 I'm Charles Freeman. I'm the Freeman chair in China Studies here at CSIS and it's my job is pretty simple I get to hand the mic over to Susan denser and have her moderate what I think is going to be a pretty spirited debate among two friends and and colleagues and Who who know a lot about the issue that we're going to talk about today? but Susan denser is Familiar to many of us from her years of PBS news hour But it's currently the editor-in-chief of health affairs Which I I would venture to say is probably the leading peer-reviewed policy journal looking at the intersection of health policy and health care issues generally so fundamentally qualified to Guide the point counterpoint that we're seeing today before I close and turn it over to Susan I just I'd be remiss if I didn't say at least something about the send I quake and and the fact that that Considering we're talking about health issues. There's a real humanitarian crisis. It's unfolding and send I and I You know my heart goes out to them and I hope all of yours does too so with that I'll turn it over Susan Thanks. Thank you very much Charles and good morning to everybody It's great to be here again at our latest installment of these debates on fault lines and global health I also want to say welcome to those of you who are joining us on the live webcast as well For any of you who missed the first three debates and desperately want to see them They are still available on the web at smart global health org slash fault lines Those events have really typified what we're trying to accomplish with this series, which is identify areas in which we disagree But also move the discussion forward by identifying areas of convergence Not complete convergence. Nothing is ever perfect But we often find in the course of these discussions that there are some points in which everyone can agree But we tried to get there by way of having a very spirited discussion about the elements of disagreement in the first place And so we're very fortunate that we have two Totally prepared to disagree people here today Jack Chao and Andrew Wong To answer the following question that the United States should press China To make the full transition from health aid recipient to global health donor So that is the resolution now the way we'll proceed is that Jack is going to argue in favor of the resolution that it is in fact time for the US to press China to become a global health donor Andrew will then respond We're going to start with their opening statements followed by questions from me And then of course from all of you and then all three of us will offer our closing remarks I'm now prompted to offer my own thoughts on this topic, but I would say they are probably going to be so less informed than the views of my two Debaters, so I'm going to yield back the balance of my time and let that it will plunge right into the Discussion, let me first though give you a little bit more information about our two speakers Ambassador Jack Chao here on my right is distinguished service professor of global health at Carnegie Mellon University And he Conducts that from Carnegie Mellon's outpost here in the nation's capital He has served pioneering roles in public service and global health diplomacy Many of you will know he was the first assistant director general of the World Health Organization on HIV AIDS TB and malaria He held the rank of ambassador as the special representative of then Secretary of State Colin Powell on global HIV AIDS And he was the deputy assistant secretary of state for health and science the first US diplomat of ambassador rank appointed to a public health mission He served at the State Department as a senior advisor for global health policy to the Under Secretary of State for global affairs He was a management consultant at McKinsey and company a staff member on both the House and Senate Appropriations Committee of the U.S. Congress and deputy assistant secretary for public health at the Department of Health and Human Services So you can see he's actually lived about 12 lives Jack finally is also a medical doctor having trained at Stanford here. Just MD at the UC San Francisco School of Medicine And also has probably it looks like about 12 additional degrees Among others from the Kennedy School of Government at Harvard. So we're very thrilled to have Jack with us today Andrew also or as he is known, but yang zong is that you're formal You're illegal name, that's right, right exactly the one you pass yourself off as here among us the folks here Andrew is a senior fellow for global health at the Council on Foreign Relations and has written very extensively extensively on global health government governance health diplomacy health security and public health in China and East Asia He has a forthcoming book looking at health governance issues in contemporary China including the current health care reform and the government's Capacity to address disease outbreaks food and drug safety and so forth He's a research associate of the National Asia Research Program at the National Bureau of Asian Research and the Woodrow Wilson Center International Center for Scholars and also a research associate at the East Asian Institute of the National University of Singapore he's the founding editor of global health governance the scholarly journal for the new health security paradigm He's also on the editorial board of several journals and is an associate professor and director for global health studies at the John C Whitehead School of Diplomacy and international relations at Seton Hall University He's taught at a number of places including Barnard in Columbia and received his PhD from the University of Chicago So you can see they come formatively equipped to discuss this particular Issue so Jack We're going to turn to you first to argue in favor again of this resolution that the US should press China to make that full Transition from helping recipient to global health donor. Well, thank you very much Susan and thank you to CSIS Steve Morrison Charles Freeman Thank you the community of CSIS for coming and hearing the argument and I also want to convey on behalf of us our art-filled compassion for the people in Japan Our friends professional and personal I'm doing okay I should state that the views expressed are my own and not necessarily I've had I've been invited to Take on the challenge of affirming this resolution Ten minutes, that's a lot of to me I thought I would the argument really cleaves into two components of disparity of need and the disparity of supply of aid Global health movement Really a special mission and that special mission is what can we do as a global community a world community to confront? the dynamic of disease death and debilitation as they intersect with the forces of poverty Impoverished regions of the world and the center of gravity of this campaign Is Sub-Saharan Africa? the World Bank has estimated that nearly half of the people Live or subsist or I wouldn't say endure at an income level of a dollar twenty-five a day basically five hundred dollars a year 40% of the children Are undernourished or are underweight and under height for their age compared to demographic standard and the Pandemics I was passed to confront a TV malaria when you add up the mortality statistics three million on a Six million deaths every year just from these three diseases On top of the devastation So it is not a just a turn of phrase that these are the diseases of mass destruction these are the societal destruction In spite of that or it to enter the breach ten years ago this country with others in the aftermath of the 9-11 attacks embarked on Signature moves in global health adding chapters to the saga the pep bar initiative Presidential emergency plan for AIDS that's now operating intensively in 15 countries the launch of The global fund to fight AIDS TV malaria that has now garnered Plus a billion dollars in pledges the presidential malaria initiative also working Stepwise accelerated fashion providing bed nets and ACPs in Africa And as that trajectory was launched as everybody knows Beginning in about 2008 the world has endured a debilitating crippling a worldwide economic Recession and that recession has produced Profound suffering here in the United States 10% unemployment Probably a next 10% are worried about their jobs and the rest of the citizen's free are Highly anxious about the economic situation last year the Europe the Eurozone under what its currency crisis so all together the United States in fighting a recession has accumulated a debt of 14 trillion dollars and From that deficit there is high anxiety about the implementation of the American health care reform Watch TV their states are struggling to cope with their Even amid this economic stress the global health movement has continued Secretary Clinton has Launched the quadrennial diplomacy and development review quitter for the Washingtonians among us that advances the notion of developmental diplomacy, how do we assert peaceful? civilian Power throughout the region some strategic interest in the United States in spite of the recession the global fund was able to raise 12 nearly 12 In pledges the 0.7 alliance of smaller countries Countries such as Sweden and Denmark who are allocating point seven percent of their GDP to overseas assistance last December Japan Launched its three billion dollar global health initiative and today I would argue that their ability to implement is understandably in question Russia repaid the global fund the grants that it had received recession and the Toronto G20 Assembly declared that maternal and child health as part of the Millennium Development Goals is worthy of another seven billion dollars in pledges so amid The crisis of 9-11 and then the economic stresses the global health agenda moves forward The words the disparity in supply the People's Republic of China in the past five years through this recession has been able admirably to grow their economy by an estimate of 11.2 percent cumulative growth rate over the past five years they have the been able to earn an accelerating budget surplus that's unprecedented in history and has Amassed a nearly three trillion dollar Foreign currency reserve and from that foreign currency reserve they've allocated 200 billion dollars for investment, but even with that they've been China has Secured a billion dollars from the global fund $150 million to fight malaria in a region where WHO says it's a fairly low prevalent state They recently yesterday earned a hundred fifty million dollar World Bank alone for water treatment they have increased their position at the IFF they have yet to declare a global health and development strategy And he's been monitoring the annual legislative session So the differentiation of the capital wealth position of the United States in China is 17 Trillion dollars and that dynamic has consequences. It has it means that when the global fund On its recent fundraising campaign came about three hundred millions of dollars short China could have made a difference people are concerned about the ability of the world to accomplish the Millennium Development Goals along a number of Already in the United States there are calls from different quarters of Congress Asking the administration So constructively What can the US Do to Persuade and engage China I refer to Jim Steinberg the deputy Secretary of State. I Had the fortune to pose a question at the Center for the national interest and I'm going to cover for Jim It's not articulation of official policy, but I asked him I said what can China do to advance humanitarian policy and said well China hasn't basically I'm paraphrasing an obligation as a global Citizen that they have a state in the solution and that on issues such as in the area that they ought to play a stronger role I Think I believe that a framework of engagement include the following elements the developmental diplomacy on their quitter ought to be multilateral and actively pursued to bring in surplus donors like China and the oil Oil of producing nations that the US China strategic and economic dialogue be a platform for Engagement with China between Ogac USAID and the global health coordinator with their counterparts that there be a trilateral approach that the US China works together in regions like Africa that there be a package of technical assistance from the US to China a biomedical research on epidemiology and science policy that ambassador nominee Secretary Locke F confirmed Can bring this agenda directly in Beijing and that what we're seeking is an outcome that China refrains from taking more global health the global fund ramps Allowing those resources to flow to the media that China Steeps a target an ODA target of maybe point five percent of GDP over the next 10 to 20 years that it repurposes some of that money it had a stimulus package of 586 billion of which 27 billion was dedicated That if there was rounded up to 30 billion dollars, I think that we wouldn't be having this conversation today that China Formulates and declares a Strategic goal and a strategic goal has three essential elements a finish line a verifiable finish line a timeline and a head line what is the declarative value of their actions and that it works in compact with the global community in implementing emergency assistance such as And then finally that it ups its contribution to the multilateral constellation Terrific and at this point precisely we do that not Andrew would give you the opportunity to ask questions of Jack Before I have to admit them there. I'm not good at the debate You clearly don't have children When I was a sophomore student And we were debating like whether China should have a shock therapy or not And I lost it to a freshman I have never been a diplomat so forgive me sometimes I'm not that diplomatic But I think this is a very good intellectual exercise asked by says to be in that position, but Don't take me Not the panda hug Well, I do I have to hear in Jack talking about the need for us to try China to make the transition from recipient to global health don't What do you mean by for transition and how do you characterize? China's status Would you think that? view China as a aggressive aid help aid seeker or a passive the Involving global health Or passive global health don't know how would you characterize China's status? the next question I Would Series of milestones that would define that transition I enumerated some of them which is to Stop taking global fun grants to start donating Right now their donation rate is 14 million dollars over five years Certainly that could be up. I I would have a suggestive goal Over the next five years of having China donate a hundred million dollars a year All they have to well with the from the interest of the city of three hundred million dollars They could easily easily cover this and that I would note that Jim Wolfensohn The past president of the World Bank is on the CIC International advisory board, so I I would see that as a positive side other other milestones is that we'd like to see China perhaps develop a Chinese version of USAID chain a Chinese agency for international development staff with the professionals that would organize and coordinate and be the nexus for interactions with our USAID In terms of country operations China could certainly Contribute technical experts of primary care physicians and nurses that work in concert with the pet bar and other bilateral So those are some of the tangible operational Objectives that I could see that can be embarked again. I'm not here to indict China and say I'm here to catalyze that dialogue and give encouragement Andrew do you have another question? I'm not sure It may have been that Jack Did he answer the question you asked because it seemed to me you were asking Something different which is how would you characterize this unusual situation China is in at the moment of being on the one hand? And as we know heavily heavily investing in African countries and many other respects building roads Etc building hospitals in some cases So it's it's it's a it's a donor and a taker at the same time. Was that the direction you were going in? Yeah My interpretation having worked at WHO and working with health ministries health ministries are typically under dots My role is to bolster them help help ministries produce the outcomes that allow them to win the budget battle I believe and I have no direct evidence, but just from my WHO tenure that China's Ministry of Health is in a similar situation that the Hard power agencies are getting the lion's share of budgetary resources so that the ministry has to go out and Get business on their own get the win the grants on their own I think that's a question that's placed to the ministry themselves, and I have I've enjoyed The coral my coral is not with with the health professionals of China, and I've worked with them Throughout but I think this dynamic is what is causing them to seek to pull money from the So it sounds like if anything you would characterize them as a reluctant aid seeker Forced into that of necessity because it is a soft power agency the ministry thought is that fair All right, well, we are going to move on now to Andrew's opening statement, and he has 10 minutes to set forth His feelings and pronouncements on the other side so Andrew Okay, well, thank you Susan. Oh, I actually well as I told us says when before we had this debate Jack and I we had a lot We agree Many friends. So that is would make this debate All right, but we do agree that I agree with Jack The China should chip in more in global health as it becomes a richer because that is good For global health governance that is good for China's own international image. We also agree that China should be encouraged To play a more prominent role in global health and the United States could play a constructive role my in working closely with China Toward this direction through channels such as strategic and economic dialogue But that being said I do have some issues with The jack's arguments First of all, let's get the facts right Foreign exchange reserve. Well, we know China has 2.5 trillion foreign exchange reserve But foreign exchange reserve is not a good way of judging a country's development level If you look at the 20 countries with the largest foreign exchange reserve six Including China, India, Indonesia, Algeria, Thailand, Brazil continue to be recipients of global fund money and More useful predictor is the GDP per capita If we actually if we plot the per capita GDP Against the share of ODA official development assistance in GNI gross national income There is actually a very strong correlation between the two that is the high the per capita GDP The more generous a country will become in providing development aid So it is not surprised that Norway, Luxembourg and Sweden But they spend a larger share of their GDP or their gross national income on official development assistance This let's look at the China in terms of per capita GDP China continues to have a very low GDP per capita The the more recent data suggests that its GDP per capita is about 3,400 dollars That is significantly lower than the world average, which is 9,000 US dollars and even lower than South Africa and Botswana and Also what Jack mentioned there are people who in sub-Saharan Africa who Below the poverty line, but keep in mind China has between 130 to 160 million people still living below the world bank designated the poverty line and also If you compare Look at some of the Chinese provinces by each province in terms of landmass and its population Level it's like a middle-sized country, right? So I found it instead of comparing China directly with other less developed countries Why not compare this Chinese provinces, especially poor provinces with those countries in sub-Saharan Africa, right? I have the data here. Some of the Chinese very poor problems including Guizhou, Gansu Yunnan, Tibet. They Just give you example, Guizhou, it has a GDP per capita of 1,500 dollars This population of 38 million people, right? It is poor than Sudan Or Guyana And if those countries like Sudan, South Africa, Guyana could be legitimate to the recipients of health aid Why not these poor Chinese provinces? and If you look at also the Chinese health disease burden despite those Progress China has made over the past decades China continued to face a huge actual growing disease burden. I'm not going to talk about the the chronic non-communicable disease just to focus on the infectious disease HIV China has 740,000 HIV carriers on The seropreference level is not that high 0.06 percent But 56.8 percent of people who are infected do not know their status So that means but that the HIV is spreading quickly from high-risk groups to the general population Let's look at TB. Jack just mentioned that in Sub-Saharan Africa There are two million people suffering the TB classes, but in China It is the second it has the second largest the TB population in the world Trailing India It has 1.3 million new cases of TB each year What about HPV a hepatitis B virus? China has 130 million people Carrying the HPV virus that amounts one-third of the world total and of the But this disease challenges pose the big challenge to China's health system If well actually based on the two-week morbidity rate in 1998 a one study predicted that between two thousand and two thousand twenty five or the number of the Patients are going to increase by seventy percent The annual outpatient visits or the people who are hospitalized going to increase by at least 40 percent And the medical spending is going to increase by at least 50 percent So that is a huge challenge to China's health system Capacity let's look at the health system capacity. Does it have that capacity to? Wizard that challenges Unfortunately despite the fact that that China is getting richer and the central state coffer is expanding dramatically There is a central local gap in financing health care This is the if you look at the local level of health financing of the 1994 the tax reform actually Make things even worse because it re-centralized the fiscal power But decentralized the fiscal responsibilities, so the central government is scooped most of the lucrative taxes and leaving the local governments with very low revenue Bear in taxes that will costly to collect and that problem was even more precarious at the sub-preventure level So decentralization has not led not led to a US style federalism local governments Focus on police power. It actually has increased the burden of local governments by showering them the responsibilities of promoting local economic growth and Public goods provision including health care provision and with GDP still the yardstick to measure their performance the local government officials this cash strapped local governments have few incentives to adequately finance health care and to reflect that marginalize the status of health care in their agenda the government health spending as a percentage of total health expenditure actually dropped from 36% in 1980 to 25% in 2008 So you see that why China is getting wealthier so richer that has not been translated into similar health system capacity at the local level and this happened at a time when those growing disease burden Reduced the state capacity when ever increasing capacities needed to tackle the challenges So if those purely endogenous solutions to build capacities unlikely going to be successful That capacity has to import it from exogenous Saucies like massive boring aid and poorly the Having a full trade transition to the donor status is not going to Leads to increased health spending at the local level actually is going to do more harm than good if we consider all those punitive positive benefits the Massive foreign aid especially our health aid has down to the Chinese health system capacity So my argument is different from Jack's that is we don't I think it's not a good idea to Seek a full transition to a global health donor status at this moment All right now we turn the Similar opportunity that we now give Jack to ask questions of Andrew based on what he's just said Thank you for your I think China lives under the tyranny of the large That any asset divided by 1.3 billion people So by that line of thought Oh You want I agree that This because this is just a too big a country whether when job all actually mentioned in Harvard that they you know a big Problem is divided by 1.3 billion. It's a small problem It's multiplied by 1.3 billion a small problem can become a huge humongous problem The but I agree that there was the this the that is the issue But I'm not this is not my attention Intention to say that China has to reach this as you be as rich as the United States to be a global health donor Actually, if you look at the trajectory of those global health donors like Japan and other countries You don't have to be as rich as the United States or other developed countries to be a Matured global health donor and I've Still have some data like Japan for example to join the club of donors in 1954 When it's GDP per capita was just a 30% of the US level Russia or that you just mentioned that there's the seems to be very The Aggressive in becoming a global health donor But it is a country with GDP per capita that is more than twice Higher than China and it is categorized as the up-middle income country by the way and China's Level today is only 10% of the US level So the in my point here is that we should give it more time We should be more patient. It doesn't have to reach the US level of the The the GDP per capita in order to be a full global health donor, but at least that we should give them more time To be a donor if you say don't be a donor at three trillion dollars What level do you think they could do it at 10 trillion dollars? I think there's a political dynamic here of the optics that They've built basically a Mount Everest Mountain-sized Cash reserve in fact the old hat That is heavily invested in US Treasury So you have this dynamic and this is an American-centric proposition of Americans who lost their jobs Because of this bilateral trade relationship, they're paying the interest on the debt that we owe And we're exporting money to support their health system Well, Jack, it seems to imply China is a passive but global health donor here that and actually just If we look at the history what China has been actually a very aggressive Donor nation until have been a very aggressive donor nation until the 1980s, believe it or not For a long time China was very generous provider of development assistance to the third world of course for political reasons and actually even during 1958 and 1961 when 30 million Chinese lives were lost in the famine China was still send that was ridiculous They were still sending money and food to other countries including Albania the foreign aid to the third world increased in 1960 and through the 1970s when China failed to support the decolonization movement and called the support of the third world countries So a Chinese development assistance as a percentage of fiscal spending actually increased to 7.2 percent in 2003 that was higher than most the developed countries at that time And it was only in the 1970s, you know way There was the agenda shift and then they are reassessed to the China's foreign aid program They draw some very important lessons for the China's the foreign aid experience You know are basically they learn from that experience that the amount of foreign aid should match the domestic development level that the There are limits of using foreign aid as a foreign policy instrument You cannot use foreign aid to pie friendship of those countries We now know that Vietnam Albania later becomes sort of like you know, especially Vietnam enemies of China even though they pump Tremendous amount of foreign aid. They also learned that the foreign aid if it's pursued should be mutually beneficial process so eventually with this growing burden of In providing foreign aid and the West and abuse The aid by those recipient countries your China reduce or readjusted the foreign aid policy in the 1970s That led to a significant drop of foreign aid as a percentage of the fiscal spending So I believe there's a reason for China to be hesitant in being a full What Jack defined a full global health donor because that Aid philosophy or that policy adjustment that was did the 1970s still pretty much affected the thinking of the Chinese policy makers Well, we've heard now these two arguments laid out Jack's essentially being Look judged by a number of metrics China's a rich country It is still receiving money obviously from the global fund for certain areas But it really makes no sense judged against China's enormous increased wealth in recent years and China really needs to step up to the plate and play a stronger role and he laid out a series of metrics for that Things that China could begin to do whether it was raising contributions to UNICEF developing a Chinese equivalent of USAID Of course stop taking the global fund grants and start becoming a global fund donor then we heard Andrews counter set of counter arguments essentially that the some of these metrics about foreign exchange reserves Etc. Are misleading that a better measurement is GDP per capita and he acknowledged that because the one three billion point three billion denominator that it tends to Lower the per capita amount, but nonetheless China is overall still a poorer country Particularly when you look at the situation of the poorer provinces and the populations in those poor provinces He mentioned the growing disease burden that China faces itself in HIV AIDS TB He didn't mention the non communicable disease burden, but that is also quite enormous and so Given all of this and given that China is still working through the internal Wrangling over how revenue is going to be collected centrally and dispersed among these poor provinces in particular It's not a good idea to lean on China too hard at this time. So that's essentially his argument So let me go back to you Jack and ask you So you heard Andrews perspective really and I will add to that that we know that there are 300 million Chinese without health insurance So China has the uninsured equivalent of the entire US population in effect Without health insurance the country is undertaking very aggressive health reforms to try to cover more people itself and radically raise the level of services provided especially in the poor provinces So the argument essentially as Andrew said is they've got a lot of their own knitting to attend to and maybe for The ability of the world not to mention the well-being of the Chinese people It's better to let Give them some cut them some slack for the moment and let them expend more resources on their own population As opposed to requiring them to become a large global donor at this point So what how would you respond to that? Sub-Saharan Africa As an emergency plan to rescue as many men women and children So for the argument to say oh we can afford to wait means Tragic outcome or you talked about the knitting it seems there's a country that can buy a lot of yarn Here's an identified provinces in China and large swaths of populations who are uninsured the English translation of the stimulus package that $506 billion indicated that China was about to Spend a hundred twenty-five billion dollars to cover We hope that they implement that there's obviously some budget disconnect in China political ecology that They put 200 billion dollars from their foreign exchange surplus and put it into the China Investment Corporation and in three years they grew that 200 billion dollars to Three hundred eighty billion dollars Investing in American and European That three hundred eighty six billion dollars is now about five times the size of the gates The interest on that three hundred eighty billion dollars or the earnings could have easily been dedicated to social Investing in China or to supplement the budget of these promises So now you have the dynamic the pathway which China is now the fourth largest recipient of Global fund grants it has a large it has earned more money from the global fund than South Africa If president Bush were to learn it Genesis of Donating funds We're going to create a global fund to confront disease in Africa Oh and past four ten years later the fourth largest recipient will be a country with three trillion dollars in exchange reserves I would have speculation. I would predict That initiative would have been so at the time of Global fund the world was very different the economics the relative status of these countries were different So in the past five years that has been radically radically So there's there's an opportunity We laid out the gas and I'm saying kind of has the wherewithal the resources It takes the willpower and the friendly nudging of the United States this administration People of the United States Congress to say hey look we need you as part of the alliance we need you as to be a part of the coalition of the caring and concern and This trajectory only makes the situation Okay, well, thank you well Andrew to turn over to you In a way Jack is being very diplomatic and polite, but if I could Take the journalistic approach And sort of to still down what he's saying is more or less saying look Andrew just because China runs a completely screwed-up fiscal policy and a Manipulative currency policy and has accumulated these huge reserves and is he says using them to invest in international companies and and neglecting in effect the poor provinces Who and reducing a large portion of the Chinese population to much more Much a much lower standard of living than is the case in the coastal regions Just because China elects to do all of that doesn't mean we should excuse them from the Investing and assisting in other areas of the world where the emergencies are quite dire specifically sub-saharan Africa So that it is it is not a reasonable excuse to say Good China take 10 or 15 years to sort yourself out Bring up the standard of living of your own people and then we'll let you off. We will not only Stop giving you money from the global fund And we will expect you to be a net contributor to the global fund as well as to other International assistance efforts. So how do you respond to that? Jack is of course, we're always very diplomat. Thank you. So present your journalist first egg I'm doing to present my scholarly perspective I Think this might be plan. I think China should not be blamed for other countries Predictment the China for example the apply for and and being awarded is the global fund money Well, they went through the same review approval process right that this same standards apply and The implements those programs we those grants with a rating So they are alleged the eligible for continuous funding and we can't blame them for that and your if that we're going to publish a punish the winners the also Get China move the other countries cheese If you look at the OECD data 113 countries receive the global fund money including 33 countries whose GDP per capita is higher than China's the and China receives a total G global fund money of 10 1 billion or if we count the 2010 data cause that is higher than four country four countries But if you divide again, this is the tyranny of large numbers If you divide it by 1.3 billion that's only 32 cents for China that is Significantly lower than most recipient countries including South Africa Which got 3.7 for in terms of the global health global fund money per capita car Congo Tanzania Ethiopia Nigeria. It's even lower than India's so the China is not aggressive of seeker of the The health aid and it won't be very failed to blame China for problems of other countries and I think there's a solution the solution is not to Press China to significantly increase its global of the health aid but to ask those OECD countries including the United States to Fulfill its political pledge of increase is the development assistance aid to 0 7.7 percent the the The level that they pledge that is the the development aid as the percentage of the gross national income Jack you mentioned the QDDR, right? The purpose of the QDDR is to call for leading through civilian power to address The the global problems, right? It presents explicit in my opinion explicit serious approach to projectively and improve the US soft power and if we are even debating Heal my Unfortunately, this is happening in the Congress whether to cut foreign aid I think this is saying a bad message to the Developing countries it also make our policy looks less coherent Okay, we're going to open this up now to questions from all of you in the audience While we're waiting for someone to ask a question and let me also add if you would identify yourself by name an Affiliation before you ask a question that would be very helpful. Let me just give Jack a brief opportunity to respond to what Particularly on this point about confusion of objectives on our part in the United States on what what we really want China to do There is a critique of the global public eligibility criteria that I would probably take an administration Can do more to tighten and clarify Happen in a real tangible way Start to take to heart This dynamic where it's not only China but others that are taking grants that Subtract from that could that that could have been dedicated again. I focus on China's budget ecology Layed out the gaps Why can't the budget system and China is now going through this annual legislative session? Why can't they Able to invest Domestically to the extent that it doesn't have to draw upon That's that seems to me where's the disconnect where is the policy architect who can say Let's mobilize whether it's from the CIC or the internal regular budget process Sufficient discretionary funds to these regions there by relieving and allowing China With your response so I agree with Jack that they should there they are these in terms of the The fiscal spending the structural while the public financing particular They should the restructure the central local relationship If you want to shoulder the local government's with more risk with all the responsibilities You have to give them the full fine adequate financing to get the job done Unfortunately, that is not happening today And in fact China where this is the the hurdles you know that preventing China from chipping more global health That does so far it still attaches more importance to domestic issues According to the senior senior Chinese health official last year I quote him China is still a developing nation and in social economic development are still facing grim challenges So China would make itself would make significant contribution to global health If it could address the major public health problems of the 1.3 billion people of their own so and of course what is happening in the Middle East actually would Make I believe even more difficult for the government to change that mentality because it highlights the importance of tackling domestic issues We know that there was a study the Chris's there We are last time we mentioned that study by Ted girl Robert Bates and others you know basically found a strong correlation between infant mortality rate and political instability including a disruptive regime transitions and actually China has infant mortality of 18 That is very close to Egypt Tunisia and Higher than Libya. So if the central leaders were reading that this the I hope they got that message Well, I hope they didn't actually Would they think hmm, I bet I have to invest more in my domestic the house system otherwise I would be in big trouble Okay, so are there questions for these folks and please identify yourself again. Hi. My name is mark Isaac I'm working with friends of the global fight here in Washington and I just wanted to direct a question to ambassador chow As to whether some of the things that he's been suggesting should happen may actually already be in process and by that I mean for example that in round 10, you know, which the global fund was Was making its latest round of grants only 15 point seven million was devoted to China I believe for a grant that actually will take place entirely in Burma I think across the border in a section of Burma and As well As I think you alluded to a moment ago The global fund board of directors is working on eligibility changes that are intended to direct more of the funding away from middle-income nations such as China perhaps to focus more on the poor nations and the global fund spent You know as I understand it tremendous amount of time and effort to try to convince China to up its donation So this is along the lines. I think of what you were addressing a moment ago But what what needs to happen politically right now in addition to what's already occurring to make these Things that you're talking about come about Now that seems like a fairly modest proposal Andrew would you go along with that that at least symbolically China should declare itself a donor It is a donor actually it is actually the situation for China is both a recipient of health aid and a donor of the global health the foreign aid related foreign aid if like when job all the Chinese premium announced the Closing of the summit the UN summit and China's commitment to contribute the US dollars $14 million to the global fund within the next three years But that was actually almost a total amount China pledged to the global fund money over the past Seven years and that actually makes a China top donor among all the developing countries And contributing to global fund because if you look at India I just I was proposing all those the the global found third the voluntary replenishment replenishment the pledges for 2011-2013 right India and Brazil did not contribute a dime South Africa contributed 2.1 million dollars and when job is more even more interested when job or announced plans to build the 200 schools dispatch 3,000 medical experts in 20 5,000 local medical personnel and provide medical equipment and medicines to 100 hospitals And all this I think is a good sign and the Suggested that China or that process has already started with China to become eventually a four-donut Declare that there would be a policy of country such as China being a net beneficiary that if you divide the one billion dollars that they've already gotten by the run rate of 14 million dollars Whatever three million dollars a year. There's actually no intention for China to ever Become a net beneficiary at this rate and a net beneficiary and that donor The intent is to allow countries such as China to be remaining net beneficiary You do the math right unless that that that trajectory changes at that run rate Right I Actually Jack I would agree disagree with that. I believe once China sort of had fixed is owing a domestic health health system and once that the mentality that philosophy has changed we would expect a significant contribution of China contribute to global health in fact It's Catherine here today. No the the CSIS is released. Oh, yeah, they released a report a couple of months ago that Entitled the key players in global health, right Yes, actually one of the crucial message actually I found it very interesting is that this give the the government's motivations For becoming involved in global health policy debates and the corporation programs vary and Depend to a large extent on domestic health and the political conditions So my I'm still I'm optimistic that in the not long Future that China could Become a significant Nation in terms of global health Let's move off of the subject of the global fund for just a moment. I'll come to this question in a moment I just want to quickly ask some of the other gestures that Jack indicated China could take that would be important symbolically and and and substantively a developing a Chinese equivalent of USA ID upping its contributions to UNICEF and other other Assistance organizations What what what would be wrong with that particularly again given? However, we want to characterize China It's hard to characterize it as a poor country anymore notwithstanding the fact that it's a Developing country with a lot of poor people and an emerging power with a lot of poor people in it Well, I think this is a good advice. In fact, I was there Jack you knew that actually Suggesting the Chinese government. You should probably has a US equivalent to the USA ID are too To be in charge of those the the foreign aid and development assistance and Currently that is the it's a very fragmented structural that that's authority of the responsibilities Scattered on different bureaucracies including Ministry of Health the Ministry of the other commerce and the very powerful the National Committee on Development and Reform and DRC The what actually there are so there are many Chinese researchers that scholars campaigning for that The problem here is still I think one of that is the political the China I believe it is on it would be unrealistic to expect Beijing to significantly Increases financial contribution to global health when Beijing still view the demands for China to shoot a more global Responsibilities sort of as a conspiracy to slow down China's growth to contain in China's rise You know that was actually The one of the political Hurders we face you know changing that the the structural and I 0.5% of GDP is hardly going to slow down China's rise Substantial right and that's what that was a threshold that Jack was suggesting Be aimed at now. I'm not that disagreeing with Jack about the the actual the numbers is here I'm talking about the political orders if the mentality is still there if those policy makers decision makers Convinced and all those pressure those talks about China's children more responsibilities It's just a conspiracy, right or in their words the these Requires to ask China to take a good more global responsibilities the obligations do not match China's Power status when they only exaggerated China's power and the influence While we attempt to choke the Western so-called developed countries responsibilities or at the same time trying in their words sowing the discord between China and a large number of developing countries Okay, that makes it difficult. Let's go to this question here, and then we'll come over here. Hi. I'm I'm Shelley Bressler. I'm with the Senate Foreign Relations Committee on the Republican staff and I do global health and one of the issues that Hits me when I go to these African countries is they show off the brand new Chinese soccer stadium Or they show off the brand new Chinese performance performing arts Center for a country that doesn't have steady forms of electricity or in a or a literacy rate above 15% Or they have a brand new road and not only that is all the workers building these projects are imported from China So it's not even making jobs in the in the host country. That is the recipient of this China's paying for this the providing the labor they're providing a lot of times the earth moving equipment that doesn't exist in these countries How can they justify just investing in that and then claim poverty that they can't invest in global health and they are starting to do a little bit more, but the main projects that have been very very Expensive have seen not to have been health related and also not investing in their own people and saying that they need the money from All different type of multilateral organizations when they're spending large sums of money abroad on non-health-related projects Kendra, well, there's some fundamental difference between the our way. I mean the American or developed countries way of Foreign aid in Africa and Chinese way of foreign aid We know that the Chinese the foreign aid or what is the government does not give the details about its aid programs in Africa but we know that Half of that was categorized as so-called the free aid the no political strings attached They are tend to be bilateral They also but the different from the the the programs and other Implement about other countries this program tend to be fast efficient the And in a way also effective You know I actually might have to disagree with you that you said China has not contribute significantly to Significant health aid to Africa that is not true You know actually China for example continue to pursue health diplomacy in Africa as the cost-effective foreign policy of foreign aid instrument the By the end of 2009 for example China has seen a total of 17,000 medical personnel to serve 47 African countries and regions and Served some 20 240 million people and more recently also China has pledged to build a 30 hospitals and provide the US equivalent 37.5 million US dollars in grants to supply those anti-malaria drugs and develop a 30 Anti-malaria the malaria prevention treatment centers in Africa so indeed it is doing a lot there But the the problem is this is a lack of cooperation Was firstly there's a difference fundamental difference in terms that approaches And secondly there is a lack of cooperation between China and the United States and other countries in Providing health aid in Africa and this I believe this is the area that we could encourage and promote the multilateral Let's take a question here Bristol I'm a freelance journalist Given the threats to the US foreign aid budget and the cultural differences between China and the US does the US really want China competing with it more heavily in this area Jack Jack I Wouldn't frame it as competition because I think this is a mission of humanitarian importance as When you when I was asked should we wait when you do the math of six million people dying from AIDS to malaria It implies that every day 20,000 about 20,000 people are dying from just those three diseases alone So to help rebuild health systems in these countries. I don't think it's really competition I think America would welcome an additional contributor based on both absolute and comparative advantages The United States has a very strong Pharmaceutical biotech industry. We have we have high rates of high high Numbers of well-trained individuals China has pioneered Much in the realm of primary care They helped to develop the Artemisinin the raw ingredient that that is the basis for the ACT medicine Which is absolutely transforming malaria treatment. So I would Articulate reframe it as America would welcome. I Don't speak for the administration, but I sense that the American people will welcome a Contributory China working in concert with our experts Have a question here and then we'll come to the rear And I'm actually a sophomore in George Washington University and my major is international fair concentrating on global health And actually my question will come from a student Perspective my first question is is there any possibility that encourage China to take a myth path which means not in not in not not In where China to become a donor quickly, but encourage China first become a self-sustained country in The house issue and also my second question will be do you think is there any Other things make China is not ready to become a donor instead of not willing to become donor All right, so let's take the first question which to paraphrase would be What what if China just said, okay, we're gonna stop taking global fund money We're not ready to be a much greater donor than we are now give us a few years and here's a plan for us to become a More a pronounced donor in the future once we've dealt with some of our domestic issues Jack Do you live with that? I think China has the financial wherewithal to address its domestic health Needs and still supply Whether it's financial or technical or health workforce contribute to the alliance of countries that are operating in these regions we It was mentioned that In in some countries there they're actually building Construction projects well why couldn't instead of building sports stadiums and and art centers They could be building clinics and and and and hospitals It seems to me that there is a a challenge of policy architecture and and and basic Vision that if judiciously applied can liberate resources domestically as well as have a Contribution internationally China has just now is is now the third has the third largest voting power in the IMF They actively sought this they want to contribute to the international stage So if you go to the next level say operationalize that work in these countries build the hospitals build the clinics build the road connectors That can be done. So it's just as the no middle ground no middle ground here time to really convert yourself into an international donor This country the United States after 9-11 through the recession still accelerates its commitment the global health Initiative authorized that 60 billion dollars. We have done it We have actually gone deeper into debt to help other countries. So here's a We have other other other Countries in the international community that are in a relatively stronger financial position that hesitates To do modest amounts in this endeavor All right, and we had a question back in the rear Mike Engelgau from the Centers for ZDs control and prevention and working in global health Focusing on non-communicable diseases, which is a huge issue now for China My question is a little more broad than that though. I'm trying to get my head around the politics here You have a country an economic power recent state visit here to the u.s. on the one hand and On the other hand, they're a recipient nation for these kinds of programs How does the internal politics? What is the political space that can allow? For what seems to be discordant, you know where you're you have this image of a power An economic giant yet at the same time our recipient of Global aid and then related to that how much of that is do and I think Jack alluded to this that the ministries of health And the leadership for health in the country May not have the influence they would need To have more in the health arena to move forward on some of these issues Andrew without giving us a What appropriately would be a five or six-day? Disquisition on Chinese politics. Could you address the first part of that question in particular? What well what creates this rather anomalous situation? where There are these enormous resources there has been a lack of investment internally And there is this strange External policy of becoming a being a donor, but also being a taker of aid. How how how does all that work? Well, we have to keep in mind if you look at the history right the China that the For a long time was not a major recipient of foreign aid In fact for a long time except for the Soviet aid They refused to accept foreign aid during the timeshine earthquake in 1976 For example, all the international organization foreign countries play Promised aid medical supplies for China just to sign and say no we don't need your Money we don't need your Equipment we don't need any of that we can do it all by our self and actually China of that did not change until 1979 to be accurate until 1987 so in the 1980s it began to receive aid from developed countries Including ODA from Japan and international organizations such as WHO, World Bank, UNESCO They all provide and later Global Fund They'll provide a health aid to China but China's acceptance basically a foreign aid was not Routinized until late 1980s So that was the basically the history right that the China's history of receiving massive foreign aid did not occur Until late 1980s actually 1987 so it's just we talk about 23 years of China receiving foreign aid and while in the meantime as I said it is already an active donor They in terms of global health, especially when we talk about its health aid to Africa You know so this is the transitional stage and we should be a little bit more patient allow actually the China are eventually to complete that transition from a recipient to Donut nation Jack I think Mike's question is is quite profound which is basically the question How can health ministries be effective players in political ecologies? And I alluded that in my time of service at WHO Bolstering health ministries was a core part of my mission. I believe we have to train now those who become health ministers doctors Being in medicine and public health is a technically demanding Profession and as you rise up through the ranks you're very specialized, but you may not have the skill set to bargain with with Versions of OMB so I believe that one agenda in the future is how can we train? Promising health ministry officials to be Better bargainers being able to crystallize strategic goals and being able to be persuasive in the track that requisite funding We we are getting close to the end of our time So let's just take if we could just one more question and then we'll go to final statements I'm Jean McDermott from the Fogarty International Center at NIH and we run research training program So I want to just follow up with Jack's last comment and say and ask him if he would see that Supporting training for those kinds of people. Is that a legitimate? Legitimate Product for China to be a recipient rather than a donor Absolutely, and in the spirit of for full disclosure. I used to work at Fogarty. So this Advancing biomedic bilateral biomedical Research ties is is a very important function in bolstering being able to train scientists how to use The scientific method how to set up laboratories how to collect data and articulate it and and hook it to a public health mission is a valuable and noteworthy Workstream Well, we're now going to move to closing statements from both of you And you both did such a marvelous job of laying out your initial Statements that I would ask you not necessarily to repeat those verbatim now Perhaps you want to give a very distilled version of that But let's close by acknowledging what that the other person said you could go along with what and what Specifically could be a way forward at this particular juncture given the state of the U.S. finances the state of the global threats that we face in terms of International health and the desire to move forward in a constructive way with the Chinese Relationship so since Jack started Andrew, I'm going to turn it over to you for your closing statement first Thank You Susan. Thank you Jack. I actually as again. I agree with Jack many fronts and that we all I think we We have no problems that the China should Chipping more in global health and the United States could play a constructive role in that process and We also agree that China should Invest more in stomastic health system that the and a Trilateral or multilateral approach would be The ideal approach in terms of cooperating with cooperating with China in that Toward that direction. So the question is how to Achieve that transition. I'm basically I'm instead of arguing for a Quick haste approach. I'm basically my argument We should be a little bit more patient giving China more time and in fact Also focus on the importance of focusing on encouraging more invested Investment in domestic health spending because if according to as Jack has suggested the reason for China's active pursuit of health aid It's political that is the minister of health is very weak bureaucratic status Then why not encourage in China to invest more in domestic health sector so that the minister of health Reduced incentives to pursue foreign money So that is one secondly, I would ask the United States to Chipping more and especially to fulfill its pledge to develop a development aid to zero point seven percent of the gross national income Because so far we only reached zero point two one percent and nearly twenty percent of that goes to the building of your post-conflict rebuting of Iraq and Afghanistan so by raising the US ODA With 67 billion to reach zero point seven percent There would be plenty of money available for achieving global development objectives and thirdly, I think We should encourage and promote the dialogues with China International development issues and projects including discussing policy a potential collaboration encourage more transparency and for Thirdly, I think in terms of these priorities of foreign aid to China, I think we should not just focus on certain salient or sexy infectious disease like PB Like hey, I'm sorry HIV or Malaria, but also focus on those infectious disease such as to be classes Hepatitis B and also focus more on non-chronical. I'm sorry non communicable chronic diseases, you know, so there Should be a lot of potential for the United States and China to collaborate on this in this areas And the last word then goes to you. Well, thank you Susan. Thank you and John I'll build on the the platform that you just laid out that because I I feel I can agree with much of it Instead of chipping in I believe America and China should be shoveling more in but that's a matter of semantics the global health diplomacy is enlightened statecraft that Catalyzes mutual pursuit that a healthier world is a safer world And that as I described earlier The global health diplomacy movement has many chapters to go So I I would like to see the next chapters of global health diplomacy On China to be filled with great stories Rather than a series of blank pages Is which which seems to be the trajectory that we're on and to use this metaphor even further the global health Journey is not even at the fork in the road. We're on the wrong road We're on a road where China depletes funds from the international community. It's creating divisions and questions from the Congress and from civil society and the NGOs about the equity in this pathway and what I'm suggesting that US China working together collaboratively in a friendly way Creates that that connector across the median strip to connect with the other road and I envision that road is the multi-lane multilateral superhighway with a supply chain that is brimming with public health goods that are going deep into impoverished nations and China has the ability to join this convoy Dedicating its workforce its finances its expertise and the heart of the Chinese people out of Chinese heritage I know I probably know this and together if we can build this convoy and look at the horizon of aspirations our most most noble ambitious goals and we can say we can say that we can achieve a fulfillment of a campaign of liberation by defeating AIDS defeating TB Defeating malaria we free millions of people we save 20,000 people a day from death disease and Abilitation and we we achieve a very tangible outcome Which is parents alive for their children children alive for their futures and entire nations Alive for their destiny and that is that is why I feel so passionately about this and thank you very much Well, we seem to have converged on a series of road and construction metaphors to Articulate the differences as well as the areas of agreement among our two Andrews basic position being yes China should be chipping in more money on global health Jack saying no it ought to be shoveling in more money on global health Andrew feeling that China is on the right road It's just going to progress slowly toward the destination, but it is on the right road and Jack feeling no It's on the wrong road at this point and needs to get on the right way and then finally we have our automotive analogy or for Transportation modality analogy which says that In effect Jack believes China has to get in on board now a major International global convoy to combat these diseases in very poor countries And I guess that would leave you Andrew arguing that China needs to develop its own unique little car at the moment and chug along and get there Get there pursue this same path pursue the same road But get there perhaps in a slightly at a slightly different timetable than Jack would like to see so with that We have our fault lines clearly established. It is unfortunate that the We're using the phrase fault lines today on a day when there has been a terrible earthquake in other parts of the world And so once again, we emphasize our solidarity with the Japanese people and with others who may be threatened by the aftershocks As well as the tsunami But we thank all of you for coming today and look forward to engaging you in the next of the Debates over the fault lines and global health. So thank you very much Thank you Thank you