that kind of trial in Thailand without that sustained presence by the Army lab in that case that represented also the longevity of these laboratories and kind of a strange resilience there in some ways fundamentally built on trust. It's mill to mill scientist to scientist that has been the hallmark of their excellence as well as a network regionally. It's not just the host country, but it's the regional network that has been important in maintaining that kind of viability. More recently, CSIS has looked at that the last 10 years really of Navy humanitarian assistance within the Pacific and Admiral Fowler alluded to it with the, it really started with the response to a disaster of the tsunami with the tremendous force of United States Navy with the USS Lincoln and so forth as well as the follow on with the USS Mercy or the United States Naval Ship Mercy. But the emphasis was on the follow on preplanned medical engagements with the idea that you start to get to the sustainability that Admiral Fallon really talked about. And so there have been follow on alternate years really into the Pacific with the big white ships as well as using other naval assets that can bring medical support right into the coast and in conjunction with the variety of host nations that also has gone down into South America and Central America. And then there are similar, not quite the same, but similar kind of exercises in Africa. So it is that sort of thoughtful use of military medical support. Now that is also in conjunction really with some of the other, the variety of other agencies. And we can talk a little bit more about that as we go on. But then you say, well, why if we look at the Pacific Southeast Asia? And when you think about it, there's obviously a compelling area because of a strategic location sort of hemmed in by the Straits of Malacca on the South and China on the North. That makes it fairly strategic just looking at that. But it is also an area that is host to what may well be the next pandemic. It has lots of emerging infectious disease concerns within this area of the Mekong watershed, if you will. It is also an area with the disparities in health that are important to all of us here on this committee and on this audience. I mean, if you think about the Southeast Asia compared to just East Asia, the under five death rate is about 32 per thousand versus 18 per thousand in East Asia. The maternal death rate is 150 per hundred thousand versus 37 per hundred thousand in East Asia. So when you start looking at the variety of objectives that we would have in focusing on this region, not to say that there are not other areas of the Pacific that will require our long-term initiatives and our long-term presence, but a place to start as we rebalance to the Pacific that gives us a chance to work with already existing programs, our own with USAID and CDC actively engaged there, but others, WHO, the Global Fund, all of those kinds of things coming together, the chance for synergy and making a real difference seemed to be a compelling approach to the group that's been working this. So when you start saying, well, what's it gonna take to be able to put that kind of thing together, given all the good intentions, it really focuses on leadership. And we believe, as Admiral Fallon talked about, that that can be really strengthened from the very, very top, but it will take more than just that voice. It means a dedicated leader, we think of the ambassadorial level, to be able to start to tie all of these pieces together. It will take a sum of money that we'll be able to leverage already the investments that are being made, but a sum of money that would be dedicated that will then enable, if you will, the smart collaboration between and among the US and other international entities, particularly finding ways to work with China. We think that's an absolutely important consideration. And to bring in also the power of the private sector, which I mean, there's some $160 billion of investment that private sector's made in that region already. So they're vested interests, and if they could be aligned, then I think that, and the group feels like that is the opportunity to start to make a significant difference in this area, near-term and long-term in a sustainable manner. So with that, I think we wanna get the panel up here. And I would like to thank all of you again for being here and again for the CSIS for the opportunity to be a part of this. Good afternoon and thank you Admiral Fallon and General Peake, John Hamrey for kicking this off. And I wanna reiterate the thanks to Chris Daniel Murray Hebert from the Southeast Asia Program. We've done this initiative jointly with the Southeast Asia Program, and we've enjoyed enormous support from CDC, from USAID, and from the Pacific Command. We started this work with the idea that in the year 2013 that the strategic rebalance would get continued consideration around what does it mean and what is a smart, affordable, and actionable option, soft power option centered in health for the US to push forward on. And that's what we've laid out here in this short proposal is the argument around the timeliness, the urgency, the ability, the opportunity to move forward. We're putting a special focus on Artemis and resistant malaria, a special focus on building preparations and capacities with partner countries to respond to emerging threats, pandemic flues. We're talking about mobilizing our efforts in a more unified way around maternal and child health. We think this is a very, very powerful and valid proposal. It builds on the work that we did on the labs with General Peake and with others. It builds on the work that we did and issued earlier this year on the Naval hospital ships and the other forms of humanitarian engagement. We issued late last fall an elaborate oral history of 15 different civilian and military leaders who had been active in natural disasters and conflict settings and other unsettled circumstances in talking about the role that health plays. So this marks a big, big moment for us programmatically in the stream of work and putting this piece out. We'll be a delegation, Admiral Cullison, Murray Hebert, myself, Lindsay and Todd Summers from our program who works with the Global Fund will be in Myanmar and in Thailand shortly and will issue in September a short analysis around the state of play and the opening in Myanmar and what that means in the health sector and in terms of US interests. We'll also on November 12th in our new building be hosting a day-long major conference on health in Southeast Asia. And we'll have folks from within the region, the leadership on the health side from within the region there and we'll have senior personalities from the Obama administration. We'll have personalities from some of the major international partner institutions like Gavi Alliance Global Fund and folks representing the Hill. I want to acknowledge we have with us today a group of 16 scholars who are foreign policy experts from around the world who've been in the United States hosted by Bard College and Joy Monagall who are here today and thank you all for being here and I hope you'll stand up and speak in the period when we move towards audience participation. We have foreign policy academic experts from Vietnam, Cambodia and India with us today among many other countries represented in that group. This round table discussion is meant to hear from four different individuals in leadership positions in four different agencies of our government to hear their outlook on how they see the bigger picture in terms of strategic rebalance in the role of health. We're not asking them to comment per se on their report and proposal that's in front of them although they are certainly free to do that but we've asked each of them starting with Michael Fuchs from the State Department to offer some opening remarks around what their outlook is on this big, enormous, very timely question. We'll hear from them and I'll introduce them each in a moment. We'll hear from them and then we'll come back for a round of discussion and I'm gonna ask Admiral Cullison, Tom Cullison who's been so integral to all of our work to kick forward the discussion with a question from Tom and then we will turn to you all. So we'll try to get to you all for your comments and input rapidly and there are folks here who are working with us who have microphones and when we get to the question and comment period we'll just ask you to put your hand up. We'll bundle together three or four comments and questions at a time and come back to our folks and we'll conclude by 2 p.m. So thank you very much on that. Our first speaker is Michael Fuchs who's the Deputy Assistant Secretary at the Department of State in the Bureau of East Asia and Pacific Affairs. Prior to that played a major role over several years as special advisor in a number of strategic initiatives and advising Secretary Clinton was in the policy planning staff there. Prior to that was at the Center for American Progress and did some very terrific work with Mort Halpern on democracy and democracy promotion globally. So thank you Michael for joining us today. We're also joined by Scott Dowell from CDC. He's the Director of the Division on Global Disease Detection and Emergency Response within the Center on Global Health. He's an infectious disease expert. Perfect for this setting here because he, going back to the early part of the naught decade, 2001 to 2005 was in Thailand working very closely and collaboratively with the Thai health officials in that period of SARS and H5N1 in putting together the proto-model of cooperation around global disease and detection. It became our GDD or our Global Disease and Detection Program grew out of that leadership and that experimentation that Scott drove in that period. He's come back and subsequently built out that program. We now have 10 global disease and detection programs with 10 partner countries around the world. All of that program has also become a collaborating center with WHO and really a central element in moving forward international health regulation implementation worldwide. We're also very honored today to have Bernard Dailin. Nalan, Dr. Nalan is the Deputy Coordinator of the President's Malaria Initiative, which we all know is the premier vehicle since 2005 in the US government in moving forward malaria control and eradication efforts worldwide. We've also been blessed by dating back to the Bush administration and through the Obama administration. A remarkable continuity of leadership of the PMI with Bernard and with his colleague Tim Zimmer, Admiral Zimmer, who heads that program up. It's a much admired and much emulated program. Bernard is a member of the US Public Health Service, medical doctor, started his career at CDC in the programs there. Spent seven years as part of the CDC. The Chemri program in Kenya doing some groundbreaking field research on malaria in different dimensions of malaria, particularly with reference to pregnant women and children and played a big role in the startup of the rollback malaria program at WHO. We're also joined here are our fourth panelist is David Smith. He is a Deputy Assistant Secretary in the Force Health Protection and Readiness. At the Department of Defense, a graduate of the Northwest Medical School, Northwestern Medical School served in very important positions on health at the Joint Staff as the Joint Staff Surgeon as a Senior Medical Advisor in Afghanistan for a period. And so we have here, I think it's just a remarkable collection of folks representing at the leadership level these four different institutions. So please join me in welcoming them. What I suggest we do is just go sort of in quick sequence, I've asked Michael to kick things off. Speak for five to seven minutes, give us an overview of how the State Department is looking at these issues in this particular period. This is a big year in terms of the Secretary and the President's engagement. Going back last year, this coming year and then what follows and then we will move to our other speakers. So Michael, thank you. Thank you, Steve. I'm really happy to be here and I wanted to thank CSIS and the authors of the report and Admiral Fallon, General Peake for leading this effort. I think this is an incredibly important set of issues to focus on now and in the coming years, especially. In the last few years, I think that the rebalance has gotten a wrap as a predominantly security focused effort. And of course that is a central piece of what the United States aims to do in the region. Our long-term alliances providing the backbone, I think, for regional security. But it really is the overall goals of the rebalance really are in this space. Are in enhancing our engagement with the entire region and a wide set of issues from economics to human rights and democracy issues, trade investment, deepening our partnerships with multilateral institutions. And so the focus here today on health issues and development issues across the board, I think is a very, very important part and sometimes an overlooked part of the discussion. Obviously, I think we've all heard the stories and all know it very well. In recent decades, the dynamism and economic growth that we've seen across the Asia Pacific in recent decades from Japan, South Korea, Singapore, so on. Now we're seeing in places like China, India and Indonesia. But I think that one thing that is also important to keep in mind and that is raised by today's report is the fact that there are still millions and millions of people in the region who are living in poverty, who are facing significant day-to-day challenges, trying to provide for their families and societies, really trying and struggling with major development challenges. And a lot of that is in mainland Southeast Asia and in the Mekong region. So why is this important to us that we focus on this particular set of issues, this aspect of the rebalance? I think that Admiral Fallon hit the nail on the head when he said that this is a lot more than just really do-gooder stuff. There's a moral responsibility, of course, but this is a security issue at the end of the day. I think we all have a strong interest, obviously, and a peaceful and a prosperous, broader Asia Pacific region as President Obama and senior officials from the administration have announced time and time again. And at the heart, I think, of this investment in the region is an investment in Southeast Asia and where Southeast Asia is going. A strong, prosperous, peaceful, united Southeast Asia and a united association of Southeast Asian nations, ASEAN, regional organization, which is a key regional organization that really sits at the center of a number of different things that are very important to the strategic rebalance and to what's happening right now in the broader Asia Pacific region. And I think that the investment that we're making right now in Southeast Asia, this is gonna be a crucial part of it, investing in the development and the economic growth across that region. Part of the challenge here, again, is actually a challenge that these nations themselves, of course, in the broader Southeast Asia region has established for itself. If you look at ASEAN right now, one of its main goals is bridging the development gap within ASEAN between much of the maritime states of Southeast Asia, which are predominantly better off economically than those of mainland Southeast Asia. And this is really, again, a primary goal for ASEAN. And so I think that this is an effort, our investment in supporting healthcare, health security, economic growth and development in mainland Southeast Asia is a part of a much broader framework here. It's supporting ASEAN's development. It's supporting economic growth and trade across borders in Southeast Asia and beyond. And it's strengthening ASEAN politically, which is very important to our longer term strategic goals. ASEAN is now the driver of the region's multilateral institutions, the East Asia Summit, the ASEAN Regional Forum. All of these strategic fora, which President Obama participates in, Secretary Kerry participates in, and leaders from across the rest of the region participate in, are driven by ASEAN. And so the stronger that ASEAN is, I think the better off the region is going to be. And this is a key component, I think, of strengthening ASEAN and its ability for regional leadership. I think the challenges here that we face in the Mekong region are stark and significant. And many of them are outlined by the report here today. I think from energy shortages, major transnational health threats, of course, poverty, malnutrition, to name just a few. And one of the biggest problems that I think we face here is that the capacity of the countries of mainland Southeast Asia and the Mekong region is significantly underdeveloped. But again, as the report lays out here today, I think that there are significant opportunities that these countries have before them. Just look at some of the trends right now in this region. ASEAN right now, again, is working to achieve its own stated goal of an economic community by the end of 2015, which is working furiously to achieve. And they've set out some big and ambitious goals for them to benefit all the countries that we're talking about here today. Myanmar, of course, is emerging from decades of stagnation and going on an undergoing historic political reform process that is having significant impacts in the economic and development space. I know we'll talk about that a little bit more here today. Vietnam is looking to reform its economy in parts of its society as part of the TPP agreement. And of course, Cambodia and Laos, I think, are growing at a significant clip in recent years and trying to create more widespread benefits for their populations. And so I think if you look at all of these trends together, there are some real opportunities for us to take advantage of, I think, in supporting the goals that these countries have outlined for themselves. The report, again, I think was very, very clear and was, again, hit the nail on the head, I think, in identifying some of the elements that we're gonna need in a successful approach here. It needs high level leadership, any effort that we undertake. It needs a core part of funding, obviously, which is going to be crucial. Strong collaboration with and buy in from partner governments, which, again, as General Peek and Admiral Fallon are making clear, if you don't have this sort of relationship with the countries and the buy in, we're not gonna be able to achieve anything close to what we need to achieve. We need, of course, strong coordination within the United States government, I think, is represented a little bit here today from the different agencies we have represented here. I think it's a good sign. And then, of course, we need strong coordination with multilateral institutions in the region, not just ASEAN, but many of the others that are investing in the Mekong from the ADB to the World Bank and so forth. So, I thought I'd just spend just one minute, very quickly, before turning it over, to talking about an initiative that the United States has started with some of the partner governments in the region that is a very good foundation, we believe, for some of these efforts, called the Lower Mekong Initiative. Mentioning some of the things that CSIS's report highlighted here, I think they're gonna be successful to an approach. We believe that the Lower Mekong Initiative actually has begun to lay the groundwork for some of these. High-level political leadership, Secretary of State, Secretary, participates and leads the initiative every year. Secretary Kerry was just in Brunei a few weeks ago, hosting his first Lower Mekong Initiative ministerial with the ministers from Thailand, Laos, Cambodia, Vietnam, and Myanmar. LMI is a whole of government approach, including many different parts of the State Department, but also something basically about more than 20 agencies across the U.S. government are involved in LMI. Partner country buy-in as well in its first few years, we've done a significant amount of work to get support from the countries in the Mekong, investing in the LMI framework, and at the request of LMI countries, who has also broadened it to include a second set of meetings in fora called the Friends of the Lower Mekong, which brings in major donor countries and multilateral organizations, everyone from Australia and Japan to the EU, to the ADB and World Bank, together to help coordinate development approaches in the Mekong region. LMI is focused mostly on capacity building. And again, I think this does speak to something that Admiral Fallon was talking about in his opening remarks, which is the need to invest for the longer term here in the region. The United States government, we have money, we have capabilities, we have expertise, and we can come in quickly and we can do a lot of things, but if we're gonna make any real progress on this set of issues over the long term, we need to build capacity in partnered governments. And that's where we believe that a small, a relatively small amount of investment through initiatives like the Lower Mekong Initiative, and issues like health, we can build up the capacity of ministries and others in these governments and in these countries to support longer term solutions to these problems. So just to run quickly through, in the LMI Health Pillar, we have six pillars of different issues that we're working on. The Health Pillar is one of them, and I'd say probably the most advanced of the pillars. We're working on everything from building capacity and coordination in response to diseases like malaria, TB, HIV AIDS, working on preventing, controlling, counterfeit and substandard medications, and supporting the implementation of the international health regulations. Now, LMI, again, is a relatively new effort, and like all things new, and multilateral efforts especially, take a significant amount of time to build. But I think that over the coming years, as we invest more into this and as partner countries invest more in this framework, there's a foundation here, I think for all the work that we're gonna be talking about here today. The one other thing I would like to mention for turning it over is that health security is of course a very crucial issue here, and I'm very happy that we're talking about that issue here today. But it's also directly linked to a range of other very important issues that I don't think we can overlook in the Mekong region. If you look at any other issue, connectivity and cross-border management issues, for instance, are key to preventing diseases from spreading across borders. Adequate food and water security are essential to address issues like malnutrition, and energy security is gonna be essential for a wide variety of health related issues, including ensuring governments have their ability to run hospitals, clinics, and medical services. And so that's why in the LMI framework, at least we're focused on bringing all of these different aspects of the development and the growth agenda together so that all of them can work as a mutually reinforcing whole. Finally, again, I would just like to re-emphasize how important it is that the U.S. government be working together on this. And again, and we'll discuss, I know, some of this here today, and I think that you've already seen some steps we've taken in recent years to enhance our ability to work together. This was on display, I think actually, a few weeks ago, a very good example of this. The ASEAN Defense Minister's Meeting Plus, which is the ASEAN group, plus eight other major regional countries, including the United States, organized in Brunei a humanitarian assistance and disaster relief exercise in military medicine joint exercise with representatives from the U.S. military who are working side by side with folks from all the other countries in the region. I think it was a tremendous display of coordination and capacity building that I think we need to continue to invest in efforts like this. So anyway, to conclude, I think that really this is a very, very important discussion and I would just say that as we're talking about it here today and as you talk about it with colleagues and others going forward from today, I think obviously we just continue to need more on these efforts, more of a lot of different things. More foreign assistance funding, of course, I think is always crucial across the board, especially with the debates going on nowadays. I think this is a very, very important issue. It shows that small investments can have outsize impacts, I think, in terms of U.S. national security and interests across the world and I think more support from not just the USG, but Congress, the private sector, NGOs, and others to have more conversations like this for what we can do working together to support this broader agenda. So with that. Thanks, that's terrific, Michael. I'd like to ask Scott Dow from CDC to offer some remarks and then I'll come to Bernard and then David. Thank you. In 2004, Avian influenza was the health security threat of the Mekong Basin. It wasn't like that at first. Initially it was seen as an agricultural problem with economic consequences and countries in the region downplayed it. But I remember seeing on the cover of the Bangkok Post a picture of a small boy whose mother had taken him to a series of clinics and hospitals and he had then died being undiagnosed with Avian influenza. It outraged the Thai public and it caught the attention of political leaders in Thailand and Avian influenza then became a priority for Thailand to respond to. I was called on a Thursday afternoon by Dr. Khamnoon, the head of the Bureau of Epidemiology. I was there at the time starting up an international emerging infections program, the precursor to the global disease detection program that Steve mentioned a couple of minutes ago. And we were there trying to develop these collaborations between CDC and the Ministry of Public Health on response to epidemics. Khamnoon was concerned because he had just confirmed a woman who died from Avian influenza and before dying, she mentioned to her nurse that her daughter also was sick a couple of weeks earlier and had died from something similar. He was worried that she had gotten it from the daughter which would have been unprecedented. And the reason was that she was living in Bangkok and had traveled up to Kamping Pet Province where the girl was, had not visited the village poultry but had just been at the girl's bedside. So in driving up there early the next morning, the story began to unfold and we scrambled thinking that this might be the virus that starts the next pandemic and we needed to get samples of it. The daughter had been cremated, the mother's body was embalmed and so it was a scramble to get that. And as we're going, we heard that the aunt was hospitalized also having spent time at the bedside of the girl. She was then in the hospital we were heading for. We arrived there and they showed us the chest x-ray which clearly had a low bar pneumonia. So we then had potentially a third patient and went to the room where the aunt was being kept and taught the healthcare workers about proper isolation and safely caring for her. Got specimens to try and identify the virus and gave the aunt Osiltamivir treatment. With us were veterinary epidemiologists who'd come up because of the need to look at the chickens and poultry in the village. And so much of the afternoon was spent in the village looking at the history of the poultry die-offs in that village and assessing who was exposed to the girl, to the poultry and giving out prophylaxis as needed. Now ultimately it turned out that that was not the beginning of the pandemic. It was one of the first and better described clusters of human to human transmission, that part was confirmed. And it served as a model in subsequent years for responses in Thailand and other countries around the world to H5N1 clusters. That early detection, that quick response, the multidisciplinary team going out and with veterinarians, communications and other staff. The ability to give treatment, quarantine, prophylaxis as needed to try and contain the spread of the epidemic before it moved further. All of those became elements of what's been done with H5N1 since then. In the aftermath of that, as Thailand controlled their H5N1, I was invited to the office of the prime minister of Thailand to receive recognition as a representative of CDC and the US government for our contributions to Thailand's control. And in a somewhat bizarre little ceremony I was presented with a large basket of Thai poultry products. Which we ate and they were very good. I tell you the story for three reasons. One, to reiterate the point that these health issues are important priorities in the Mekong Basin countries. Second, that US government collaborations can be critical. Especially if we build those relationships ahead of time that can serve us in a time of crisis. And third, that the collaborations from our government to host governments are highly valued. Really there's almost nothing else that we can do that's more valued or more consistently valued than helping countries at a time of a public health crisis to respond adequately to that crisis. So currently, where are we? I think we have a unique window of opportunity as the report points out. There is a stuttering progress towards implementation of the international health regulations to which all countries in the region have agreed. And that most of them are waiting for help to make progress on. We also have some new technologies in the area of informatics and in the area of laboratories that allow us to detect earlier than ever before and respond more effectively than ever before. And finally, right now, there is concern in the region and here about the MERS coronavirus. About false sipper malaria, resistant to Artemisanins. About H7N9 influenza. And those come together to make it a very good time to talk about these issues. As many of you may know, Secretary Sebelius took a trip to the region just last month and with director Frieden from CDC, visited poultry market in Vietnam and highlighted some of the progress that has been made since 2004 but also some of the needs that are still there. So what needs to happen? It's not complicated. Three things, detect these problems as early as possible, respond effectively and prevent the ones that are possible. I'd highlight just two quick things under detect early. All countries in the Mekong Basin ought to have nationwide laboratory systems that are able to characterize influenza and resistant malaria and the full range of pathogens that can cause these epidemics. And second, they ought to have trained field epidemiologists in adequate numbers to do these field investigations and to get on top of the small epidemics before they become big ones. In the area of response, all countries should have an emergency operation center that's equipped and staffed and able to stand up an emergency response within 120 minutes of a public health emergency declaration. And secondly, they ought to have rapid response teams. Modeled on the ones that I described for Thailand and Thailand has done a lot of good work in this area that have veterinary epidemiologists, human disease experts, communications folks and so forth that can go out and respond early. And then third, I mentioned prevention. It is possible to prevent some of these epidemics in a microbial resistance in particular and focusing on artemiscent and resistant malaria. It is possible to track that much better than we have and to stay on top of it by providing early combination therapy. And then laboratory, biosafety and biosecurity, a simple but effective preventive measures. Labs across the region want to have biosafety and biosecurity programs to prevent the kind of outbreaks we saw after SARS where on several occasions in that region, SARS broke out even after it was controlled worldwide. The cost and result of this, pretty minimal. As the report points out, a minimal investment of between one and $2 billion would be enough to ensure this kind of progress throughout the region. And we could see in the region and worldwide, a situation where we all are safer because epidemics are detected early and responded to effectively. Thank you. Thank you very much Scott, Bernard. Thanks, Steve. And again, congratulations to the team that put this timely report together. I think the issue of focusing on health is appropriate as a first step in this. It's clear that US government's efforts in global health have been one of the most cost-effective soft power tools we have, not only to benefit the people that are being served by these efforts, but also to assure our own nations of continuing prosperity and perpetuity. So like one of the best demonstrations I think of American values. And moreover, frankly, it's saving the lives of tens of thousands of men, women and children around the world as we're sitting here. The US government's investment in the Mekong region in the health sector, on the one hand it's not new, so I think what's going on presently, if there's any rebalancing, it's actually doing more and doing it better. For example, the issue of the emergence of Artemis resistant malaria was first recognized by US government investments through the USAID regional office in Bangkok, working with the Armed Forces Institute of Medical Research that many of you are familiar with, and other research institutes in the region to set up a multi-country surveillance system, similar to what Scott had set up for other emerging pandemic threats. Specifically to look at the challenge of this region is notorious, particularly Western Cambodia, is notorious in the world of malaria for having some of the most clever and meanest falciparum parasites out there, to the point that any drug that's been thrown at them in the past, eventually there's been resistance that's developed. The Artemisanum class of drugs, many of you are familiar with, were frankly first developed by China, and are the most effective drugs we have at this point in time to rapidly clear parasitemia and save lives. The fact that now parasites have emerged in this region that are resistant to Artemisanums is indeed an urgent emergency, not only for that region, but frankly for the whole world. I mean if you look at what happened, for example, with the emergence of chloroquine resistance back in the 1970s in the same area of the Mekong region, chloroquine resistance was introduced into Africa, and the seven years I was out in western Kenya, you could see the devastation of that cause, because on a daily basis in these hospitals, you could see kids dying from malaria, which was not being treated with effective drugs at that point in time, because chloroquine no longer worked. All the countries in Africa now, and in the Americas, have now moved to these Artemisan based combination therapies. So if indeed Artemisan resistance is not, I don't wanna use the term contained, we need to get rid of it in the Mekong region, there will be a similar sort of level of devastation if this were to show up in these high transmission areas of Africa. So that's why I think the report appropriately has this as one of the major things to focus on. When the President's Malaria Initiative was first launched in 2005, and many of you are familiar with it, it's an initiative led by USAID and implemented together in 19 high burden countries in Africa, the Mekong itself was not quote unquote, didn't have a PMI fingerprint. So even though USAID was working with CDC and others in the region to set up the surveillance which eventually detect Artemisan resistance, it's only when that actually came to the fore that we decided it was time to put more resources into this area. And that's where we are today. I was just at a meeting a week before last in Phnom Penh where the Global Fund is now putting an additional $100 million on top of their in-country grants that they already have existing in Myanmar and Cambodia and Vietnam and Laos, putting additional money in to try to address this problem. I think this problem has some of the major factors that Michael and Scott and others have already referred to. First of all, there is a high level of political leadership. There are resources on the table. There is a buy-in from the countries because the countries themselves have, first of all, the good thing is this region, the countries have had some pretty remarkable progress over the past 10 or 15 years of driving down malaria transmission. I mean, case burdens have decreased by like 80% in most of these countries. Of course, Myanmar is the country where having been cut off for so long from the sort of technical assistance and resources that are needed to address this problem have a longer way to go. So I'll just stop there. There's a, the fact is that Artemis resistance is a global public health emergency at this point in time. We need to do something about it because frankly there are no other drugs in the pipeline at the moment that will be available within the next five or 10 years. So, and also referring to what Michael Fuchs said, the US government, I mean, these health issues are, of course, linked to food security, to the environmental changes that are going on in the region. And USAID and others have programs in these other areas as well. One of the challenges from the health perspective, I'm sure it's probably similar to avian flu. I know it's certainly similar with tuberculosis and what's going on there, are these mobile populations and how best we can reach them. And the mobile populations are not only those crossing borders to work in the agriculture and fishing sector, but also the military. I mean, the military are deployed in these border areas where Artemis resistance has emerged. So at the recent meeting in Bangkok, there was actually a representative from Paycom there as a follow-up to the meeting which took place and some discussion now of having a joint military, civilian meeting as a follow-up to that sometime later in the year. Thanks. Thanks very much, Bernard. David, thank you. Well, good afternoon. And I also would like to thank particularly Steve and Chris for inviting me to participate in the panel. And I always enjoy these thoughtful conversations and what's brought forth in these forums and also would like to congratulate the task force leaders for raising these issues as the other panelists have acknowledged. So I think we all know that global health activities are critical to building a country's health capabilities and are essential to infrastructure. And DOD generally engages in these activities on primarily a military to military basis. And in some cases, military to civilian basis to teach and learn lessons in public health, sanitation, trauma care, logistics, disease surveillance and disaster preparedness and response primarily. And this helps prevent the spread of disease and illness. It will ideally create healthier populations and increase local preparedness. I think, as has already been mentioned, this can lead to more stable nations advancing our national security objectives. However, when the U.S. military does act, we're generally doing it in a supporting role, not alone and we are generally doing it with our U.S. government partners, as has been noted, from HHS, from USAID and Department of State primarily, to accomplish these missions. And the collaboration is key to ensuring our missions meet the needs of both the host country and USG objectives. So the Department of Defense has a significant interest in the Mekon region, as you might expect, because of its strategic importance in the Asia Pacific Theater, as has already been noted. We're investing in the Mekon region to help build health capacity of the host nations in areas of vector-borne illness, drug-resistant infections, surveillance capabilities and novel respiratory illness. And the Department has a robust global health surveillance capabilities that we can leverage to monitor disease and pandemic outbreaks, as I think you're aware in partnership with some of our other USG partners. And our labs that are relevant to the discussion are primarily in Thailand and in the Pacific, as has already been noted, and these in combination with the other labs, we partner with host nations to develop skills and capabilities to research, detect and prevent the spread of hazards common to each of these regions. And just to highlight the two in the area, the US Naval Medical Research Unit 2, Namro 2 as we call it, evaluates new preventive measures and treatments focused on malaria, dinghy, influenza, infectious diarrhea and emerging infectious diseases. And they're headquartered in Hawaii but have field activities in Cambodia, Singapore, Laos, Malaysia and Vietnam. And the labs US and international military and public health personnel all collaborate on research and surveillance that enhance local capacity to address infectious diseases and of course advance global knowledge. The other facility that's been referred to is the Armed Forces Research Institute of Medical Sciences are a firm and it's run by the US Army in Bangkok and it unites the DOD, the US Public Health Service, the Thai military and civilian medical researchers to collaborate on developing affordable products that rapidly detect, prevent and treat illness common to the region. And it's been noted the labs made important breakthroughs such as hepatitis A vaccine, Japanese encephalitis vaccine and the first HIV vaccine that General Peake referred to earlier that has been shown to have efficacy in human clinical trials. And it's now a key participant in a number of trials on the Thai-Virma border looking at the malaria resistance. Another example of our efforts in the area, the Pacific Command, PAYCOM, has facilitated over 20 contingency preparedness engagements in the Asia Pacific partners in recent years providing training to over 7,000 disaster preparedness practitioners in the region to help our military partners and host nations develop capacity and capability to respond to health crises. These growing collective Health Theater Security Cooperation activities emphasize the interagency approach that builds both host nations capability, interoperability and crisis response capability and resilience. And as I noted, the global health activities are an important part of our engagement around the globe. And because of that, we have recently established a global health working group to think through the roles and responsibilities that DOD does play in global health. And this group has been assessing the manpower needed for these missions. As you can imagine, we have a large resource pool with lots of talent, but actually keeping track of that and figuring out putting the right people in the right seats is part of the issue. And then also making sure that we have the most effective training to be effective in the field. And the group is also looking at measures of effectiveness of our global health activities. As you can imagine, particularly and as the financial constraints get tighter, that becomes more and more important to be able to actually judge the effectiveness of what we're actually doing. And these findings clearly will be rolled into our planning and policy at the department and may have applicability to others. So in summary, the US military has been active in global health activities for a very long time. And we will continue to participate in those global health activities that strengthen our partnerships. The MECON region is important to the department and we will continue our partnerships with the host nations in the area. So I thank you and I look forward to the discussion. Thank you all. We're gonna move into our discussion period. I'd like to ask Admiral Tom Cullison to kick things off with an initial question to our panelists and we'll come back to them. And then we'll, in this next round, open it all up to all of you. Tom. Steve, thank you very much. And thank you to all the panelists for your very cogent remarks. I guess where I would like to take this is to kind of expand a little bit beyond the comments that have been made about working together. And there were many comments about national leadership both within the United States and other countries. Common problems, there were lots of discussions about particularly the US overseas military labs working together with our colleagues from CDC and other infectious disease agencies. There were also comments about the episodic nature of particularly DOD health engagement with the hospital ships going overseas and the episodic nature of military to military engagement. So if we are going to, as a nation, as the United States, support our national interests and our national strategies through health using a whole of government approach and if we're going to work with our partners both within the United States and the international agencies in the countries with which we're going to work, how do we go about this? My observation over the last several years is that within the United States we seem to be coming closer together. And the fact that we have you four on this panel speaks to that. And the fact that the papers that Steve has led from CSIS has been talking about this topic as we go. My question, particularly to Dr. Smith, would be within DOD, you mentioned the Global Health Working Group, should it be a role for the Department of Defense to have personnel whose main job or a major part of their job is to be focused in this area? And to Admiral Dowell, how do you work with DOD with CDC on these topics? And for Michael Fuchs, how does State Department include this in the goals that you have for our nation that the State Department leads? And for Bernard, as a non-DOD, non-State Department agency that works with USAID, how do you get involved in this? How do we proceed as a government? I see the glasses half full, so I'd like to know how to fill it up completely. Thanks, Tom. Should we start with Dave? I think that you were the first designated target there for that question. So my question was whether or not we should have folks that are dedicated to this effort. And I think my personal opinion is clearly yes. We have a group now that's looking at this issue. I suspect what's gonna happen is is that we're gonna have a trained cadre that hopefully a small group that can do this for an entire career and gradually develop that expertise and capability. We're gonna have others that are gonna go in and out of this area and take that knowledge to other aspects of our mission. We presently now have been setting up and are cataloging all of the opportunities that we have in the area. We have liaisons at a number of different USG organizations now, which I think are clearly contributing to that knowledge base. And actually the chair of our task force that's looking at this issue is in the audience and they are in the process of cataloging what's available both within the DOD and then what we can leverage from academia and other places. One other, how do we liaison within the USG? One of the opportunities is my boss and the health leads in state and HHS and in USAID meet on a quarterly basis to discuss common issues and how can we better collaborate where are there crossed wires and various and they can be very active interesting discussions when we do actually meet. So that's one of the ways that we try to facilitate communication between the various departments. Scott? Yeah, I would tend to agree with observation that things have improved. I think the communication is good and the relationships are cordial back at headquarters and if you look in the field even more so, the communication is good across the different agencies, military to civilian and so forth. Now having said that, everybody has their day jobs and when the communication ends, people tend to go back to their day jobs. And I wouldn't say that we have worked as effectively as either US government or as an international community at some of the things that we should be doing and the implementation of the international health regulations is a case in point. As I said, they're falling behind, things aren't getting done. So if you're asking the question is could we do even better at collaboration if there was a coherent US government plan and there was a series of country plans that people bought into and really pushed to get implemented. I think there is the possibility for even better work. Michael? Well, I would echo your comment and Scott's about the fact that US government coordination I think is improving. Again, I can speak from a State Department perspective and with the experience of the Lower Mekong Initiative, I think in particular that has happened in the health pillar alone in the Lower Mekong Initiative, we have representatives from multiple different agencies including DOD participating in that on a regular basis. But the one thing that I would say in addition to of course better coordination within the US government that we really need is partner-country coordination. Of course with us, but with one another really. And it's part of the reason again why LMI is one framework again, it's been one of our goals within LMI is to get the countries of the Mekong actually working with one another. And especially in the health area, but across all these areas we know these are transnational issues and underdevelopment in the rural areas, especially there is very, makes it very difficult to coordinate responses and lack of capacity even more so. And so just getting the right people from these partner countries in the rooms and the right places in the right times, having the right conversations is incredibly important. And no matter how coordinated we are here, I don't think that we're gonna achieve very much if they're not as coordinated as we are. So that's at least where we're putting some of our efforts. Bernard? Yeah, so I can only speak from the malaria perspective which is where I spent most of my career. And frankly even going back to my days in Kenya where as the CDC director a large part of the funding for the studies we were doing actually came through USAID. We had a great relationship with the USAID country office there. So I was a little surprised frankly when I left that environment to hear that there were real problems in some countries with not as a effective collaboration with some of these major agencies. So I guess I was a little protected and naive at that point in time. I think, you know, I wasn't around when PMI was set up but I think some of the lessons were learned from other sorts of initiatives that maybe got off to a rockier start. I came about a year and a half after it was set up. Again, the decision had been made to have this hosted led by USAID with CDC as the main implementing partner with USAID and we have an interagency advisory group which includes NIH and DOD and others. I think that, if you just look at what happened that actually made quite a bit of sense because it didn't require PMI then to set up new country offices because it's basically part of the USAID health team reporting to the USAID mission director to the ambassador and sometimes the ambassadors do get involved with assisting us when we have things that are stuck. It is really like most things about people too and I think there's some advantages frankly to encouraging people to move between agencies and have some cross fertilization because you do see things from both the strengths and weaknesses from different perspectives once you've had that opportunity to do so. Lastly, from a PMI perspective, we've put a lot of time and effort on supporting the national malaria control programs, updating their national malaria control plans when there's new technical issues or the emergence of, I mean the new tools for example, rapid diagnostic tests, so the new recommendations from WHO, how do you implement those? And we actually won't fund anything that's not part of the national malaria control plan and which isn't a priority for the government so that brings in the issue of the military now where we're trying to encourage the civilian and military to have these sorts of discussions so that the needs of the military populations are actually included in the national malaria control plans. I think there does need to be, having lots of different plans and people different agendas becomes very problematic at a country and at least from our perspective, the way to do that is to have a technically sound robust national malaria control plan which is updated as needed. Thank you. Why don't we open things up and I'd like to invite you all to offer some quick comments, questions, please keep them succinct, please identify yourself. Just put your hand up and one of our folks will come forward with a microphone. We have someone here. We'll take three or four comments and questions so please, those of you who do wanna jump in also put your hands up. Yes? Hi, my name is Morgan Wolfe and I will be a rising senior at Northwestern this year and I was wondering, is there things that people in my position, people who recently graduated her who will be graduate soon, is there anything that we can do immediately to leverage our position and jump into this movement to help forward it or to help continue it when we get to a different place, I guess. Thank you. Do we have other comments or questions here? Gentlemen there. Thank you, respected all speaker. I am Ron from Cambodia. I appreciate your comments on the Mekong reverse project and I appreciate your project, what we call human security. That is a new term that I think we had just heard of a few decades or something like that. And I completely agree, sorry about my English maybe. I completely agree with you that the US right now put forward its foreign policy of smart or slash soft power to the region of Southeast Asia and as you see that Southeast Asia is an emerging region compared to other regions and of course Asian is a diversification of society, especially in terms of development and economic growth. As you mentioned, we have Cambodian, Laos and Myanmar, Vietnam is the less developing country compared to the other Asian country. And I support of course your project right now what we call human security, health security is functioning right now on the right track in the region. But I can tell you that how I can see that China probably see that you are not trying to put all the interest not only in the sea base interest but right now you come also to the river base power. I don't know what are you thinking about? From my point of view, I can see China can tell you that you are now not only interest in the sea base power in the Chow Sinai Sea and now coming to the river base power in the region. That is the point that I just would like to have a note from you, you will be encounter with China emerging in the Mekong region because China is the, you know, the Mekong region is the China, Mekong river is the China rivers because it's from China originally. And we call that we are in the lower Mekong river right now. So I would like to have some comment say that China is ahead from US compared to right now. I don't know how many steps you are behind China. China was in the region for many years and if you look back to the history, also China involved much in the region and China put their investment a lot on physical infrastructure in the region. And you are, right now you put what we call health security. China may think, wow, you bring both health and military to the region. What China is going to do to counter with you in the future. And I think China can see your point of view on that, I think. And if you would like to catch up China, I would like to suggest you also put investment on infrastructure. Let's say build road, build bridge, build irrigation, build hydro power in the region because we are desperate to need all this investment to the country or to the region. China right now build more than 1,000 roads in Cambodia on small loan and US just only build 200 roads in Cambodia and the road that was built by the US since 1950. So and since that the US never focused on build our, build the road or build physical infrastructure in Cambodia and that is my comment, thank you. Thank you, very powerful question set of comments. Can we get any other comments in front here and then back? We'll take two more and then we'll come back to our, we'll come back to our panelists. Please identify yourself. Thank you. My name is Jinning Wen with Voice of Vietnamese Americans. I just want to talk about the road of Vietnamese Americans for years now many of us have come back to Vietnam as NGO and we've done many medical mission short trips with sometimes we do it on our own. We raise our own funds and we gather our own capacity and put in medicine and things and our own doctors come back and treat the people in Vietnam. Is there a way that we can collaborate and be part of the proposal program moving forward? And also recently there's an effort to treat hepatitis B and hepatitis as a whole in Vietnam. And just recently there are many newborn babies being vaccinated and died immediately. So is there a way that we can look into it and help to build up that capacity and prevent such disasters. Thank you. Yes. Good afternoon. My name is Lieutenant Colonel Allen Chambers of the Air Force International Health Specialist Program. I have a comment and a question specifically for Dr. Smith primarily. And speaking in terms of health capacity to developments and mill to mill engagement specifically looking at Burma that's a very appealing situation in as much as over the last two to three decades many of the health infrastructure commodities and resources have been siphoned or funneled away from civilian populace to the military and largely resides now within a military infrastructure. But as the Department of Defense has several proposals potentially to launch and engage with the Burmese obviously there's some significant diplomatic issues as there's ongoing progress in democracy but still some human rights issues specifically in Erecon, Rocking provinces. I'd like to ask your opinion sir on any hurdles the DOD could anticipate in engaging in step with the Department of State as we approach Myanmar and working to improve both their military and civilian health capacity. Thank you. Thank you very much. So we have from Morgan we have the question around how do young graduates folks entering this field contribute from the scholar from Bard the question around China river-based power which is a great phrase and the question around how do we counter that from Jeannie around collaborating with groups like your own that are already active and the Lieutenant Colonel around Myanmar and the special sensitivities that are surrounding expanding the mill to mill we've heard from Bernard about how the military's within the region remain absolutely essential to any kind of effective response on the Artemis and resistant malaria and the question is how do you begin to sync up with them? Maybe I could ask that many of those move towards the China certainly and the mill to mills head towards the larger diplomatic and political issues so why don't I start with Michael and then we can move to our other panelists and they can also to the degree any of you can talk about the question that Morgan raised around advice to this generation that are interested in these issues and how to see the future. Thank you. Well, I'll start with a response to one of the questions in particular from our gentleman from Cambodia. China obviously plays a tremendous role and has for a very long time and will continue to play a probably increasing role in the region and I think that where we see it as hopefully a collaborative effort or complimentary effort over the long run and we have ongoing conversations with the Chinese about how to cooperate on issues on development issues across the board and even specifically on how to cooperate if there's a possibility to cooperate on health issues in particular in the lower Mekong region. So our goal is very much to have a collaborative partnership relationship with China in the region and to your point about specifically infrastructure in the region, that's obviously where a lot of Chinese funding goes. For the United States, obviously we have programs from USAID and some of the other agencies as well that are focused on some of the things that you were talking about here, whether it's irrigation and other related food security related issues. There are some infrastructure type projects going on in the region but they're more focused on capacity building and responding to requests from the lower Mekong countries and again, it's the framework of the lower Mekong initiative but more broadly from some of our efforts is to provide the assistance where requested and where we think our value added is and it's in sharing expertise and experience in a number of these different areas. One program that we started recently is actually providing technical assistance on infrastructure projects in the lower Mekong such as dams and related areas to requests that are made from countries in the lower Mekong providing them technical assistance when they're developing their plans and designs for those sorts of infrastructure projects. But more broadly, again, I think it's sort of this software building side of things is where we're spending a lot of our time and effort and I think where we have a significant value add and you see from the expertise across this table here but again, it's done very much in the hopes of a collaborative and complementary effort with other donors as well. China is a huge one but again, as I mentioned, there were a tremendous number of other outside donors from multilateral development banks to Japan and the EU, Australia and others and I think it's working together with all of them that's gonna be very, very important over the long term but I'll open up to others as well. Scott? Yeah, word about China. About five years ago, China asked us for help, technical help with the problem they had with Enterovirus 71 was rare as a virus that can attack young children and cause widespread outbreaks and occasionally severe illness and death. They wanted our technical assistance in laboratory area and epidemiology area which we provided. Last year, Cambodia had a big epidemic of Enterovirus 71 and asked for our assistance as well and in the course of responding, we found not only did we have a team responding to help Cambodia but China also had a team bringing laboratory and epidemiological expertise to Cambodia, some of which we had taught them just a few years earlier. This month or last month, within the last month or so, there was an article published on the first trial of an Enterovirus 71 vaccine from China, not from the US. So not only did they learn from our technical assistance and provide it to Cambodia but they are now ahead of us in developing an EV71 vaccine. So if the aim is to keep the US out in front and the situation the same as it was 10 years ago, we've lost. If the aim is to have a secure and more safe region, it's all good. The Chinese assistance in Enterovirus 71 to Cambodia adds to our assistance and makes the whole region safer and therefore us safer. But we shouldn't forget the lesson. What I said in my opening remarks was there's very little we can do that's more effective at building diplomatic relationships than helping countries when they're in a crisis. And that lesson is not lost on the Chinese. So it behooves our country to keep that in mind too. Others are learning those lessons and we need to make sure that we stay out in front also with that kind of assistance. I don't know if Commander Gustafson or Mary Ann can help me out with the Miramar question but in general, clearly we're working closely with state. Paycom has a number of medical niches specifically that they want to address there. We do the technical piece and then policy works with state for the where and when and frankly I don't know where we are yet on that and I don't know if you guys are prepared to say something quickly or not. Well sir, I think the size that is going to be two and then we'll come back on these questions. Quick comment please. Yes, my name is Laura Fogable from the Office of Global Health in the Department of State and I just wanted to follow up a little bit about working together. In the case of Miramar I'm sure we're going to run into some observative capacity questions and that's where the interagency close dialogue that happens at many different levels is very useful and for example, I just wanted to note that CDC runs these excellent field epidemiological lab training programs and when Laos found that it didn't have the ability to afford to send its health workers through a two year training program, there was a discussion and CDC was flexible enough to change its two year program to a one year program wasn't ideal in terms of the training that you want to have people absorb but it shows that when the agencies come together we can figure that out. Yes. Good afternoon, my name is Thu, come from Vietnam and I'm very honored to be here today to listen to the talks, the round table talks about the health support to GMS region including Vietnam and being a Vietnamese person I highly appreciate the support of United States in through the Mercy hospital shifts in my countries and also the building capacity for health worker in my city especially. 10 years ago my father-in-law went to United States to take that for a six month course improving the capacity and also I highly appreciate the American support in the program of diocesan clearance in land microlens, diocesan clearance in my cities in Da Nang city in the center of Vietnam and I have on questions, is that feasible and possible for United States government to push forward strongly forward the support to like the war victims to resolve the landmine clearance and also the victims of diocesan in Vietnam because you see in some province in Vietnam we lost the children, many children every day due to the landmine, so just my questions. Thank you. Did you have a chance to complete your thought on at that point and any to these issues? Well, just going back to Megan Wolf her question about what can someone just leaving college do to get involved. I actually find it pretty remarkable when you go on college campuses these days it's been a while since I was a student but the sort of level of interest and enthusiasm and global health issues and the fact that many universities now have global health programs that students I find pretty remarkable. I don't think there's any one way to answer your question. I think people come out from different ways. USAID, I'm probably the only myself and Admiral Zimmer are the only non peace corps volunteers but that's one way some people get involved is spending some time in a country through Peace Corps or working with an NGO to get some direct hands on experience and that then helps people decide what they want to do next or they want to go become a clinician do they want to do public health do they want to get involved in other sorts of issues so I do think it's important from a malaria perspective I continue to be surprised and thrilled that the American people, the taxpayers and Congress continue to put money towards something as important as malaria because frankly most people in the US are not threatened by malaria and as opposed to some of the other diseases we're talking about so I think the sort of advocacy that's taking place in college campuses and through other things like I don't even have a TV but what's the singing? American Idol, that's it. They actually had it. I've heard of it. I see most of my TV on airplanes and they don't show American Idol but I mean even things like American Idol having a malaria focus and stuff that sort of advocacy at the college campus is very important. It's something you can do now. And again going back to the question about NGOs. NGOs in the Mekong and actually in every country where we work are one of the main implementing partners but as I said, the way we fund is actually through the national air control program so an NGO working in malaria should be at the table with that and part of that plan as an implementing partner. Michael did you want to say anything about the issues raised with regard to the dioxins and missing? I would just note very briefly on that. Thank you for the question and it's a very, very obviously important question and a very important issue and it's something that the United States has been working on for a number of years now and is doing work on unexploded ordinance, landmine, removal, dioxin remediation as well. I think it's a key piece obviously of the partnership and commitment the United States has to our relationship with Vietnam. I think you saw some of this, some of the discussions that happened when President Song was here last week meeting with President Obama and so anyway, I would just say that our commitment sort of is ongoing on that so. Thank you. On the question around universities there, of course Northwestern has a long tradition is one of the most distinguished campuses with respect to Africa going back 60 years and has been very strong on the global health. There is a consortium of universities of global health that was founded a few years ago which brings together some 70 American campuses and almost 30 non-U.S. based or non-North American universities and has a large annual event. It was here in Washington back in March where almost 1,400 people participating in that and we've played a strong role in helping them get started three, four years back and participating with them. I think there is, as Bernard said, there's a very strong upsurge of interest among faculty and students and the big question it raises is the career connection, like how do those people find meaningful and gainful employment as they go forward and I think we're learning as we go forward about where those jobs and I think many of the job applications are actually turning out to be in some of the traditional areas. A lot of pre-med students are coming to us with global health majors and then they go into their medical training with a much broader outlook than earlier students and others are going into other lines of work and I think this is all very promising and very interesting. We published a piece by Mike Merson from Duke University back in 2010. You can go to our website, smartglobalhealth.org. You'll see a piece by Mike Merson that tries to analyze the root causes of this explosion of interest on American campuses. What are the root causes and where is it going and what does it mean in terms of the emergence of a very important constituency within American society now with respect to global health. We have time for a couple of final closing questions and comments. Please be very brief. We'll start with a gentleman in the front here and the woman next. Hi, I'm Jeff Grann. I'm with the US Department of Commerce. I direct the Office of Health and Consumer Goods and I just want to mention a project that we're involved in which I think hits a lot of the buttons mentioned and this relates to medical devices, regulatory harmonization and we are working with USAID industry, there's also commerce funding. We've been doing this for a while but it's ASEAN-wide training in implementing a common medical devices directive for the region and we're doing a pilot program which included a ASEAN-wide training program and in-country training coming up last two weeks in August in Thailand and Indonesia working with both ASEAN regulators and industry and the Thailand program we're inviting reps from Cambodia, Myanmar and Laos and we also have a program coming up in Vietnam. The dates are not yet set but it will likely be October and along with some of the comments that people made today it's really important to work with the regulators in the region, the industry in the region and also under ASEAN there's a ACCSQ series of industry focused working groups and we're working with the medical devices working group. Thank you. Thank you, one issue that we flagged within this report which grew out of a larger IOM study Institute of Medicine study is just how important fake and substandard drugs are as a problem within Southeast Asian particularly when you start looking at the resistance issue and this is something that it's very difficult to begin to get your arms around but there's been some progress the IOM study being one of the most recent but recent efforts that have tried to fill in our understanding. Ma'am. Hi, my name is Anisa Akbarukhta and I just have a question regarding female engagement teams working in conflict situations to collect intelligence, whether it's medical or national security for national security purposes and from either of you panelists, has this been something that you all have seen or yielded any data for any of the projects that you guys have been on? I'm sorry, can you just clarify what's your question? The use of female engagement teams in both Iraq and Afghanistan working on global health issues and was wondering if the use of them in any of the public health projects that you all have been working on has been of use. Okay, great, thank you. Phil Castle, Global Cancer Initiative. Two quick questions, one is could you elaborate on your NGO engagement? You sort of touched on it but you've maybe could say more about that and second question is more of a political question which is local sensitivities of having the Chinese government involved in some of the Southeast Asian countries. Thank you. Commander Gustafson and I was just wondering, I mean the DOD, we do quite a bit of training of patient care providers and providing equipment, building clinics but I'm curious to get your opinion on what do we need to do more if we're already doing it or what do we need to do if we're not doing it to really build partner capacity at a higher level because we could train all the people we want but if the countries do not have a sound ministry of health to facilitate a prolific healthcare system we might be just throwing good money after bad. Thank you. Thank you, let's take one last comment over here and then we'll come back to our panelists and we'll go down this way starting with Bernard. Hi, my name is Payang Lifang. I'm a Hmong American specialized in global health law and my question is what do you see the role of the diaspora in I guess in the US in helping out with projects on global health in the Mekong area and then the second question would be would you have examples of technical assistance, global health assistance programs that have actually promoted democracy in those countries that are I guess just emerging from authoritarian regimes? We go down our speakers and ask them to speak selectively according to which issues are directly relevant to each of them. Thank you. Sure, well I'll give a little more information on the NGOs since I think that was directed to me. Again, if you look actually there's a, those who are interested in further details there's a website, President's Malaria Initiative website where we actually have our annual Malaria operational plans for each country that are approved by the center agency group and in there you can actually see how the funding flows and what you'll note is that I can't think of a country where there's not a significant piece of the funding that actually goes through an NGO because it's very much based on who's best position to do this and most countries it gets into this issue of the systems in most countries are too weak to do everything they should be doing so most countries are very welcoming of NGOs that actually have the experience to actually be able to do some of this and the Mekong in particular, we have a grant to an NGO it was competed as a URC Kenan Institute grant to work on the Thai Myanmar border in this area of Artemis and resistance and frankly in some of these border areas the NGOs actually have a better reach than the governments themselves so I'll just stop there but if you actually want further details you can actually go on and whatever country you're interested in particular and look at the Malaria operational plans where that's described. Thank you. Just to hit very quickly on a couple of the questions I think that the question about the local perception of Chinese involvement in the lower Mekong I think actually raises for me at least a broader question about this which we try to pay a very close attention to which is local perceptions of outsiders, countries, donor countries and others getting involved in any way, shape or form and sort of how we do and this is of course something that's relevant to development assistance and collaboration across the entire world but it's something that we pay particular attention to I think because again coming back to one of my earlier points about the need for partner country buy-in and leadership on it I think that again across anything that we're doing here in the health sphere or in any of the other related areas in the Mekong if we're gonna be successful we need partner country buy-in and leadership from it which means inherently that I think they need to be supportive of the US involvement or the involvement of any other country or multilateral development bank or anyone else that's doing it and doing it fully in partnership with hopefully again partner country leadership in identifying what the issues are they need to work on with our support and then just very quickly I'd say to the question about how do we get at the training of higher level folks in these local governments and again I mentioned what we're trying to do at least with the lower Mekong initiative as an example of it and that recognizing that if we're gonna get at some of these systemic issues that you're talking about here and actually building long-term capacity for healthcare or again any other related development issue we're gonna need to build capacity in the ministries in these countries to build up their systems and so that's one of the things that we focus on through lower Mekong initiative but USA and other agencies have seen a thing and focus on that as well and again I think it's making sure just coming back finally to one of the points I made earlier is making sure that those the right folks from those ministries, the right levels are not only ones that we're working with but are also the ones that they're working with their correct counterparts from their neighbors is an incredibly important part of it so stop there. I'll take on the female engagement teams since I'm probably the one at the table that can do that having been in Afghanistan the teams that I've worked with were very effective to actually because of cultural issues we were not able to reach from a health point of view particularly in conflict areas because the NGOs primarily take care of it when it's not the conflict areas but in the true conflict areas where there's a desperate need we know in Afghanistan as an example that there has been a tremendous lack of healthcare availability to the females and so what these teams allowed because culturally men were not allowed to do it quite frankly were to get into the villages and actually help in the most needy areas in maternal and child health so I think on balance they've been very successful in trying to open that up and develop a better understanding because we clearly know that particularly in that culture the mom is the one that actually instills the health behaviors, the sanitation, all of those pieces and so that's really been I think a tremendous asset to be able to use for that purpose. Scott would you like to close for us? I was thinking about the question about training the higher level health workers that I wish I knew the answer. We ran into this challenge in the recent Middle East coronavirus problem where there's a serious lack of information about the virus and the epidemiology and so forth and communicating with the lower levels of public health in the area it is possible to communicate effectively but it seems as if when they breach the levels above them there's a lack of communication. So one potential solution is to train field epidemiologists and then just wait for 20 years but there must be a better solution. Maybe some of the college students who are out there can think of a way forward. Thank you. We've had a very rich discussion. We've covered a lot of ground. I want to again thank Admiral Peake, I mean Admiral Fallon, General Peake for their leadership and their commitments on this project which we would not have been able to carry forward without your contributions. Chris Daniel, Lindsey Hammergrin who engineered our work with a very complicated set of activities, travels, meetings and the like and Admiral Cullison who's made a deep personal commitment to helping us move this along and then of course to our panelists here today Bernard Naylon, Michael Fuchs, David Smith, Scott Dowell to a great thank you to all of you for being here with us for this discussion. Please join me in thanking them. Thank you.