 Well, hi everyone. I'm Bob Schieffer and from TCU, the newest member of the Big 12 as of this week. Already the current Rose Bowl champions. But we'll try to talk about something other than football today. We have just a really kind of exciting thing to talk about and something that sometimes we do these talks and it's something I'm familiar with and know a lot about. This is one I have to say until I got to looking at the research. I was surprised at how much I didn't know about it. So if that's the case, maybe there are others that don't know that much about it. And so maybe we can perform a little service here and help folks to know what this is about. Today our subject is a really big one. It is the U.S. commitment to global health and we have four people. We'll soon have four people who know a lot about it. One of them is still in root. But here on the stage Dr. Thomas Frieden who is the director of the CDC. He is a dynamic health pioneer. He spent five years in India working on TB after working on the TB crisis in the early 1990s in New York City. Mayor Bloomberg made him health commissioner there in 2002 and empowered him to eliminate smoking in public places. And we all know of the success of that program in New York. He has been at the CDC since 2009. Congresswoman Kate Granger is former mayor of Fort Worth which is the home of TCU and also my hometown. She is the chair of the House of Appropriations Foreign Operations Subcommittee. How long have you been at Congress? Fifteen years. Fifteen years. She has become a strategically important advocate defender of U.S. foreign investments in development and global health. Over the last decade the massive expansion of U.S. assistance and global health has rested on an unusual bipartisan support in Congress. That of course has come under most recently a great deal of stress. And many look to Congresswoman Granger to preserve the bipartisan spirit that has sort of marked this particular issue in these tough times. Susan Dinsler who will be with us shortly I think she's kind of caught in traffic. She is the editor in chief of health affairs. She's a well-known widely admired expert on domestic and international health policy and brings a very unusual mix of skills and perspective. And then Dr. Steven Morrison who is the senior vice president and director of the Global Health Policy Center here at CSIS. Dr. Morrison writes widely, testifies often before Congress is directed several high level task courses and commissions as a frequent media contributor. Served for seven years in the Clinton administration. Four years as a committee staffer in the House of Representatives and taught for 12 years at the Johns Hopkins School of Advanced and International Studies. So you can see the expertise that's represented on this podium. We're going to try to divide this discussion today into three parts. The unprecedented growth of the U.S. commitment to global health over the past decade. Second, what happens to that commitment during this new era of austerity. And finally, how should the powerful platforms that have been built and created for HIV, TB, malaria and now maternal and child health. How or should they be used to meet the new challenges such as non-communicable diseases. Let me start with some figures that I think you will find as startling as I did. The U.S. global health investment skyrocketed between 2003 and 2010 rising from $1.7 billion a year to $8.8 billion a year. Reaching over 30% of our total foreign assistance. So Dr. Frieden, let me just ask you, how is it that we have come to spend this much money and what are we getting for? I think you have to divide that into two things. Why do we do it and what do we do? So first to start with the why. First off, it's in our interest. We can't build a moat around the country. We're all connected by the air we breathe, by the water we drink, by the food we eat. We're increasingly interconnected. So whether an infectious disease like measles starts and spreads this country or drug resistant organisms develop and spread here, it's in our self-interest. Second, it's in our self-interest also that our trading partners are productive, that they're stable and what we know is that if you increase exports from this country 10%, you increase jobs 7%. So most of our growth and our most dynamic growth in exports has been to developing countries. If we can help them be more stable, more productive, that's in our own self-interest as well. It's also a wonderful form of soft power. I wish American taxpayers could come with me when I travel around the world and talk to women in Nigeria who say my baby is born without HIV because of American assistance. This is so powerful in our self-interest as a country, but ultimately it's who we want to be as a country, that there are literally millions of lives in the balance. We're not responsible for the whole world, but we can make a huge difference and with leadership of Representative Granger and her colleagues, we've been able to change the world in dramatic ways and it comes down also to being able to say we're getting results. Polio is down 99%, eradication is within view. Measles, we've prevented nearly 13 million deaths in the past decade from measles. Through PEPFAR, there are 3.2 million people alive, walking around teaching, learning, helping in their societies who would be dead or dying otherwise and 110,000 babies were born without HIV last year because of PEPFAR. These are results. They're driving down rates and I think the fact that we can, as Representative Granger has emphasized, do what works, demonstrate what works and if there are things we're doing that are not working, not having an impact, cut them back and ensure that every dollar we spend because they're precious is making as much of a difference as it can. Dr. Marshall, what was the driver behind all this HIV-AIDS? Well, looking back to the beginning of the last decade, there was a remarkable convergence of several things that happened. You had the exceptional threat that HIV-AIDS was seen to pose as the explosion of new infections translated into folks getting sick and the sudden awareness of what this meant, the magnitude of that and the emergency sense that came across. There was also presidential leadership, the fact that President Bush embraced this issue and drove it and leveraged his administration. There was the bipartisanship within Congress, the spirit of standing behind this and thinking in much bigger terms. There were changes in our own leadership, in our own society that you had foundations, you had the Bill and Melinda Gates Foundation, you had faith-based institutions that came to this agenda in a new and very profound way that you had this burst of altruism and interest on American campuses. Our own society was beginning to change. Most importantly, it became apparent that we had reliable and worthy partners in the countries in which we were operating and that fact in and of itself was perhaps the most profound discovery in this period because we did get results rapidly as these programs were scaled up and no one had predicted this outcome. No one believed that this set of factors were coming together in quite that dramatic and powerful of action. What would you say are the two or three most important things that happened? What are the most important achievements during that period? Well, Tom has given us some very good indications. The fact that we can stand back at this point eight years later and say that we are directly contributing to the life, to the sustainment of 3.2 million people on life-sustaining therapy who are living with HIV, that was unthinkable. That was unthinkable, simply unthinkable eight years ago, that we would have discovered the ability to create the kind of basic infrastructure for the delivery of multiple services in low-income countries and be able to have these immunization campaigns that Tom alluded to that we could bring massive changes in malaria programs. That was a second initiative that President Bush launched in 2005. These are some achievements that are very long-standing and profound achievements. Congresswoman, with all the emphasis on cutting and balancing the budget, remarkably these programs have enjoyed bipartisan support for the most part. I want to ask you about what happens now before we talk about that. What happened then? What was it in the Congress that caused people to actually come together? We're a very compassionate people. The United States is a compassionate country and we pride ourselves on that. We also had the technology and the innovation and then I think one of the most important things of partnership. We really said we're going to be partners with countries and partners with foundations like the Gates Foundation and so many that were in there working so hard and doing such a good job. And then we also took that partnership to industry and had Procter & Gamble, for instance, our Coca-Cola and said we're in this too and so wherever we're in the world. And we really got smarter and smarter about it as well as caring. And here is the fourth member of our panel, Susan. Hello. I hear you got tied up in traffic. Yes, indeed. Once we fix global health we'll work on traffic congestion in Washington, D.C. Well, thank you. Go ahead, Cos. And I think that was very important that we really recognized that. And as countries, PEPFAR, for instance, a huge, you know, $15 billion five-year commitment, PEPFAR, the Global Fund, GAVI on immunizations and vaccines, 288 million children have been vaccinated. But it was a partnership and I think that was a big step forward. What do you see? And I mean, I think that takes us right to the next part of this discussion. Where are we now? Obviously there are going to be great pressures to cut the budget. People always want to cut foreign aid, which actually is a very small percentage of the budget. What is it something? One percent. One percent. Although not this audience because they know better, but I do this all the time in other members of Congress and in front of an audience. They'll say, well, if you just stop foreign aid, stop spending that money to other countries, we could balance our budget. So I always ask the audience, well, how much, how much, what percent do you think it is of the spending? And it always is between 20 and 30 percent, about evenly divided people would say it's 20 percent or 30 percent. I said, no, it's 1 percent. But it's still, you got to use it right. But this part of it is a pretty good, good, pretty good part of that 1 percent, isn't it? That's what surprised me. Right. So how's it going to survive in the current atmosphere? It will survive, but it's like everything else. In this time where we really have to cut the spending, it's being cut in every department, in every type of funding. It's my job because I chair that subcommittee that does the funding. It was really important to me that it not being across the board, we're just going to cut by this amount. Because if you do, we lose all of our flexibility and all of our, you know, the ability to respond to emergencies that have been huge. Haiti, for instance. And so I really fought for that. I had great help because it is bipartisan. And Neal Lowy, who's the ranking member, she was the chair and I was the ranking member when I came on. And then we got the majority and so I became the chair and she's the ranking member. But we do it as a partnership. Absolutely. And we speak often and really come to decisions together. But it was how do we preserve this, particularly these programs that are so important, but we have to be more innovative. Because the need hasn't lessened. It's just the funding that's lessened. And that's what we've got to really be aware of. And so Raj Shah and I have long conversations. He's wonderful. We talk and communicate how we can do this in a time of less funding. One of the, just to build on what the Congresswoman says, the partnerships are key. Partnerships within the U.S. government. So we have a whole of government approach and we can use the comparative advantage and special skills of the Peace Corps, of the Department of Defense, of the CDC to ensure that whatever resources we deploy are as efficiently and effectively deployed as possible. And then the partnerships outside of the government. If you look at polio eradication, Rotary has been a key partner there, driving the way I know that you're a Rotarian. And I've been in, I was in India last month and there was a fight between two different officials over one logistic detail of the polio eradication campaign. And it was Rotarian who got them together and said, you know, none of this. This is about kids health. Get over it and work together for the society as a whole. And I think that kind of working together within the government, with the State Department playing a core role as the coordinator and facilitator, and then working together within society, having groups outside of the government, ensuring and pushing and helping and strengthening and extending what the government can do. These are essential partnerships. Well, Susan, you're the journalist here. So we've heard from advocates, we've heard from a member of Congress. Where do you think all this is? Right. Well, I think we have so much to reflect on that is positive and really to celebrate. And that, frankly, is a journal interested in chronically not just the challenges that we face in global health, but the successes that we faced and learning from those. We like to focus on those. I was just in preparation for today. I was assembling what would be on your list of the top five triumphs. Well, more than half the countries around the world are, in fact, lowering maternal and child mortality and are on track to meet Millennium Development Goals four and five. All of the people that we now have on treatment and HIV AIDS that was unthinkable, unthinkable 15 years ago that we'd ever get to this point. 33 million tested around the world for HIV last year alone under PEPFAR funding. We just sort of go down the look today, WHO notifying us that tuberculosis deaths are falling. We have a long way to go, but we have just one success after another, demonstrable successes, not just as a consequence of some of these so-called vertical programs like PEPFAR, but clearly because of the success in health systems strengthening that has gone on as a consequence of the investments in these vertical programs. We have a ton, a ton to celebrate and should not lose sight of that at this point in time. Now that said, we face all the challenges that the Congress and others have already discussed, and we also face some opportunities to stretch our dollars farther. I think that Raj Shah would be the first to say, we know we could do an even better job in procurement under PEPFAR, for example. We still have a lot of overhead going to U.S. and other entities that probably we could squeeze out. We know that as Tom Frieden said, the embrace of countries and partnerships with countries can go even farther. We know from some research that has been done by the Institute of Health Metrics and Evaluation that an unintended consequence of us giving more money for these global efforts is that some countries have reduced their own spending. So we know we can encourage them to be better partners in this effort and spend some more money. So it isn't just the large donor countries that are spending it. So we have all of these challenges. There's no doubt about it, but we have enormous successes and we have some room for improvement even within existing budgets. And I think obviously for the next year we're going to have to push as hard as possible on that piece of it to get more bang for our bucks. Let me just bring up one thing that some critics, and I'd just like to get the sense of the panel on this, some critics argue that what happened in the last decade that we responded overwhelmingly to an acute emergency HIV AIDS without thinking clearly about the long-term costs. Have we created a sort of an entitlement now for AIDS and related infectious diseases that is not affordable and crowds out other vitally important needs for a scarce foreign aid dollar? Let me just go around the horn here. I think we've created a situation that requires us to be extremely careful in this phase right now. I think that there's no question expectations have been raised that we've created a carrying cost that's quite high and in some respects could be much more efficient and that the ownership and partnership of the host governments that's oftentimes been wanting or been weaker than could otherwise happen. I don't think that that reality argues in favor of disengagement. I think it argues in favor of some kind of medium to long-term strategic planning in our relationships. Right now, just to give you a very powerful example, we were in South Africa in August looking at that transition now when the U.S. government decided to launch its PEPFAR program there. We had a government that was hostile to the notion of even acknowledging that there was an HIV-AIDS crisis and a need for a response. We made a commitment of now over $3.1 billion in South Africa and since 2009 we have a government there that's completely reversed its policies is making massive commitments but trying to correct that gap and we need to, in an orderly and systematic way, respond to let the South Africans lead and scale down but not walk back. And in that case you can make the argument that yes, there was a huge possibility of an unaffordable mortgage but there's been a political change and an evolution that makes it possible to manage that as a success story but it's going to be complicated, it's going to take four or five years to get to that point. So I think there are solutions. One thing that I thought, based on that in the bill that passed the subcommittee one of the things we did is we didn't put numbers by diseases. We didn't say it's HIV-AIDS, it's this much and whatever because there was starting to be that expectation we said in some cases we respond to a crisis and then it was not a crisis anymore then how do we have sustainability? So I think two things. One thing is we gave that flexibility and said we're not going to say this much and have the diseases or the country so much competing with each other but the other thing is to change in our thinking and really focus on sustainability. If we're going to do this then how do we sustain it? Well we sustain it by helping to build the infrastructure in those countries that they can take it over and not just us. And two things I relied on right in my bill. One was the CSIS, the commission report that talked about that and the Quadrennial Review which said work towards sustainability. In some cases that means that there's some countries that can't take that on. If they're not even trying to take it on then they won't get funded because we have to have a partner in the country in building that infrastructure very much. I think first off we've learned a lot and we've been able to drive costs down substantially and what CDC does we consider that every dollar is precious, we have to be responsible for it and we use operational research to say how can we drive it down even further and we think we can drive the unit costs for treatment down even more through sensible protocol changes. That's going to allow us to treat more people which is very important and we now know that when you treat someone you reduce tremendously 95, 96% their risk of spreading it to others. So treatment is prevention not only in TB but also in HIV and by driving down the unit costs we can stretch our dollars even further. Second, transferring to host governments. This is in our genes at CDC. We are the counterpart with the Ministry of Health. We help transfer it to them and to much lower cost workers and systems the ability to run programs but it's kind of a build-operate transfer arrangement where you set up the infrastructure, you set up the reporting, you train the staff and it's easier to transfer it at a much lower and much more sustainable cost going forward. And third, to make optimal use of the money. We have to take the resources from PEPFAR and from the malaria program and TB program and ensure that they're used as broadly as possible. If we're preventing maternal child transmission of HIV we can very easily prevent syphilis which affects still hundreds of thousands of babies a year. If we're preventing malaria we can also address the need for blood transfusion and safe blood transfusion. If we're addressing TB we can strengthen laboratory services all over Africa and so it's not only using the dollars more efficiently to address the problems that we're addressing but using them more efficiently to make sure that we're broadbanding what we can have while we still keep ourselves laser focused on the outcomes to ensure we know from today's release that last year 400,000 fewer people died from TB than died five years ago and that's because of the kind of programs that we're supporting through PEPFAR and other global funds and other efforts around the world they're making a huge difference in helping countries be more able to take on the burden themselves. I think the comeback to the accusation that we've got into the emergency response in HIV AIDS without fully contemplating the end results the comeback is what Tom just said. The key point that now we know that treatment is prevention that we really can seriously sit here today and talk about ending the HIV AIDS epidemic. Now whether we're going to get there or not who knows but we know that we could potentially put a lot more people on treatment and prevent a lot more transmission of HIV AIDS. We also look at the way the science has evolved. Male circumcision, microbicides, you know there are all kinds of things that we just could not possibly have contemplated when we got into this response that now really do give us the tools to end the epidemic. And how can you turn back the clock and say we shouldn't have done all this? Look at the lives that we have saved and look at the potential that we now have in front of us to save even more lives at lower unit cost to boot. Let me just ask the panel, where are we on AIDS right now? And I say this because it's probably getting on 10 years ago and he's a very good friend of mine. I mean he had discovered he was HIV positive and I mean he was literally at the point that we were talking, his friends, we were talking about who was going to speak to his family. I want you to know he's alive and well, working and probably needs to lose a little weight, you know, needs to get out and get some exercise. He's just healthy as a horse. He's, you know, still weathered. Where are we, doctor? Is it still an epidemic? Certainly we're... I'm talking not just overseas but in this country. Well, we still have high and constant levels of new infections each year. I think the numbers were revised a year or two back. It's a little under 60,000 now per year in the United States. There's a bit of a quandary over why are those numbers staying constant like that and are we being sufficiently energetic in our prevention and education campaigns and reaching the populations that really do need to be reached continuously in America? And CDC and others are vitally important to that. Are we keeping those programs as energetic and effective as they can be? I think on the global level, we haven't turned the tide yet. This is the theme that we'll hear next July when the Global AIDS Conference comes to the United States for the first time in 22 years to hear in Washington. And I'm going to ask you about that July. And there I think this question that you pose of where are we will be center stage. And I think the message will be we're making, I believe, the mega question is that we've made massive progress and we're continuing to make massive progress and that it is imaginable that this epidemic, that the arc of this could be turned in the foreseeable future. And that is a new revelation. That is a turning point I think that has happened. I have a similar experience to yours. In 1996, when I left the U.S. to go to India and work, I had two close friends who were at death's door and I figured I would never see them again. They're both working full-time still. Because in late 96, we came up with a combined antiretroviral treatment as a physician in the 80s, I took care of hundreds of people, mostly men for whom I could do basically nothing. So this has been a revolution. The fact that you can convert an incurable disease to one where someone can live essentially a normal life span as long as they take medications is an enormous change. We wish we had a vaccine, we don't, but we do have some very powerful prevention techniques that we didn't have before. You mentioned male medical circumcision. For years, we weren't sure whether it was just a coincidence that the places in Africa that didn't circumcise had much higher rates of HIV. Three rigorous studies were done, 60-plus percent reduction in the risk to males if they're circumcised. Kenya has now circumcised hundreds of thousands of men and the guys get it. They know they'll be safer. It's not forced, it's voluntary, and in fact there are lines around the block to get this done. So prevention through circumcision and prevention through treatment are real breakthroughs. Microbicides have real potential as we figure out how to roll them out. So we don't have a vaccine. It is still an epidemic. In this country, more people have died from AIDS than died in every war since the Civil War. I want to get some questions from all of you in the audience, but let me just talk first and get the panel's view on... There is no question, and you've talked about them here, these new platforms that have been developed to fight these diseases of AIDS, malaria, maternal and child health issues. Is it time, and should we now start thinking about other emerging challenges, such as non-communicable diseases? Congresswoman Granger, what do you see as the challenges coming up for future ones, not to just keep the funding we have going for what's going on right now, but are there other things we need to be looking to and thinking about? The famine that's coming, without our intervention, probably lose 750,000 people of all that happens when there's a major flood and the disease that comes after that, and those are things that we're better at delivering now than we were. But again, I talk about the flexibility and not knowing what's out there. HIV, AIDS, still, it's certainly not where polio is, it's not the crisis it was at one time. So we have to say, that's still on the books and we're still helping, but it's the one I'm most concerned about is the famine. And what happened after that? Dr. Mars. We just had the high-level meeting in New York a few weeks ago on the chronic disorders on the non-communicable diseases, and that was a watershed event. It brought home that, in fact, in low-income countries and emerging markets in particular, that cancer, diabetes, lung disorder, heart disease are rising very steeply in a county for ever-higher numbers of premature death and disability, and that there are some shared risk factors that are within reach in terms of inactivity, in terms of the diets that we have, in terms of alcohol and tobacco consumption, and that we need to get our minds around this, and I think the response level is going to be different this time around. This is not something that the donors, this is going to be different from 10 years ago when the world was reacting to the crisis of HIV-AIDS. It's going to be a different pattern of response, but there's no question that we have to get our minds around this and that we have a lot of expertise, we have a lot of best practices, we have a lot to learn and a lot to teach and share, and countries that really face these demands are going to take matters into their hands and be looking for help. The extreme irony we face is that we will probably save a lot of people from HIV-AIDS who will go on to die of cardiovascular diseases and some of these non-communicable diseases because the problem is so pronounced, as Steve says. I think coming out of the high-level meeting, though, there were two interesting conclusions. One is there's a lot of, relatively speaking, low-hanging fruit to go after here, tobacco use. As WHO predicts, a billion people, a billion people will die in this century around the world from tobacco use. Well, we know how to deal with that, right? We've shown in this country how we have a ways to go, but we've gotten it down to one in five, roughly speaking, one in five U.S. adults smoking from double that at least 30 years ago. So we know that we have tools, and if other countries would avail themselves of these similar tools, raising the effective price of tobacco being one of the most effective one, smoke free spaces, et cetera, we could really seriously drive down those rates. So that's low-hanging fruit as things go. The other clear conclusion coming out of the high-level meeting was that we have a lot of science that we can bring to bear on these conditions. And this is where the large, traditionally the donor nations can take the lead. They won't be donating money in this case, but they will be throwing money and effort at advancing the science. For example, there is no reason why we couldn't have the equivalent of a human genome project oriented toward Alzheimer's and dementias and essentially conduct the kind of global effort to resolve or at least advance the science very, very substantially in the next decade so that we really could talk about halting Alzheimer's at least once it was diagnosed and perhaps potentially even preventing it. So I heard one participant in some of the high-level meeting discussions come away and said, we have an all-hands-on-deck mentality now towards non-communicable diseases that we didn't have going into the meeting in terms of what we can do as a world to come to grips with these. Doctor, what do you see as the biggest challenge? Well, more people will be killed this year by tobacco than by aged TB and malaria combined. 400,000. Tobacco will kill in this country 400,000, but around the world will be more than 5 million deaths from tobacco and on a scale to continue increasing over the coming years. I think as Susan says, we're not proposing expecting a big development program or big donation program to assist countries, but that doesn't mean there's nothing we do. Just because we don't do that doesn't mean we do nothing. The first thing we do is to help to document the problem, to monitor and do surveillance. And at CDC, we're delighted to operate a global surveillance system for tobacco. We've standardized it so that when one country talks about it, they're using the same definitions another country uses. Just as we do with polio and measles, we have to standardize how we monitor, identify best practices. The country of Uruguay was able to reduce smoking by 25% in three years. Probably the fastest declined in tobacco use ever documented. Why? Because the president of Uruguay, Tabarevezquez, was an oncologist. And he said, you know something? I'm going to do whatever I can to reduce tobacco use. And it shows really how pivotal leadership can be because in the noncommunicable diseases, yes, there are important treatment methods, but there are also very important prevention methods. And they can pay big dividends in reduced healthcare costs. In this country, just to switch back and forth for a minute, someone with diabetes costs on average $6,600 more per year every year for healthcare than someone without diabetes. If we can prevent those conditions, we can increase the productivity in our own country and others. And we have important lessons to learn from other countries as well as important best practices to document, disseminate and do technical assistance on how we can work together to figure out solutions that are going to help people live longer, healthier lives with lower healthcare costs. Well, you know, those who are careful watchers of Face the Nation will know that I as someone who has diabetes and has survived a cancer that was caused by smoking, I challenged President Obama and Speaker Boehner to join together and swear to stop smoking and the President, as I'm told, not because I urged him, but I'm told that he gave it up, but Ms. Granger, you're going to have to work on the speaker. I'll do my best. But I certainly endorse everything you say there. We have a very informed audience here today and I want to get to some of your questions. I know among others here are some folks from the TCU School of Nursing, which where are you all? Here you are. Welcome. So we'd like to get some questions from the audience. Would you all like to start it off? I caught you. Tell us who you are and we're very pleased to have you today. Susan Weeks, Associate Dean for Harris College of Nursing and Health Sciences at TCU. We've talked a lot about the ways that we've contributed to other nations this evening. What are some lessons that we are learning from other nations to help the health of our own nation? Could I answer one of those? Absolutely. I had the most wonderful experience to go to Peru two years ago and Peru decided they were going to take on maternal mortality and they did and it was, you talk about leadership, enormous commitment. They produced the deaths of mothers giving birth by 60%, and what they did is they said there will be a plan for every woman who is pregnant in Peru and so when she goes to a rural clinic and there are many more than there were before, she's tested and said if she's pregnant, she has given a plan for her pregnancy at that day and this is where you'll go. You'll go for a checkup every month for this length of time and then more often this is where you'll go. This is the hospital where you'll give birth. This is your transportation who is responsible for your transportation. It's just remarkable, a wonderful commitment and can be transferred to many other countries if there's that kind of commitment. Anyone else? One of the responses we're seeing now is an interesting trend of reverse innovation where technologies used overseas are now being brought back to the US in part because those countries have been able to leapfrog legacy systems that we have here. So for example, cell phone use around reporting adherence rates of HIV, AIDS drugs in Africa. It's much more advanced ironically than it is here. We've started to bring that back. We now have text for baby, the technology that Voxiva introduced. So we're re-importing those things back that we haven't needed to use here but that turn out to be very effective, relatively low cost technology oriented interventions that make a big difference in developing countries and obviously have application back here in the US as well. Yes ma'am. And tell us who you are. Good evening. I'm Dr. Donna Schaefer. I'm a computer science professor at Marymount University. And Susan, that was a great segue to my question. I've been trying to encourage my students into Health IT. So am I giving good advice? Am I leading them astray? Thank you. You're giving them excellent advice because we've only begun in this country really to seize full advantage of all manner of information technologies and frankly just harnessing information. If we were doing half of what the country of Sweden is doing in compiling registries for almost every disease condition, we'd be a lot further along in understanding what are our most effective and what are our most cost effective interventions as a country. So absolutely they're doing the right thing is technology going to be the panacea? No. Is it an obviously extremely important critically important tool particularly for our own country and getting a more cost effective system? No question about it. There's a real link between those two questions actually because one of the key lessons from other countries is how important team based care really is that we can drive down cost, drive up quality and have more decent paying jobs and ensuring that the whole healthcare team is involved in ensuring the effective care of patients and one of the ways that they can do that very effectively is with Health IT. Health IT is a growth area. It's not a panacea but it can make a huge difference. A couple of weeks ago we launched a million hearts campaign. We think we can prevent a million heart attacks and strokes in this country in the next five years by prevention and better treatment. The better treatment really involves focusing on blood pressure and cholesterol control, gastric and smoking cessation, Health IT and team based care. Those three key interventions in the clinical sphere. Who else? Yes, sir. One non serious and one serious. Bob, I'm from Oklahoma so I have to say do you want to care to predict the score next year when they play this game? Well, we came to play. Okay, the serious question really is that a lot of the U.S. assistance is given through USA aid and there are a lot of rules that basically require that most of that assistance is given and provided by U.S. subcontractors. I help them to work and help run some of the USAID programs in the former Soviet Union in the last lifetime. Actually, I'm Ross Anthony. I work at RAN. I run the Global Health Program now. So my question really is this. We found that partnerships with U.S. groups work much better than U.S. groups actually doing the work. Maybe we might move to a different model where more of the assistance is actually given directly to local groups perhaps working in concert with U.S. groups more directly to the groups instead of having to always go through U.S. subcontractors. Who'd like to take that? I think that's very much the focus that Rod Shaw is intending to introduce even more broadly within the PEPFAR program as well as beyond PEPFAR. It's also certainly my experience and having gone and seen some of the PEPFAR programs operating. It's almost an exaggeration to say that it's always done by U.S. people. It's really not. When you go to these countries, even if a program is nominally run by a U.S. university or whatever, most of the people working there are people from the region. So you get into kind of these funny lines as somebody from Benin who's employed by Columbia. Is he a Columbia person or is he a Benin person? My view, he's from Benin, and we're actually working very hard to train a new cadre of individuals who will be able to take these systems forward long after the U.S. assistance has gone away. That said, I do think Raj is very much pushing in the direction as the Global Fund has been traditionally to basically make these plans that are owned by countries and implemented as much as possible by countries. This really has been the CDC approach for years and is our approach to immunization policy. We train local staff at every level, epidemiologists to track disease and set policies and help them to implement programs. So this really is our basic approach to care, is to go in, often it will require embedded staff for a few years. We think that's not an example of the U.S. doing things. That's actually the best way to transfer technology to the local institution to build the systems of care and the systems of management that are needed to ensure the program can run and run effectively for years to come. There's a little controversy there, however, and I do agree it's the way to go. At one time USAID was just a giant contractor and so Dr. Shaw is absolutely moving away from that, but the direct assistance, when you're not dealing with a government and oftentimes where we're giving so much assistance, there's not much government there and people are tired of reading about, well, this much money was given but what happened to it, corruption, graph. So there are some places where the direct assistance can't work unless it's done just exactly as it was described where they're embedded and you know what you're dealing with. But there was kind of a move to just send the money and that's not working out real well. Next question, over here. Hi, I'd like to thank the panel for a great discussion. My name's Steve Kniebel from Public Citizens Global Access to Medicines program and several of you mentioned the importance of making our treatments more cost-effective as a way to sustain our levels of program and programs and even scale up treatment as budgets are reduced. So my question is how can we do this where we have a U.S. trade policy that's actually aligned with our global health objectives rather than the U.S. TR pursuing policies that make generic medicines access more restricted and enable big pharmaceutical companies to maintain monopolies and make these drugs very expensive which in turn makes it very difficult for our programs to use their money effectively keeping treatment costs high. You want to tackle that Congresswoman? We're not doing so much in trade agreements. I would say where it's working better or we've got a model is the Millennium Challenge, the MCC where we said we want to help and we're going to help with a compact. If you make these improvements in humanitarian efforts in healthcare, that sort of thing and we kind of make a pre-compact agreement and most of the countries then come up in what they're doing for themselves and work with a compact. In some case they can't and so they never get the compact. I think that's the best model I've seen. Does anybody else want to comment on that? Yes. I think that we need to keep in mind that there's been some pretty dramatic changes in pricing on some key medications that were driven by advocacy and were driven by negotiations and in June when the GAVI Alliance had its first pledging conference which was a huge success. 4.3 billion pledged against 3.7 requested. The manufacturers of the HPV vaccine dropped their price to $5 a copy which had been almost $100 a copy of that and it opened a window for the kind of initiatives that you're seeing now, the pink ribbon, red ribbon initiative to expand screening and early treatment, early pre-cancer treatment for women that are vulnerable to cervical cancer, making use of FFR platforms. I think these instances offer a lot of hope for working with industry to find solutions. It's also the case that there's just a phenomenal amount of innovation going on in many of these countries themselves in Southeast Asia in particular the pharmaceutical sphere and the biologic sphere and I think we can expect over time more and more of the medicines consumed in developing countries will actually be made in the developing countries. So we have not figured out the perfect arrangement in our own country about pricing for pharmaceuticals and the trade off between pricing and innovation and we haven't figured that lesson out for the rest of the world and I suggest to you that 15 years from now we're going to be looking at a situation where most of those medications consumed in the developing world are going to be made in what we will have once considered the developing world. Another question? Right here. Good evening. Thank you very much to the panel for brilliant and good information that we heard from you. I'd like to represent myself. My name is Miulza Ahmetay. I come from Kosovo over the Atlantic quite far. As a gentleman started with PLED I would like also to continue with PLED but before I continue with PLED I would like to thank you very much to the U.S. government giving us such an opportunity to come through the program of HOPE Fellowship and USAID. There is a program regarding health issues that we want to also improve in our country. We will be here for a certain period of time and we wanted to hear as much as possible from different organizations and luckily we had that opportunity to hear all this information from you. We heard that there are going to be there are going to be budget cuts. I wish you can continue with all that amount of money because you are very active in my country which is quite young almost four years as a state and you are very active in through the Global Fund in Kosovo fighting HIV, TBC which and the mortality among children and luckily we had reduction reduction and decrease of these mortal diseases recently but unfortunately we had quite increase of vascular diseases and also cancer which is harming over there so I would applaud you to continue and help Kosovo as a young state as you did and as you are almost I mean constantly doing to continue and help us in the future. Thank you very much on behalf of Kosovo people. Thank you. I think we are getting close to the end and before we do I want to talk about what is going to happen next summer. You are going to have the annual AIDS global meeting. It is coming to Washington and the bi-annual. For the first time in 22 years this has been held on U.S. soil and the reason why the organizers ceased holding it here after Congress imposed a ban on immigrants and visitors who were living with HIV. The Obama Administration eliminated that ban in 2009. Obviously this meeting is going to come in the middle of not only a presidential campaign but senatorial campaigns and congressional campaigns all over the country and I would just like to get from you there are going to be 25,000 participants coming 2,000 journalists is this going to be a good thing to communicate with the American people the value of leadership on the global health or will it spark controversy and criticism and in the end hurt the cause. Let's just go around the panel. I'd like to see what all of you think about this. I think this is a great opportunity for the American people to reconnect because we have an enormously positive story to tell about what's happened in our country and what's happened outside our country in U.S.-led achievements and partnerships and so I think the overall story is an enormous amount of accomplished a forward momentum and a clear path forward we've heard from our other speakers about the many discoveries and the many critical opportunities now for moving ahead on HIV particularly on the prevention side and what we know now with the new scientific achievements that have come forward. I think we need to be careful and go into this meeting to make sure that we are celebrating in the right way that we're celebrating the role of President Bush and his achievements the role of bipartisan partnerships in Congress the role of the faith-based community the role of the business sector. This is a remarkable thing and many other key Americans who have really stepped forward I think we'll have to be sensitive to the fact that the domestic community dealing with HIV AIDS has been quite separate from the international and we need to be sensitive to that and take that into account. Do you think it will impact on the U.S. elections? Will it be an issue? Will some people say we don't want those people here? No, I don't think it will be I completely agree with what you said I think it makes a difference how the media decides to report it. Well, Mr. Schieffer Well, we'll just show up and see what happens and frankly the administration is worried that a lot of the HIV AIDS activists will be pushing so hard on the side of doing more that there won't be sufficient recognition for how much has been done and that somebody will get up and do as they have always done at the AIDS meetings take a bag of tomato juice and call it blood and throw it at somebody and those will be the pictures on the news when in fact, as Steve said there is just so much to look back on. Tony Fauci who was sent by President Bush in the early 2000s to Africa to come back and make recommendations for the program that eventually became PEPFAR he came back and at first he suggested let's take the prevention of maternal to child transmission program that was already in place and let's grow that and George W. Bush said to him nope, we want a game changer nope, we want a game changer we want a game changer well, just to repeat these statistics these are right from Eric Goosby four million on treatment now 114,000 children prevented from becoming HIV positive in the last year alone 33 million a person testing effort in 2010 we as US taxpayers now are helping to take care of four million orphans and vulnerable children around the world talk about a game changer and if there isn't something that we can celebrate on a bipartisan basis other than that, I don't know what there is well, having worked with the ADAP because the community for nearly 30 years I don't think they will organize to give a rounding show of applause to the US government however, the reality is that the ADES advocacy organizations have learned that by pushing they can achieve more access and achieve progress it's a great opportunity to showcase the wonderful leadership of the US government bipartisan across many administrations with a deep commitment to getting results to working with host governments and to challenge the rest of the world to step up as well host countries to contribute more to the care and other donor countries to do more it's not the case that the US has the responsibility of caring for every person living with HIV in the world it is the case that we are the global leader in doing that and I think next July provides the opportunity to showcase that alright, well I think that's a good place to end thank all of you for coming today thank you thank you very well thanks