Three Decades of Commitment to the Fight Against Global HIV/AIDS

Uploaded by CDCStreamingHealth on 25.07.2012

Good afternoon, everyone,
and on behalf of the Emory Center for AIDS Research,
I want to welcome everyone to this incredible panel.
Having this panel here
came as a result of one day that I was talking to Debbie,
and she was telling me about this event,
and she said to me, "I want to have this at Emory.
I want to have it outside of CDC for two reasons.
Number 1 is to have students --"
which I see a lot of you in the audience --
"And number 2 is because
getting everybody cleared to get into CDC takes a while,
and if you're foreign-born, it may take a lifetime."
And since this is dealing with the response
to the global epidemic, we thought it was only fair
to have the global people be part of this event.
The Emory Center for AIDS Research
feels particularly honored to have as our partner --
In the response to the epidemic, CDC --
We're always boosting our NIH applications and other things
that we're the only CFAR in the country --
While there are 20 in the country,
we're the only one that has CDC next door.
And this is more than just a neighborhood.
We actually have a very tight collaboration,
and we work closely together with them,
and we really feel like we're part of one global effort,
and I think in HIV,
this has been unbelievable and has been unprecedented.
For many of you
who haven't seen this epidemic from the beginnings,
you will realize that, for many years,
when antiretroviral therapy became available,
it became very clear that the world was going to be divided
into the "haves" and the "have nots" --
the developed and the developing world.
And it was because of leadership of many people,
including many that are sitting right in front of you
and you're going to be having the pleasure of listening to,
that that epidemic is beginning to be turned around globally.
And there are more people with HIV
being treated around the world than there are --
in developing countries --
than there are in developed countries.
And that's where the epidemic is,
and that is the right response.
So it's a response that we all need to be proud of.
We have paid for it from our tax dollars,
and I think we need to be sure that the support
in these difficult economic times continues.
So after this talk,
I want to encourage you to go home, go to your computers,
and e-mail your representatives, e-mail your senators,
and say, "The global response is awesome.
Let's continue it."
Thank you very much.
[ Applause ]
Thank you very much, Carlos.
Colleagues, friends, good afternoon.
Thanks very much for being here for this session
devoted to the 30th anniversary
of the first recognition of the AIDS epidemic.
And thank you to Emory for hosting this session.
It was -- My task is fairly simple.
I just need to say a few words of introduction
for our distinguished panel,
and I just want to make a few additional comments.
It was on June the 5th of 1981
that CDC's "Morbidity and Mortality Weekly Report"
published a humble, little article
describing five cases of pneumocystis pneumonia
in men who have sex with men,
cases described in Los Angeles.
And 30 years later, here we are.
Who would have thought when they read that small article,
who would have thought what that actually was a sentinel for?
Our panel consists of Sandy Thurman,
Ambassador Mark Dybul, Ambassador Eric Goosby,
and is going to be moderated by Dr. Debbie Birx.
30 years ago -- Haven't they aged well?
[ Laughs ]
[ Applause ]
Where were they 30 years ago?
I'll start with who I think is the youngest.
Mark --
[ Laughter ]
But I'm not going to go in order after that.
[ Laughter ]
Mark was a student at Georgetown University.
He was a student in theology and philosophy,
and he was debating what to do his graduate studies in,
wondering whether he should do
English literature and poetry.
But he read an article in Newsweek devoted to AIDS,
and he decided he wanted to become a physician,
and trained in medicine at Georgetown.
Eric was walking the wards
of the San Francisco General Hospital in 1981 --
really, the epicenter of the American epidemic
at that time --
seeing patients with this strange, new disease.
And Debbie will elaborate on the career paths
my colleagues have taken.
Sandy, in the early '80s,
was working with juvenile offenders
and became involved in hospice care.
All of that -- 30 years ago.
It's worth reflecting, or thinking back,
to what the epidemic was actually like
in those early days.
A lot of it is recorded in the "MMWR,"
which published over 70 articles,
or different types of papers,
between about 1981 and 1985.
I think that period rather significant --
sandwiched between the description of the first cases,
and in 1985, in August,
the introduction of a blood test
able to detect antibodies to HIV.
If you think back to those early days,
it was remarkable how much science was achieved
in a very, very short time --
how much epidemiology contributed
in understanding the disease, its modes of transmission,
actually defining the essential modes of prevention,
even before the virus itself was first detected.
But one of the things I recall is
that as this science kept rolling out,
the news really was progressively worse.
Every time something came out, people would say, "Oh, my gosh.
It's in the blood supply. It's transmitted heterosexually.
Mothers pass it to their children."
I remember -- I think it was the first conference on AIDS
that was held here in Atlanta in 1985.
I remember attending a talk
where the neuropathology of AIDS was being presented,
and you could hear a pin drop in that room,
as people were just awestruck and horrified
that this disease was causing dementia
and irreversible neurological damage.
And then we heard about Africa
and the extraordinarily severe heterosexual epidemic there
with, really, no understanding at all
of where this was all going to go.
And there was, in the mid- to late-'80s,
great concern that actually Asia, with its huge populations,
would go the same way as Africa had,
which, of course, did not occur,
but we weren't to know that at that time.
I want to show three slides that, for me, capture some of --
Well, I wanted to show three slides, yes,
that, for me, some --
A couple of quotations and a picture that, for me,
capture some of the elements of the epidemic as it evolved.
This actually is a recent quote.
Geoffrey Canada is an educator in New York City, in Harlem.
In the early days,
people who worked on this epidemic
and who treated patients,
as some of my colleagues here did,
were actually taking risks.
They didn't know what they were getting into
or what the risk actually was.
Canada wrote...
I think in those early days,
we really did not know where this epidemic was going to go
or, indeed, how we could possibly begin to halt it.
And you recognize Jim Curran,
the dean of the School of Public Health here.
One of my mentors when I first joined CDC,
who's contributed so much to the struggle against AIDS.
Headed CDC's first work.
We've always, throughout the era of AIDS,
we've always been looking for the magic bullet.
If we could find that one magic bullet, we'd be okay.
And, of course, it's not like that.
And Jim said...
Then, finally, this picture,
by an Austrian artist, Ivo Saliger,
which was painted in about 1920.
This, actually, is one of my first memories in life,
because my father, who was a surgeon in Belgium,
had this print hanging on the wall of his study.
I inherited it from him, and it now hangs in my study.
And it shows a physician fighting death over this woman.
I've always found this eerily emblematic of AIDS.
The skeleton representing death,
but representing this awful wasting disease.
The artist actually painted this
when his own sister died of leukemia
in her early 20s.
And then, of course, in 1996, which, by coincidence,
is halfway into our 30-year story --
In 1996,
there was the extraordinary conference in Vancouver --
the International AIDS Conference --
that drew attention of the world
to the remarkable introduction of antiretroviral therapy.
That, you know, fundamentally tipped the balance
in this epic struggle between death and medicine.
And what a pivotal time we are in now,
and I'm sure my colleagues will talk about that,
as in just the last couple of years,
so much research has shown a prevention benefit
from antiretroviral therapy, which --
I think we're still left with the fundamental question --
How best do we use this remarkably precious gift,
both for prevention and treatment for public health,
as well as individual health?
I want to finish just with thanks to my colleagues
for everything they have done.
I think all four of them have contributed remarkably
to the global effort against HIV/AIDS.
And I want to just say a word in support
and in praise of PEPFAR.
I think PEPFAR has been a game changer,
not only in HIV, for what it's done,
which Carlos alluded to, but actually in global health.
I think the impact, the influence, of PEPFAR
is way beyond HIV alone,
and, really, it's a line in the sand
about approaching health problems with a global approach
and with levels of funding
that we never dreamt were possible
just a few years before.
But it took leadership of some of the people here
to actually do that.
So with these few words, thank you for coming,
and I'm going to hand it over
to my friend and colleague Dr. Debbie Birx,
who is the director
of the Division of Global HIV/AIDS at CDC.
Thank you, Debbie.
Thank you, Kevin. Thank you very much.
[ Applause ]
It's a real pleasure to be here
and importantly to have, really, four close colleagues of mine
sitting on the stage.
And thank you, Carlos, for lending your space,
and thank you for the vibrancy of students
who grew up with always AIDS in their life,
because half of us --
'cause I see a lot of gappers here from our division --
are a little bit older than the students.
You don't stand out, though.
You look all the same from up here,
particularly without my glasses.
But sitting on the stage today are --
The three panelists are really --
The first time that they've been together in a forum like this,
and they are really the three
that are really the heart and the soul
of what became PEPFAR,
but really recognized
as the first U.S. Government recognition
of the Global AIDS Program.
Just picking up on the global AIDS problem,
just picking up where Dr. De Cock left off,
in 1996, in Vancouver,
and, actually, Dr. De Cock and I
were responsible for summarizing tracts at that time.
He had the epidemiology tract,
and I had the basic science tract.
I have to say, I was quite overwhelmed,
because in the room that holds 25,000 people,
there's, like, a 100-foot blowup of you on the screen,
which, I can tell you, is a little frightening
when you can see every pore in your entire face blown up in --
quite a drama.
But at that conference,
with the antiretroviral announcement --
At that time,
all of our patients that we were taking care of
that made it to the time of combination therapy
are living today.
Many of my patients are still living
because of the protease inhibitors
that became part of that powerful combination.
Prior to that, many, many patients of mine
and many, many patients of Ambassador Goosby's
and Dr. De Cock and Sandy Thurman didn't make it,
and this is also really to honor them,
and we have the AIDS quilts here
to remind us of the amount of loss that has occurred.
But to take you back to 1996,
remember, we were just then rolling out therapy
in the United States
for all of our patients,
and none of us were looking somewhere else.
But Dr. Sandy Thurman, a dear of colleague of mine,
she looked elsewhere.
Although part of AIDS Atlanta
and bringing all of that compassion,
she was called to the White House
at a time when the two AIDS czars before her
were summarily -- let's just say dismissed.
She still took that position
and not only aligned our response --
our large domestic response --
that we're ensuring the needs of all
that were infected and affected by HIV.
Just upon arrival,
she was absolutely looking outward
to what we could do internationally,
and this is at a time
when everybody was focused domestically.
And there were, I think,
under $10 million or $15 million total
in the total global health portfolio
focused in any way on infectious diseases,
including HIV.
And she's going to talk today about that struggle,
that groundbreaking struggle,
of having Americans not only look inward, but outward,
and bringing tax dollars to a disease and to a continent
that many people thought the continent was the country.
And so she's going to talk about that struggle today
and talk about what it takes
to get a new program through Congress
and an administration,
starting in the Clinton Administration.
And building on that is Ambassador Mark Dybul,
known to me at the time as Dr. Dybul coming out of the NIH,
responsible for many of the guidelines that you read today
and responsible for many of the guidelines about ART treatment
that was utilized within the United States,
working out of Dr. Tony Fauci's office.
And he has really,
although he's too shy and humble to say it,
is really the architect of the whole entire PEPFAR program
as we know it today.
Now, there are those who have grown up
just knowing that PEPFAR existed
and don't understand the struggle
to get that size of a program
through the United States Congress
and the arrows and the shots and the difficulties
and that commitment that it took every day.
And Ambassador Goosby comes to you today
with the passion and compassion of a clinician,
bringing his new direction and new vision
that all of us are just beginning to realize now
and implement as fast as we can, because we share his concerns.
We share his deep dedication
to every individual that's infected by HIV,
and it's his leadership that's bringing us
to the new place that you'll hear about today --
very much focused on countries taking ownership,
investing their human capacity,
and meeting the needs of their own population
with support of the U.S. tax dollars.
So in that brief summary,
there are some attributes that the three of them share,
that I want you to take home,
both those of you from CDC and from Emory.
They share the ability to translate
their own personal commitment, compassion, and passion
into a programmatic, realized program.
Now, taking a vision and making it real
is very difficult,
and they are going to give you, I hope,
some insights today how they've done that.
This is why I am humbled to ever be around them,
because they were bold, they pushed the envelope,
and they took the United States
someplace where it had never been before,
and it's been sustained now by Ambassador Goosby.
So they all three share one other thing --
they don't ever accept "no" as an answer to anything.
No means "maybe."
No means "maybe tomorrow."
But "no" means always that they will turn that into a "yes,"
and each of them have done this in a way that,
when you work in the U.S. government,
there are moments of opportunities,
and you must seize them,
and you must make the most of them.
And each of them have done that,
and it's just a deep pleasure to introduce each one of them
and to bring Sandy Thurman to the microphone.
[ Applause ]
Thank you, Debbie,
and thank all of you for being here today.
And, of course, thank you, Dr. De Cock and Dr. del Rio,
for being here today
and for your extraordinary good work.
It's been a lot of fun for me to work at CDC
and always had incredible amount of appreciation
and respect for the work that CDC does,
but I have even greater appreciation
now that I've been working as part of Debbie's team.
I have more bosses than anyone I know.
Kevin is a boss, Debbie is a boss,
Dr. del Rio is a boss.
There are bosses everywhere, and they're all surrounding me.
I might have an anxiety attack.
[ Laughter ]
But, anyway, I'm happy to be here with all of you --
from CDC, from Emory, from PEPFAR --
and for all the great work that you do.
You know, the 30th anniversary of AIDS
is a great time to reflect on
how the U.S. government's response
to the global AIDS epidemic evolved,
you know, to sort of reflect on why it evolved
20 years after the AIDS epidemic began
and how the USG and its partners can continue to drive a response
to the epidemic and other health challenges
that's driven by science
and commensurate with both the magnitude of the crisis
and the complexities that it presents
to all of us in our work.
You know, the development of the global AIDS response
is an extraordinary tale, really,
at the intersection of public health,
politics, policy, partnerships,
and, most of all, people in the field
who made the global AIDS epidemic a reality
for people who had never seen it or touched it --
the American public.
Those infected and affected
and those who were working valiantly around the world
to prevent new infections, to treat the sick,
and care for those who were left behind.
They are the ones, ultimately, who are responsible
for garnering the support of the American public
to expand our AIDS efforts overseas
and ultimately to launch PEPFAR --
the largest and most aggressive U.S. effort
to fight a single disease in history.
It's really a great, great story...
and a great example, I think, of teamwork.
A large, actually in the beginning,
fairly covert collaboration
of the most unlikely cast of characters you can imagine
from CDC to USAID,
from Congress to the White House,
from the activists outside, from DoD --
many of those characters
are sitting immediately to my right --
who were involved in that covert operation
to see if we couldn't bring the attention
of the White House and the Congress
to do something about this epidemic
that was happening in Africa and elsewhere around the world.
Mostly, it's about bringing
the problems and solutions in public health to life
for people who haven't experienced them personally.
And I think that's a really great legacy
for the beginning of our work in HIV and AIDS,
up to the PEPFAR days.
Most of you have read, I'm sure,
Nicholas Kristof's book "Half the Sky,"
and he talks about this
in years of his experience working in Africa.
And he recently wrote a fabulous article for Outside magazine
entitled "Nick Kristof's Advice for Saving the World."
He expounds on the importance of storytelling
when we are trying to engage people
in complex, data-heavy issues or events
like health and development.
And he asks, "What would happen
"if aid organizations and other philanthropists
embraced the dark arts of marketing spin"
and psychological persuasion used on Madison Avenue?"
What would happen is that we would save millions more lives.
He goes on to say
that well-meaning people do wonderful, important work,
sometimes feel too pure and sanctified
to sink to something as manipulative as marketing.
But the result has been
that women have been raped when it could have been avoided,
and children have died of pneumonia unnecessarily
because those stories haven't resonated with the public.
So I think that's something important for us to think about
in the context of how we began to get people engaged
in looking at an epidemic in a very new way.
And he talks about learning to focus on individuals,
and I think this is an important part, too.
We were actually talking about this earlier in his columns.
And after getting the facts that the hardest work of all
was to find one particular person
who could be the centerpiece of that story,
who could put a face on the facts and figures.
And his key points were this -- the power of hope --
that this becomes a basic principle
in all of our communications,
and that you'll never move people's hearts and minds
with lots of stories at a time,
but you will move them with one story at a time.
And I think he's been a master of that.
And as Mother Teresa said,
"If I look at the mass, I will never act.
If I look at one person, I will."
So with all that in mind --
I mean, none of this is news to any of us.
But it was really, really important
as we began to think about how we would engage people
in what we knew was, really, a storm happening in Africa,
and how we would get people to respond
when most people felt very, very separated
from the African continent and context.
I want to start with this slide from the quilt,
and I'm so glad that the quilt is here today.
This is taken in 1996,
when the quilt was on the Mall in Washington, D.C.,
with President and Mrs. Clinton looking at the quilt.
And at that point in time, I was working on the campaign --
on the Clinton campaign.
We were sitting in our office, and it was always a great treat
when President Clinton came in to visit people.
We were working on the weekends.
I think this happened either on a Saturday or on a Sunday.
And he came running down to my office,
which is really kind of intimidating anyway,
when the president sort of bangs into your door.
But he banged open the door, and he said,
Sandy, you won't believe what just happened.
I said, "What happened, Mr. President?"
And he said, "We just came from the quilt."
And he said, "I only spent 15 minutes there,
"but I saw the quilt of three people
that I knew who had died."
And so that was very, very personal for him.
And so, you know, as we began to take this journey,
we already had a President who had an extraordinary commitment
to fighting HIV and AIDS
and a real compassion for trying to -- and passion --
for trying to do something about it.
Can we have the next slide, please,
since I don't exactly know how to switch this?
Oh, look at that.
Oh! Wait a minute. Back up.
Ah, there we go.
So, I was looking, when I was thinking about this,
and I went back and tried to Google
global AIDS articles from 1996.
On CNN, there was not a single one.
There were a handful in The New York Times and A.P.,
but very, very small articles,
which sort of tells you where we were,
even as late as 1996,
when our colleagues were in Vancouver
with this great news about antiretroviral therapy,
some protease inhibitors.
It was a really interesting time.
There was no domestic support for a global AIDS effort.
Our domestic AIDS community
was so focused on getting treatment
and focusing on research and getting services to people
that the idea of doing something overseas
just simply wasn't in their lexicon
at that point in time.
It was just in 1996 that UNAIDS was formed.
We had had, as most of you know,
some stumbles at the World Health Organization
around the global AIDS response,
so UNAIDS was formed,
but a very fledgling organization.
So there just wasn't any locus of support
for global AIDS response.
Let's see if I can do this myself.
Ah, there we go.
And so in 1997, I took the job
as the director of the office of National AIDS policy,
which was actually the last slide.
Very shortly after that, I took my first trip to Africa,
and I have to say that it was a life-altering experience
from which I have never recovered.
And as you can see,
I was visiting an orphanage in South Africa,
and I will never forget this child.
I was holding her. She was a child living with HIV.
We weren't able to treat anyone in South Africa
at that point in time.
And she has my cross in her hand.
Now, for someone who has a degree in theology,
that was pretty powerful stuff for me.
And so I kept that and still keep that picture on my desk
to remind me of the first time that my heart was stolen
and that I really understood, emotionally,
the impact that this epidemic was going to have in Africa.
So, right after that, I came home from that.
Wasn't very long
that USAID actually published their first report
on the impact of the AIDS epidemic
on children in Africa,
and it was pretty, pretty extraordinary.
It was really hard for me to grasp what I was reading.
And then again, right after that,
President and Mrs. Clinton
took their first trip to Africa in 1998.
It was more like an invasion.
I think they had 1,000 people in their traveling party.
And in that trip, I think,
President Clinton's passion was even heightened
to do something about the epidemic in Africa.
But what was interesting on this trip is
that I was already at the White House,
and I tried very, very hard to get people to pay attention
to what was going on
and to see if we couldn't talk about HIV and AIDS
with the heads of state
of the countries that they were visiting.
And we got an enormous amount of pushback from that,
not only from our colleagues in the White House,
but, more importantly,
from our colleagues and our heads of state in Africa.
They simply didn't want to talk about HIV and AIDS.
Eric will remember that.
He was a part of those conversations,
when we were actually trying to get AIDS on the agenda
in this first trip that happened in 1998.
We were making a little progress,
but we weren't making nearly enough.
What did happen that was to our advantage,
and we have a fun lecture
if you all would ever like to come hear it,
that I try to give about once a year over here --
It's how Monica Lewinsky was responsible
for the Global AIDS Program.
[ Laughter ]
It's very interesting.
So, when this was taken -- this photograph was taken --
we were embroiled in the White House
in this Monica Lewinsky scandal.
And so, you know, every year, UNAIDS has a theme,
and that year the theme was talking to youth and teenagers
about HIV and AIDS.
And so we had so much trouble
getting people to focus on the global AIDS epidemic.
The only piece of information we had
was this USAID report that focused on young people.
So, with a very straight face, Todd Summers, my deputy, and I
went to see Ann Lewis,
who was then the communications director at the White House.
Now, some of you may not know who Ann is,
but you may know her brother, Barney Frank,
who is a very bombastic
and very bright congressman from Massachusetts.
And so we went to Ann,
and with a very straight face, we had prepared two proposals,
and you can imagine how these were received.
The first proposal we prepared for her
to address adolescents around HIV and AIDS was
that we would have President Clinton
talk to high school students
about the importance of safer-sex practices.
[ Laughter ]
Well, I won't say to you in here exactly what she said to me,
but, you know, sort of unnatural acts
were involved in the conversation,
and we were clearly, you know, told no in no uncertain terms.
And then we presented to her this report that we had
on the impact of AIDS in Africa on children.
And I said, "Well, the problem is that it's overseas,
and we're going to have to commit some money,"
She said, "I don't care what you do. Just go do it.
Children in Africa, anywhere but here."
And I was like, "Okay, bye."
[ Laughter ]
So, it was very lucky.
It was taking advantage of a situation --
the things that we all have to do in our work in public health.
And so we got the mandate
to go take a presidential delegation
to look at the impact of AIDS in Africa
and got $10 million to boot just to get rid of us.
It was like hush money.
Take the money and go was kind of the message.
But that announcement was made here
on World AIDS Day in 1998 --
with the president and Secretary Albright
and Brian Atwood, the head of USAID at the time --
to announce that we were going to embark on this mission.
So we were off and running,
but we had to pull a fast one to get it done.
That's a really important lesson for all public health students,
in case you didn't catch it.
[ Laughter ]
Okay? So, this was --
We decided that we had, before we went off to Africa
and took a bunch of members of Congress with us,
that we would have to do an advance trip.
And so to go see what countries and programs
we would want to visit,
we took an extraordinary group of folks with us,
including Steve Sternberg,
and we had to think very carefully
how we wanted to tell the story and to whom and in what context.
Steve Sternberg was then
and I think still writes for USA Today.
He may have just switched,
but he's been there for 20-something years.
And so we took Steve Sternberg with us
so he could capture the story
in a publication that would be read
not by folks who read The New York Times
and The Washington Post every day --
not that there's anything wrong with us.
But we wanted folks out in the hinterlands
to understand what was happening in Africa,
and so off we went on this wonderful odyssey.
We came back, and during that time,
we met two extraordinary people in Uganda.
This is actually leading up to the trip --
the manifest for the trip.
But we met some extraordinary people in Uganda
who helped us tell the story.
One was a woman named Bernadette,
who was a 70-year-old widow
who had lost 10 of her 11 children to AIDS
and was caring for 35 grandchildren.
So that was Bernadette.
The other was Olivia,
who was a young orphan who had cared for her mother.
Her mom died while she was 12, and, oddly enough,
she was taken care of by TASO.
I didn't know this was going to be here, I swear.
And but it's a great -- I feel like Vanna White.
And she was taken care of by them
and became one of the faces of AIDS
that helped us tell the story.
And, really the faces of AIDS for us,
for about two years, I guess, Eric, or more.
We came home,
and this article was published in USA Today.
It was the first spread
that anyone had done on AIDS in Africa.
It was a seven-page piece of work in USA Today,
more than all of the other publications had done, combined,
in the year previously.
And this was the first that the American public knew
about the impact of AIDS in Africa.
It was an extraordinary story.
That is another piece of work that came out shortly after.
That's Olivia and Bernadette,
who really helped us tell the story in extraordinary ways.
You know, it's interesting when we think about that,
the two people who, you know, never would have thought
that they would make a tremendous difference
actually did make a difference
and saved millions of people's lives
without ever knowing any of them.
Really pretty incredible.
So, we came home, we had that information,
we wrote a report to the president,
which he had asked us to do.
We worked really hard to get funding.
We worked with Jack Lew,
many, many colleagues that are still working in government,
who were just wonderful.
And we were really excited about
finally announcing this initiative --
what we call the LIFE initiative --
Leadership and Investment in Fighting an Epidemic.
And so we were about to get ready
to go make this announcement,
and the vice president announced
that he was running for president.
And some of you may remember this.
He, I think, announced in Tennessee,
and there were some AIDS activists
who protested at his announcement
about drugs and South Africa
and our inability to buy and produce generic drugs --
all the WTO business.
And so President Clinton
in, I think, a really ill-conceived idea,
decided he was going to give the announcement
to Vice President Gore,
which he did.
And we were horrified and dismayed,
not that we didn't love President Gore,
but you can imagine that President Clinton's
a little more charismatic
and attracts a lot more cameras than Vice President Gore does,
bless his heart, as we say in the South.
[ Laughter ]
So, anyway, I was apoplectic about this.
And I get a call from Gore's chief of staff,
who tells me that they're going to announce this,
but they're going to put it
in the sixth paragraph of an existing speech
that was about to be given at the National Urban League.
Okay, this is our first Global AIDS Program.
Well, I was so mad.
It was only the second time in my time at the White House
that I screamed the "F" word out loud in front of grown-ups.
And it was really funny, because I had this hot flash,
and, all of a sudden,
I realized that the man had thrown me into menopause.
He had made me so mad.
[ Laughter ]
It was my first hot flash.
And every time I see him,
and now he's chief of staff for the vice president --
I run into him, and it's so horrible,
'cause every time I see him,
all I think of is my first hot flash.
And it would be wonderful if he were cute
and gave me a hot flash, but he's nice but not so cute.
[ Laughter ]
Anyway, so, we had this, you know, pending announcement.
So we decided, "Okay, what can we do to save this?"
Now, this really another, I think, important lesson, is,
What can we do to save this?
We needed someone
who could really bring the story to the people
who were going to be in the room at the White House
when we made the announcement,
after I scared the man so badly that he backed off
and said we could do something at the White House.
So we did,
and we decided that we would bring Olivia,
the orphan who had never left her village,
put her on a plane,
and have her come to the White House
to tell her story in front of all these people.
And then we decided, "Where's our moral authority?"
Well, we were kind of short on moral authority
at the time at the White House,
so we decided we better import some.
And so we called Desmond Tutu and asked him if he would come
and announce this initiative for us,
which included sort of a multisectoral approach
to the epidemic.
We have religious leaders, we have political leaders,
we had business leaders, we had leaders in academia,
we had NGO leaders,
and we had wonderful folks from government.
And so Desmond Tutu agreed to come, and on July 19th --
this is more arguing with the vice president
about where we're going to have it.
On July 19, 1999, we made the announcement
of the first multisectoral global AIDS initiative,
called the LIFE initiative,
which included funding for DoD, CDC --
for the first time,
included in that effort on a large scale --
USAID, and the Department of Labor.
And it was really pretty extraordinary.
And what I love about this is
that this is Desmond Tutu looking directly at the folks
at the Office of Management and Budget
and saying to them, "You are an instrument of God."
He said, "You know, when you use your power
"to do things that are good for the world,
you are an instrument of God."
And I thought that was just an extraordinary --
And, plus, he's funny. He has to stand on a stool.
It's really cute to watch big, old Al Gore,
who's not very graceful,
pick up the stool and carry it over,
put it down for Desmond Tutu.
Really was a really funny initiative.
But in that initiative, we did several other things
that led up to the rest of the story
that people will tell you.
We decided that we needed leadership
from the top to the bottom.
It was already July 1999.
We didn't have a lot of time,
and we had a lot of territory to cover.
And so in this initiative,
the president promised to have the first lady meet
with people in business and philanthropy
at the White House and chair a meeting,
which she did.
He promised to have the Secretary of the Treasury
and the chairman of the National Economic Council
meet with business leaders at the White House,
which they did.
He promised to have the Secretary of Labor
and the president of the AFL-CIO
meet with labor leaders and workers around the world
to address AIDS in the workplace, which he did.
We also asked the Secretary of Treasury
to go over and look at the economic impact
of the epidemic of AIDS, and he did.
And just a long, long series of about 18 events
at the White House -- or in the Cabinet --
that happened over a series of 18 months.
It was really, really an extraordinary effort.
And, in the end, we wound up with an unbelievable commitment
and interest on the part of the president.
That's just one of many memos going back and forth.
This particular one
happens to be his notes back to John Podesta
about a pediatric AIDS initiative,
which we're still working on after all of these years.
More arguing with our friends
to get more support for HIV and AIDS, globally,
from our domestic partners at the National Security Council --
was very, very involved.
Had a joint task force
and began to look at AIDS as a national-security issue.
More press and increasing numbers of articles.
In 2000, our meeting in Durban --
the International AIDS Conference --
where Nelson Mandela
finally contradicted the sitting president
around HIV and AIDS and our need to respond to it.
The president actually --
Yeah, "A Cashmere Glove Over a Steel Fist."
Well, there you have it.
[ Laughter ]
I took it as a compliment, really.
But we appointed an envoy, an AIDS envoy,
to focus solely as a presidential representative
on AIDS in Africa.
And we ended with something that was really incredible,
which was our Religious Leaders Summit at the White House
on HIV and AIDS on World AIDS Day in 2000 --
right at the end of the Administration.
And what's so extraordinary about this -- Eric was there.
It was an unbelievable event, but it happened on --
The meeting started on the eve of the 40th anniversary
of Rosa Parks refusing to sit down on the bus.
And the person who gave the sermon was Andrew Young.
And if you really sort of want to be put in your place
and reminded that struggles are long and hard
and you make progress and it's slow and sure
and you make steps forward and you make steps backward,
there was no one in the world to tell us that,
and sort of to wind up our crazy 18-month odyssey
around trying to get a global AIDS effort started,
which we did.
We were finally on the map.
But at the end of the day,
we didn't get all the money we wanted to.
We tripled the global AIDS budget,
which was actually $125 million.
But it'd been flat-funded for seven years when we started.
We did some really extraordinary things.
We got the Cabinet involved in ways they hadn't been before.
And so we did some really great stuff,
but we fell short a little bit of our goals.
But there were great lessons that were learned in the process
that moved us toward that cold January day
when President Bush announced
the President's Emergency Plan For AIDS Relief,
which was incredible.
But it's all about the power of politics --
politics at its best --
the power of the press, the power of bipartisanship,
the power of strong leadership,
and, most importantly, the power of the American people
to respond to a crisis beyond their borders.
And I think that's the great lesson for all of us
in this odyssey that leads us to PEPFAR.
And so I will leave you with that.
Thank you so much.
[ Applause ]
Thank you, Sandy.
She went quickly over the congressional delegation --
Many of you know that Congress, both the House and Senate,
including the Senate, who sits for six years,
is a legacy that transcends any specific administration
or any specific election.
And building on that,
we're going to hear from Ambassador Mark Dybul,
who comes to us now from --
He's a Distinguished Scholar
and co-director of
the Global Health Law Program at Georgetown,
and, importantly, is the inaugural Global Health Fellow
at the George W. Bush Institute
and serves as the managing director
of the Office of the United Nations
Special Envoy for Malaria.
He was also one of those
that was in the back room, back scenes,
and he'll take you from 2000 and 2003
and what it took to have
that incredible and magnificent announcement in 2003.
Mark Dybul.
[ Applause ]
Thank you, Debbie.
It's great to be with you all here at Emory and close to CDC.
I want to start by thanking the people on the stage.
Kevin didn't mention that, in 1981, he was in Africa
while the rest of us were back here running around,
trying to work on stuff.
He was actually on the front lines
doing some very serious work,
and it's wonderful to be with him again.
He's done extraordinary work throughout his career.
And it's great to be near CDC.
Looking around the room, I see a lot of wonderful people
who I got to know often in the field,
and the work you did inspired us every day,
I have to tell you.
CDC's an extraordinary institution
filled with some of the best people in the U.S. government,
best people anywhere,
and it's great to be back with all of you.
And it's especially nice to be with students.
We're 30 years into this.
It'd be nice to say we've had enough of it, but we haven't.
We've got a long way to go,
and so, sadly, we need to pass the baton on to you all.
And so as students,
thank you for your interest and engagement in this,
'cause we need you now more than ever.
And Eric will talk about this --
I don't want to spend too much time on it --
but the opportunity you have is extraordinary.
We now have the tools, as Debbie alluded to and Kevin alluded to,
to actually end this epidemic.
Now we need to actually use them,
and you will be the ones to end this epidemic.
So thank you for coming and for your interest in this,
because we very much need you.
I do want to give a special thanks to Debbie.
As you can tell, Debbie's kind of a force of nature.
Someone pointed out that this is the first time
Eric, Sandy, and I have been together on a stage,
and that's basically Debbie.
She asks, and you say yes.
She was in the military, you know.
It's always, "Yes, ma'am."
And so that's why we're here.
And my good friend Eric, who is --
We are so lucky to have him
as the U.S. Global AIDS Coordinator.
It's not the easiest job in the world.
As I like to say,
we finally have a truly nice person
as the U.S. Global AIDS Coordinator.
But we also have one of the most competent people around.
And Sandy alluded to the fact
that Eric was around through the Clinton Administration.
I'm going to mention some of the key points
where he played in the Bush Administration, as well,
and now in the Obama Administration.
So he's truly served multiple presidents,
often from behind the scenes.
Debbie said I'd start in 2000,
but I actually want to back up a little bit,
'cause I think to understand where PEPFAR started,
first of all, we need to understand
what Sandy just showed so clearly.
There's this notion, particularly in Washington,
that things just happen to de novo.
They're created out of whole cloth,
and the new administration is brilliant
and just did something.
That's never the case.
Things move over time,
and everyone stands on each other's shoulders.
And as you can see,
what happened in the Bush Administration
was standing on some very big shoulders,
in particular Eric's and in particular Sandy's,
because they laid a lot of the groundwork.
And President Clinton did bring AIDS to public awareness.
Even if the money wasn't there,
it's important to begin those steps and begin those processes.
But I really think we need to back up
to where development and global health began
to understand what happened
in the last decade in global health,
which is truly one of the most remarkable things
to ever happen,
not only in global health and development,
but I think globally in terms of engagement in the world.
You know, if we're honest with ourselves,
where did global health begin?
Where did development begin?
Well, unfortunately, it began with some pretty dirty laundry
in the earliest stages.
It grew out of colonialism.
Development began as a process for people
to basically steal resources from other countries.
And to do that, they actually had to build buildings
and create infrastructure,
and that's where we actually started to engage in areas
we are now engaged in global health.
And then we moved to colonial missionary zeal.
Some good things, some bad things about that.
Then we advanced into world wars and the response to world wars,
where we began to actually create institutions
for development and global health.
And some of that was incredibly altruistic and well-intentioned,
whether it was the Marshall Plan
or what Herbert Hoover did,
which was created the first really global food program
after World War I.
And we started to create some institutions
in fairly philanthropic ways
but always with a little bit of paternalism attached to them,
going back to the colonial days.
And then we hit the Cold War,
where engagement in development and global health
from a geopolitical standpoint,
not from the people on the ground,
not from the people like Kevin,
who are out there doing the work,
but from a geopolitical perspective.
It really was about simply buying influence.
It was trying to get people to support
your political points of view.
It wasn't about concern for people's health
or for their own development.
And then we entered, along with that,
an era of post-colonial guilt from the Europeans,
who really just wanted to get some money out,
'cause they felt terrible about what started all of development,
which was colonialism.
And you really had Cold War and post-colonial guilt
and economic interest
as the drivers of global health and development.
We don't like to actually acknowledge that,
but that's fundamentally true,
not for the people on the ground
but in terms of the impetus for why we actually were engaging.
And I think it's really important to understand that
to understand the radical shift that occurred
in around the year 2000,
when people actually were willing to recognize
where we'd come in global health and in development.
And there was
a really earth-shattering and historic event,
the Monterrey Consensus.
and for especially the students,
anyone who's interested in the area --
It really was a radical, fundamental shift,
and it was a fundamental shift
on how we understood development.
It was a radical shift on how we understood our engagement
in development and therefore in global health.
And it was only a three-page communiqu.
It's not a complicated thing.
But it radically shifted the paradigm.
And fundamentally -- fundamentally --
it started with moving from a paternalistic approach
in development and global health
to a true partnership
with mutual accountability and shared responsibility --
that we were as accountable
to governments in Africa that we were supporting
as they were accountable to us for the use of resources.
And that was really a break point for a lot of reasons.
We call it "country ownership." We attach this name to it.
But that understanding, that fundamental difference
from 100 years of engagement in development and global health
was really radical
and is informing, as we move forward,
how things are changing.
Now, to achieve that mutual responsibility,
mutual accountability,
a couple of things were required.
One was actually focusing on results.
Many people in this room remember
that literally 12 years ago,
if you asked anyone in the United States government
or anywhere else what was happening for HIV,
what was happening for education,
what was happening for diarrheal disease abroad,
the answer would have been,
We are spending 'X' millions of dollars,
or, "'X' hundreds of thousands of dollars," unfortunately.
The answer was never,
"We are setting this goal and trying to achieve this,
and therefore we need this amount of money to do that."
And that really is a fundamental shift --
a radical shift from monies spent.
And if you understand where we came from,
it makes a lot of sense,
because if you're trying to buy influence
and make people feel good about you,
or if you're trying to assuage post-colonial guilt,
make yourself feel better about yourself,
you don't particularly care how the money's being used.
But if you focus on mutual responsibility,
shared accountability,
and working together in partnership,
that changes the paradigm completely.
Now you actually do care about what the money's doing,
how many lives you've saving, what your goals are,
and the direction you're going.
To achieve country ownership and shared responsibility,
you also need need good governance.
And, importantly, you need all sectors to be engaged.
That true development in health doesn't happen
government to government.
It happens people to people.
And everyone from the local village --
people engaged at the local village
to the people in the State House
to people in our faith-based organizations,
community-based organizations,
and non-governmental organizations
to all of you and to the government,
everyone needed to be in the game.
Now, I spent some time on that,
because I don't think you can understand
what's happened in the last 10 years
unless we understand where we were before
and the Monterrey Consensus,
which was a radical, radical break point.
And it was a radical break point
for those of us working in the Administration,
which, at the time, actually, I was an NIHer --
a lifer at NIH.
So I was peripherally engaged.
But that philosophical shift,
which the Bush Administration drove,
informed PEPFAR in ways that it's really hard to understand
unless you were in those rooms.
Those principles drove the creation of PEPFAR.
They drove the creation of the President's Malaria Initiative,
the Millennium Challenge Corporation.
They drove how the global fund was structured,
which the U.S. government was very much engaged in.
And that philosophical, intellectual foundation
was critical to what's happened in the last 10 years
in global health.
And PEPFAR would not have happened
were it not for that shift,
and I think it's really important to understand that.
So, sorry to take so much time on it,
but I feel really strongly about it.
So, then I want to talk a little bit about
how that intellectual, philosophical foundation
led to action,
because ideas in and of themselves are dreams.
They don't matter unless you actually engage in the world
and do something with them.
So taking that intellectual activity
and how we would change the way we acted
to actually implementing programs
isn't always a straight line.
In fact, it's never a straight line.
President Bush actually --
People still ask me, "Why did he do this?"
And I've actually talked directly with him about it
a number of times.
You know, he came into office
wanting to engage in global HIV/AIDS.
There's so many myths out there.
It's really amusing to hear them,
you know, about which faith-based organization
was whispering in his ear.
And I got to tell you, everyone takes credit for PEPFAR now.
Someone once told me,
and which I think is probably true --
"If everyone who took credit for PEPFAR
adopted an orphan in Africa,"
we wouldn't have an orphan problem anymore."
And that's probably true.
But there really is only one person,
that's President Bush, and he came into office
wanting to do something on global AIDS,
and there's no one reason for it.
As I've gotten to know him,
I realize he's a remarkably well-read,
really compassionate person,
and he just knew about it and could not believe
that the world wasn't engaged in this issue.
And Condi, he's admitted publicly and in his book,
helped a lot on that --
helped him focus on Africa during the campaign.
But they came into office
wanting to do something on HIV/AIDS,
and that's kind of easy to see when you look at the course.
Everyone looks to January of 2003,
but there actually were a series of steps before that.
In May of 2001, President Bush, in the Rose Garden,
with President Obasanjo and Kofi Annan next to him,
gave the first gift to the global fund of $500 million.
That didn't happen accidentally.
That happened because of the desire to engage
in global health
and, in particular, in global HIV/AIDS.
And so people forget that that was before 9/11
and all the things people say, "Oh, that's what drove --"
All those myths have nothing to do with reality.
And that gift to the global fund is a great demonstration of it.
9/11 then happened, which we're going to commemorate in a week.
And as you can imagine, that kind of shifts emphasis
and focus in a White House pretty dramatically,
but it's pretty remarkable to me
how rapidly they moved back to HIV/AIDS.
So within a couple of months of 9/11,
Tommy Thompson and Tony Fauci were on the continent of Africa,
and some of you may have been actually in the countries
where they visited, in the CDC offices,
to look at,
at the behest of the president in the White House,
What could we do in HIV/AIDS?
That was a couple months after 9/11,
and that was in December, January 2001-2002.
By May of 2002,
it had been decided that something needed to be done,
and prevention of mother-to-child transmission
was the place to go.
That was only a couple months later.
Two months later, the president, in the Rose Garden,
announced an initiative many of you remember --
the initiative to prevent --
the President's International Initiative
to Prevent Mother And Child HIV.
That was a $500 million, five-year initiative.
And I have to say, we were all very proud of ourselves
when that got announced.
We thought that so much had been accomplished, how great it was.
The president called people in and said,
"That was a really nice start.
Think big. This is not enough."
"Come back to me with something
that's really going to make a difference."
Come back with a game changer."
And that started a small working group,
which is pretty much the small working group
that put the plan together for PMTCT to create PEPFAR.
Before I talk a little bit more about that,
it's really important
if you want to look at where PEPFAR came from,
how important the PMTCT initiative was.
For those of you who are involved,
it really set the tone, the direction,
and the approach to PEPFAR.
13 countries -- the same countries
that wound up being the focus countries in PEPFAR,
except the Caribbean region.
Focus on results, focus on accountability,
focus on country ownership, focus on national plans,
focus on interagency.
Now, those of you who were around
remember the early bloodletting days of the PMTCT initiative.
It wasn't pretty.
And some of you in the room probably participated
both in-country and at headquarters
on some of those very difficult interagency battles.
That bloodletting actually let us get through a process
that was necessary.
So when PEPFAR was announced, we already had a running start
on how the interagency process would work.
We would have been way behind had PEPFAR been announced
without the Prevention
of Mother-to-Child Transmission Initiative before then.
But it also set
a lot of processes and procedures in place,
which are the boring stuff that no one wants to talk about,
including me most of the time,
and I know Eric doesn't, but that matter.
So there were, for those of you who remember,
the EOPs -- the Early Operation Plans --
the IOPs -- the Interagency Operation Plans.
Painful, painful processes.
The ambassador being in charge
and having to submit that plan on behalf of the agencies.
So the processes were put in place
that allowed this one government interagency approach,
and that allowed those early and very difficult discussions
to have occurred before PEPFAR was announced.
And then it was really that day
that the PMTCT initiative was launched
that the planning for PMTCT began.
Now, there's been a lot of controversy over the fact that,
literally, eight people created PEPFAR,
or created the concept for PEPFAR.
And a lot of people, and I think the agencies in particular,
in particular USAID,
was not overly amused by that, and I understand that.
And the president's point,
and it was his decision to do this,
and, I think, looking back in history,
he was dead right.
If you're doing a normal policy process in the U.S. government,
interagency is absolutely right.
You want to look under every rock.
You want to try to work out every process you can.
But if you're dealing in an emergency response,
the interagency process --
If we had gone through a normal interagency process for PEPFAR,
we would still be talking about it today, seriously.
We would still be talking about it today.
So pulling that together,
keeping it secret so that people wouldn't hear about it
and try to pull it down,
was absolutely essential to the success of PEPFAR.
And it's not an easy decision
for a president or a White House to make,
because they know the arrows they're going to take,
which I'm going to talk about in a moment, but they did it.
And that allowed us to move, literally in four months,
to launch the largest international health initiative
in history for a single disease.
That would not have been possible
through a normal interagency process.
Eric Goosby was actually very important in that process,
which not many people know and we haven't talked about.
Tony Fauci and I were the only ones in the group --
they were mostly of White House others --
that actually had some experience in health
and in Africa,
where I'd been doing some work in Uganda
and seeing the work that CDC was doing in Tororo,
actually, that President Bush mentioned --
delivering antiretrovirals on motor scooters with TASO.
And so they wanted to make sure that we knew
what the heck we were talking about, literally.
In fact, one of them said, "You know, we need to make sure
you guys aren't pulling the wool over our eyes."
So they asked us to name a couple of people
to come and truth-test it,
and Eric was one of them.
Paul Farmer, Bill Popp from Haiti,
Peter Mugyenyi from Uganda --
These were the people who were brought in to talk about it.
Now, the White House made the mistake
of letting us pick who they were.
So the night before, we had a dinner with all them
and told them what we needed them to say.
[ Laughter ]
And it's amazing to me, to this day,
the White House people have no idea that conversation occurred,
and they think it all just happened spontaneously.
But it worked extraordinarily well.
So Eric was actually very important at that time.
And that led up to the January 2003 address.
Now, there's no reason any of you should know this,
and I actually don't like the fact that I do know it.
I wish I never had to learn any of this stuff.
But the State of the Union address
is probably the most fought-after speech --
Literally, people start fighting over it
the day after the last one is done.
And, you know, people commit virtual murder
to get a sentence in the State of the Union address.
And the President of the United States
has no greater policy forum.
So for the President of the United States --
and they rarely talk about development;
they rarely talk about anything
that has to do with anything but the United States
unless it has to do with warfare --
devoted three paragraphs
with no one knowing about it until that morning,
when other governments were notified.
Cabinet members were notified that morning.
Members of Congress were notified that morning.
No one had any idea.
And only a few,
and only people who he knew wouldn't get to the press.
So that was a complete surprise to anyone.
That's also not so common, either.
And it was about HIV/AIDS,
and it was for the largest international health initiative
in history for a single disease.
Really, standing on this end of it,
that still takes my breath away --
what happened that night.
And then President Bush followed that up,
talking about HIV/AIDS
in multiple States of the Union address,
and that is extremely unusual, including in the United States.
Now, the initial response was pretty favorable,
mainly because the Administration picked
people like Senator Frist,
who they knew would say positive things,
to talk about it after the announcement.
The glow of the wonderfulness
of the American people engaging in global health
ended pretty much on Tuesday morning
when the attacks began.
The top health official at CDC for global health
called it "half-baked."
The USAID administrator, I think,
threw his notebook across the room when he heard about it.
And there was an all-out attack, pretty much, on it.
The Congress --
Actually, the Global Fund --
Richard Feachem was irate
that the money was going to a new bilateral institution
rather than the Global Fund.
An all-out assault began because of that.
Advocates went ballistic.
This is still the most astounding thing to me.
The HIV advocacy community --
the number of people who actually wanted PEPFAR to fail,
because they didn't like President Bush,
is still breathtaking to me.
I still have conversations with people
who can't get over the fact that he announced,
who are still furious about it
and who literally wanted it to fail
because they didn't want him to succeed.
It's really remarkable
and teaches you a lot about what motivates people over time.
But that was one of the biggest eye-openers to me.
I actually thought they would be falling all over themselves
'cause they were friends for so long,
to praise this wonderful initiative.
And long before we started debates
about abstinence and all that stuff,
there was just an utter "I can't believe this"
and opposition to it -- immediate opposition to it.
And then probably even more surprising
was the U.S. Congress,
which was Republican -- controlled by the same party
as the Republican President of the United States.
We thought this was going to be a cakewalk.
We'd walk in, everyone would love it, and we'd be done.
The first meetings, which they called us up for,
with the Republican leadership were brutal.
We were pariahs.
We were the least popular organization on the planet.
I mean, literally, we just got torn into,
with people saying,
"You're not going to get a dime of this money,
no way, over our dead bodies."
And there were a couple reasons for that.
One is the president just pushed through
$500 million for the Global Fund.
Now, in a Republican Congress,
doing that isn't particularly easy,
for an international institution,
for a global effort.
Then he launched a $500 million
Prevention of Mother-to-Child Transmission Initiative.
They'd also just pushed through
the Millennium Challenge Corporation Funding,
which is a $6 billion effort.
And they turned around and said,
"There's no way you're getting this.
You just made us do all that, and we're not going to do this."
It wasn't this --
In retrospect, in fact, I was at a dinner the other night,
and someone said, "Well, you know, the Obama Administration
"just needs to do what the Bush Administration did.
All the president needs to do is get out there."
People fell over themselves to be supportive."
I don't know what history they were reading,
but it wasn't reality.
So, how do you go from that, which was rather a mess,
to what happened?
And the way you got to it
and, in particular, in the interagency process,
was focusing on saving people's lives
and showing you can save people's lives
and walking people through how you save people's lives.
For those of you who remember
some of those early meetings from CDC,
we always began and ended with 2-7-10.
Whenever we started getting into really tough turf battles,
everyone tried to take their breath and say,
"Remember what this is all about.
It's not about whether you get"
"this money in that account or that money in that account.
We have a lot of money."
This is about saving people's lives."
And I remember those meetings with some of you in this room,
where people just turned from the old approaches
that were inbred in all of us
to defend our accounts and our institutions,
to defend the people
whose lives were intended to be saved with this money.
And that really was a remarkable thing,
and it was those goals,
despite some people not liking the fact that we had goals
and saying that development was too complicated,
that, in many ways,
helped people focus on what mattered.
And the opportunity that, for the first time,
many of us had in our lives to do what we set out to do --
why we went into public health,
to actually implement a program
that could save millions of people's lives.
And that actually also resonated in the centers of power
in Congress and in the White House.
But the single most important thing,
and many of the people don't want to admit this,
in both the launch of the initiative
and the success of it, was President Bush.
President Bush was engaged in PEPFAR
from the first moment and to the last.
For those of you who are here and knew about it,
cabinet secretaries did what was necessary,
administrators did what was necessary,
because they knew the president was going to ask
and the president was going to care.
And if they weren't going in the direction he wanted to go,
they were going to hear about it in the Oval Office from him.
I'm not going to go through all of the things he did --
the different meetings.
Public diplomacy
was actually directed at the U.S. government repeatedly
to make it clear that this was going to work
and the president cared.
There are a lot of presidential initiatives you know about
that presidents don't even know about.
This wasn't one of those, and everyone knew it.
And everyone knew the president would be asking,
and that gave us access to the chief of staff,
the director of OMB,
and allowed us to make the case on your behalf.
But it was really the results-based
that changed everything and allowed us to get the money.
What turned the Congress around
from hating, literally hating, this program
to holding it up
as one of the greatest successes in development
was the work you all did to achieve the results,
the work you all did to support the people in Africa
to achieve the results more appropriately.
And it was that national scale-up,
the ability to report twice a year on the progress,
that made all the difference in the world
and made Congress turn around and say,
"This is a good investment.
We actually are spending our money wisely,"
"and we're going to protect this program,
and we're going to help it grow."
Also related to that was the strong bipartisanship
that was brought about in this initiative.
It's really remarkable when you look at it.
Sandy talked about strange bedfellows,
but from a congressional standpoint,
it's rare to find the number of votes
for an issue like this across party.
When PEPFAR was first authorized,
I think it was 90 senators voted in favor
and about 380 members of the House.
When PEPFAR was reauthorized during very difficult times,
316 House members voted for it, including every Democrat,
and 82, 83 senators, including every Democrat,
with a Republican president.
And that didn't happen by accident,
because we started with Congress not liking us
and spent an enormous amount of time --
and this is an incredibly important lesson, I think,
for people who want to study health and policy --
is that Congress actually does matter.
And when you treat Congress as a co-equal partner,
not the subsidiary branch
that has to actually do things when you ask them to,
it changes the world.
And the information you all were able to provide
and the stories you were able to provide changed all that.
And one of the most important things we did is, from day one,
even when the Republicans were in charge,
we always met with Democrats.
We always met with the minority and the majority,
so when they got in power, they remembered that.
Not many people do that.
Not many people take the time to do that.
They only focus on the majority.
They remembered that
'cause they were the same staff members.
We also took the time --
and I think this is an important lesson --
to meet with staff.
Eric's position, my position is
the level of an Assistant Secretary of State.
Not many Assistant Secretaries of State
will meet with staff members.
In fact, when we were doing it,
I was called by other Assistant Secretaries
who told me to stop doing it
because they don't want to have to go do the briefings,
and that people were telling him, "Well, he's doing it,
so you have to come up and do it."
I was actually told by the most senior person at USAID
that we should stop giving Congress information
'cause they're just going to ask for more,
which is why their budget is earmarked to death.
And we never had a hearing in a subcommittee in the Senate,
actually, on our budget,
because they said we gave them all the information they wanted.
And what matters in that,
and the reason I'm spending some time on it,
is the drudgery of what you all do from CDC
to produce those reports that are incredibly painful
actually is one of the fundamental reasons
millions of people are alive today,
which gets to one of Sandy's points,
which is everything you do every day
when you're involved in a program like this
contributes to saving lives if you remain focused on
"Am what I am doing today
actually directed at saving lives"
or directed at my little world for that day?"
And if we focus on the first piece,
millions of lives will be saved.
If we focus on the other piece, we won't have any money
and no one's life's going to be saved.
I'm going to end with
what is probably the most important thing
and, in my view, perhaps the lasting legacy of PEPFAR,
which Eric is really picking up
and moving forward in new directions
and taking it to new heights,
which is going back to what I started with --
country ownership.
You know, the paternalism that we had in development
was as prominent in HIV as anything.
When the Millennium Development Goals were adopted,
you all remember there is
no treatment Millennium Development Goal?
Why is there no treatment Millennium Development Goal?
I don't know how many of you remember the conversations
that were publicly had that functionally said
that people in Africa were too uneducated and stupid
to do something as complicated as antiretroviral therapy,
that we had to limit development and global health
to immunizations, something like TB,
'cause it's only a couple of months,
but we could not do chronic care
and we couldn't do something as complicated as treatment.
People were literally saying this
in U.N. meetings a decade ago,
just over a decade ago.
That paternalism of, "we are the ones
who are bringing development to Africans"
was so prevalent.
And the Monterrey Consensus began the philosophical shift,
but the reality of that had to take hold.
And the reality of national plans,
supporting national governments, supporting people,
not just governments in their country
to be the most creative and innovative,
to find the solutions to their problems
so that they own their response --
that piece is probably
one of the most important pieces of PEPFAR.
And treatment,
because it was the first entry point to chronic therapy,
to chronic care,
shattered those paternalistic myths
in ways that will radically change global health.
And it is that basis, I firmly believe --
but I'm obviously biased --
that is allowing us
to now talk about noncommunicable diseases
that we never could have talked about before
'cause people didn't believe it was possible
to do something as complicated as chronic therapy
or chronic care in these settings.
And that belief and hope in the people in Africa,
that belief and hope
in the people on the ground doing the work
and us supporting them --
that radical shift, which was philosophically embedded
in the Monterey Consensus,
was made reality in PEPFAR.
And we have a long way to go -- a long, long, long way to go --
but we're so fortunate that Eric's the one leading it,
because he believes it more deeply
than anyone I've ever met.
So, thank you very much for all you have done.
Really, truly, you have changed the world.
[ Applause ]
Thank you, and it's my pleasure to introduce our last panelist,
and we'll take a few questions and answers
after he completes his discussion.
Ambassador Goosby comes to us, as discussed,
from San Francisco General Hospital.
And for those who were at the front lines
early in the epidemic,
when you had 18-, 20-, 22-, and 25-year-olds
dying from an unknown disease,
at the time when you had dramatic treatments
for leukemia, lymphomas, bone-marrow transplants,
any infectious diseases that came through the door,
and there you were,
confronted with young people who were dying,
it is probably the most humbling experience
that you can experience.
Usually, with many of the other issues,
like breast cancer and others,
we know people fail therapy,
but there's always something new and something else to try.
And eventually, if you lose a patient,
you know you've tried your absolute hardest.
Having these patients die in the bedsides
without any true intervention
as a physician was extraordinarily difficult,
and dealing with their families, their loved ones, their partners
was also incredibly hard.
Ambassador Goosby did that
throughout the early time in San Francisco
and then brought that passion to the Ryan White Care Act.
And the Ryan White Care Act, as many of you know,
sought to address many of the disequities
that were out there among HIV/AIDS
but brought care and treatment to millions
that it still does in the United States today.
He then worked very hard globally
and set up the Pangaea Organization
that worked alongside governments
to help them develop national plans with more impact.
And so he was on the front line, working with governments,
before we arrived on the doors, working on their national plans
and working alongside as ministries of health.
So, it's really a pleasure to introduce Ambassador Goosby,
our Global AIDS Coordinator since 2008.
[ Applause ]
Well, thank you so much.
It's really an honor to be up here
with my friends and colleagues
to reflect some of the moments that we've all gone through.
It's surprising how infrequently you're really asked
to reflect backward in time on your career,
think about the motivators
that put you in front of opportunities.
I think Mark was really eloquent in saying
that this is something that was started
by President Bush realizing this extraordinary need,
knowing that a response could be mounted,
had the courage to engage it.
We started something,
but it is clear to all of us up here
that you are going to be part of those who finish it.
That iterative process that we are all engaged in --
I think medicine is wonderful in that regard
in that you learn and depend on colleagues
in a way that is unusual, kind of, in the work world.
We take it for granted.
But what we do better than a lot of other arenas
is we really do build on the scientific understanding,
allow that scientific understanding to inform policy,
and policy, scientific understanding,
to inform program.
That continuum of and evolution of
a thought to a service
is a privilege to be allowed to shape,
inform, to mold,
and it is thrilling to be able to watch the results.
It has been a true honor
to be part of those at different points in my career.
But I want this talk to resonate with you,
to think about your motivators,
to think about what makes you get up and do it again each day,
because it is never a quick solution for public health.
It is always something that we build on the work of others.
So, I'm going to get a little concrete
and go through what's happened in PEPFAR
over more recent years,
think about a little bit where we're going in the future.
So, let's see.
Do I -- There you go.
We're going to look at the outlook --
PEPFAR's role,
accelerating progress on treatment,
progress on prevention,
and then making the transformation permanent.
Launched, as Mark said, by President Bush
at a time when I think we can look with Sandy's comments
on how that platform and discussion was fed
before President Bush and the Bush Administration
took it and transformed it into a programmatic reflection.
I think that, again, it is iterative.
Again, it is working on the work of others
and being willing to acknowledge and share in that workload
but also in the acknowledgement
of the contributions made over that time period.
It did change the course of HIV/AIDS epidemic.
It continues, as we've heard from everyone up in the panel,
to save lives.
It's an extraordinary lifesaving machine.
It has done it through comprehensive service delivery
in both prevention, care, and treatment.
As we move forward,
we now, in 2010 alone,
we're serving 3.2 million people on antiretroviral drugs --
men, women, and children.
We had directly supported antiretroviral therapy
for pregnant HIV-positive women.
We had to test about 8 million women
to find the 600,000 HIV-positive women
to receive antiretroviral therapy
to prevent the 114,000 infants not being born with HIV in 2010.
We've supported 11 million people with care and support,
including almost 4 million orphans and vulnerable children.
Indeed, PEPFAR really is the largest OVC effort
on the planet.
Supported HIV counseling and testing
for nearly 33 million people in 2010 alone.
As a platform to identify, enter, and retain people
in continuums of care and services,
PEPFAR really puts a huge opportunity in front of us.
We have a shared responsibility to make this work
and to make and allow this to evolve
and continue to expand,
to embrace the large unmet need that continues to be out there.
We have tried to turn our efforts,
as Mark started in his tenure, to look at how we do this work,
to make the smart investment not sometimes
but more times than not, if not always,
and to promote and save our service delivery portfolio
to allow it to save as many lives as possible,
to make it sustainable,
to strengthen our partner government's capacity
to manage and operate these programs,
to expand prevention, care, and treatment
so they're targeted, effective, and high-impactful,
and to integrate and coordinate
with health and development programs
when and where possible to potentiate that impact
and to allow us to invest in an innovative culture
so the learning and continued refinement
to increase impact continues.
The deaths per year in sub-Saharan Africa
have dropped as the funding has gone up.
Over time, it has been a remarkable, concrete example
of throwing resources at a problem
and seeing those resources reflect in outcomes
that show impact continuously year after year.
This, for the public-health arena,
had been a sea change
and, as Mark said so eloquently, I think allowed and enabled us
to maintain the interest and commitment
in our appropriations discussion
through what now we move into our eighth year.
3.2 million people treated,
each year going up significantly.
Our rate of accrual has not dropped off
with flattening of funding.
It indeed has increased in our ability
because these platforms have reached a level of maturity
where they are there.
People have heard and received care in our systems,
spoken to their family members,
brought in their family members and friends,
so it has kind of viralized,
like throwing a pebble in a stagnant pond.
That ripple goes out until it hits the shore.
The TASO group that Sandy referred to up in the quilt
in Uganda and Kampala recently published,
really, the observations
that we've seen in the developed setting
since the 19-- really, '94 and '96 period,
when highly active antiretroviral therapy
became available in centers of research,
medical centers in the United States and in Europe,
and then '96 began to be available widely
in kind of the larger medical community.
Increasing life expectancy --
People essentially with HIV,
if cared for by a knowledgeable provider,
really should be dying from something else.
I think that we have had our costs driven down.
When Mark began this activity,
you were looking at costs in the $1,200 range --
in a few countries, even more than that --
down to about $435 per patient per year.
This includes the cost of the drugs,
monitoring labs,
the human resources that are involved in putting that person
in front of a knowledgeable provider,
and following them over time.
This in the context of countries
that really were only set up for acute care management --
the concept of continuity care,
follow-up care, outpatient services
really not well embedded, if present at all.
And I think one of the added benefits
of the PEPFAR kind of wave hitting many of these countries
has been the realization that acute care medicine
does one small piece of the treatment-burden need
but that if we can move
more into identifying individuals earlier,
more of a prevention strategy
as to how we interface with populations,
driving our medical-delivery- system decisions,
we are able to save more lives with that.
The prevention impact has been dramatic.
The incidence rates
on that column on, I guess, your right
showing -30%, -10%, to -81% in Namibia
drops in incidence.
This is multifactorial, but a dramatic turn has occurred
in the reflection of this virus's ability
to move through populations.
I think that this is something
that has kind of slipped through.
The media has not been picked up as much as it should.
But we have strong evidence
in 27 of the countries in sub-Saharan Africa.
I believe we will see it in 37 of those countries
when we're through with this --
a drop in incidence rates throughout.
I think that our ability
to look at how to combine our prevention interventions --
We have taken the step
to move toward high-impact prevention interventions,
to know your epidemic, know your context,
know your response, and know your costs.
It allows your program-planning managers
to be creative with how they move their resources
to be reflected in a delivery system
and develop continuums of care
that continue to be responsive to the patients' needs
as those needs change.
I think that our ability to say,
This is more impactful than another
has also become apparent,
and I think we are now ready
to put pressure on our program portfolios
to move in that direction,
go for the high-impact PMTCT,
male circumcision-type interventions,
the role that treatment plays in prevention.
We're working on that now aggressively.
Kevin is playing a central role in that dialogue.
We are going to incorporate these new findings
into our ability to come back
with a stronger, more effective prevention portfolio
in every setting we're in.
It does not mean
that behavioral interventions do not have a central role
in our ability to prevent
movement of the virus in individuals,
within their social sexual networks.
Testing and counseling promotion,
behavior change does have its role
tailored to high-risk populations.
The general kind of public health announcement
has a role, as well,
but it should not be to the exclusion
of the high-impact prevention interventions.
They should be supportive of it.
And then moving for those more, I think,
issues that sustain populations who are HIV-infected or affected
with policy changes,
looking aggressively at gender-based issues
in both violence
as well as in ability to sustain and maintain family structures
with inheritance rules and laws becoming more and more important
as our patient populations are reached and are not dying.
These become the predominant focus
as you move in to what we hope
will occur in every country we're in --
the care of a chronic, progressive disease.
Through PEPFAR, the United States
has been aggressive in the PMTCT effort.
It's how PEPFAR evolved, as we heard from Mark.
The PEPFAR program now, as I mentioned,
had 114,000 infants born in 2010 HIV-negative
because of this intervention.
We know that we have dropped
the number of HIV-positive pediatric cases globally.
We are committed in partnership
with kind of our global armamentarium,
including the Global Fund, but in partnership with UNAIDS
to create an initiative that aggressively tries
to converge resources
to move the number of pediatric cases
down to, basically,
those who are not in care that we can't reach.
So, saving children, mothers, and families,
accelerating the PMTCT,
80% coverage over testing
and 85% coverage for prophylaxis and treatment.
This is a program, as I mentioned,
that we have now expanded into a global initiative.
It will be something that, by 2015,
we hope we are able to move those numbers down
to as close to no new, zero, conversions
as is possible.
We created a pledge of resources
that brought in the private sector
because we really believe
that it not only is more sustainable
if there's a diversification of your resources
but also we need the extra resources
in these economic times.
The Gates Foundation, the corporate sector,
Chevron, Johnson & Johnson,
and now about seven other corporate entities
have come to the table
with real resources that will be renewable
and will be in this fight,
as I say, until 2015 or for as long as it takes.
Male circumcision I just put in here
to emphasize that we are looking
at a convergence of prevention interventions
that included in the PMTCT impact
added to male circumcision
added to the treatment as prevention.
We really do feel that we have pushed ourselves
into a moment where the opportunity
to impact the viral spread of HIV
is at a unique moment in time.
The 0052 study that many of the people in this room
participated in,
really showing the 96% drop in infectivity
in individuals who are compliant,
adherent to the medication and viral load drop,
that this indeed now has to be recalibrated
in our prevention portfolio,
not just as a treatment intervention
but also acknowledge and try to quantitate
the contribution it makes to the prevention effort.
Pre-exposure proph
for populations that are at high risk,
that are difficult to reach,
or are unable to change their behavior
is a legitimate intervention to consider.
The use in discordant couples,
both for the treatment as prevention
but also in the pre-exposure prophylaxis
has been something that has been looked at.
It's difficult to put kind of a formula together
that works in all settings,
but to have these in our armamentarium
and for countries to think of this as a tool
to better move their ability to, again, arrest the movement
of that virus within the population.
So, we are trying
to translate the science into policy
to inform programs, to change programs
so they have a higher, stronger impact
on the populations that we're focused on --
basically, to save more lives.
WHO, in their development of normative guidance --
PEPFAR, since its very inception,
has supported WHO in creating these guidances.
Before the guidances in the prevention arena
and the antiretroviral guidelines that WHO has put out
have been going on, really, since probably
around '98, '99 -- in that range.
Formative research for implementation
to really look at the building blocks
to make a medical delivery system that is responsive,
has outcomes that are measurable,
most importantly, that are also sensitive enough
to identify changing needs
in the population that we're serving
and allow programmatic changes to accommodate that,
increasing the role that --
increasing testing plays,
supporting and trying to identify the elements
that burn providers out, nurses in particular,
ensuring linkages to care and prevention
of those who are HIV-positive for other family members
so that one individual becomes an access point
for others who are probably at higher risk,
getting our medical delivery systems
to play a treatment and prevention role
in a more creative fashion,
and then not missing the opportunity
to target those populations that we know
are participating in high-risk behaviors.
To overlook that is a mistake.
Male circumcision, we've talked about.
So, innovation --
I've pretty much addressed most of these.
The cost issues, I think,
are what we have an opportunity
now to continue to work on within the PEPFAR model,
but as we move in to a different relationship with countries,
understanding their contribution,
both in human resources, as well as in money to this effort,
quantitating that,
including that in the planning process,
discussion to merge our planning and implementation efforts,
not just with the country, to have them as the convener,
to have them as the prioritizer of unmet need
and making those allocation decisions
but with the Global Fund.
It's our belief that we will,
with convergence of planning and implementation efforts
with the Global Fund,
actually realize more savings.
The collapsing of generic drugs now at 98%
in the PEPFAR portfolios.
We are also in a situation
where we're looking at administrative oversight
and indirects for covering
one kind of manager, program manager
to cover five clinics
instead of having five program managers
for all five clinics, separate ones.
Looking at procurement distribution systems
has been very productive
in identifying significant savings.
All of those types of kind of operational research activities
we really are trying to rev up now.
Have created a scientific advisory board
that is, in part, very much focused
on what I would put in the family of operational research.
The country ownership is a critical piece.
I believe it is the conduit
through which we will get and sustain these programs
for the time that they are needed,
which we're looking at years, decades into the future
for the people who are using these services today,
looking at a different dialogue
with ministries of health, with ministers of finance,
with legislative leadership
within the countries in which we work,
as well as the president,
is a new emphasis that we are aggressively pursuing,
putting our U.S. ambassador in a central --
creating an expectation
that he or she have those dialogues
with senior leadership in country
not once but repeatedly,
to use the relationship we've created
by our efforts in the PEPFAR arena
in developing these service delivery systems
in these countries,
to use that as a platform
off of which other discussions in the diplomatic portfolio
can be dealt with and brought up --
that so-called use as health diplomacy.
The Global Health Initiative --
President Obama's attempt to kind of transform
what has been an extraordinary effort
to continue that effort
but also to try to take advantage
of what we really have
in a lot of vertical systems and vertical funding lines
to look for every opportunity
to use existing platforms that are already up and running --
HIV, TB, maternal and child health,
family-planning platforms --
and to try off of those already existing platforms
to add services that will be delivered
off of that same platform --
not rebuild it, not create a parallel system,
not create a situation
where an individual with HIV but with another disease --
diabetes, hypertension, coronary artery disease --
can also be followed and cared for
in either linkages or on site.
Those types of expansions,
that type of, I think,
anticipating the use of laboratories
so one lab is feeding 20 different sites
as opposed to 20 separate lab efforts,
type collapsing of resources,
is really what the Global Health Initiative is about.
It's the right thing to do.
It's swimming upstream in a USG context.
Our bureaucracies don't relate to this,
but we believe that we will be able
to bring more people in front of knowledgeable providers
and we believe we'll be able
to save more lives at the same costs.
So, health systems and local institutions
are the other piece of country ownership
that I think are critical.
Looking at institutions
and supporting capacity expansion in institutions
is a major contributor to sustainability.
I think that if we can,
through the African Society for Laboratory Medicine,
in conjunction with
the Medical and Nursing Partnership Initiatives
for medical schools and nursing schools,
create a new self-expectation
within our colleagues
in sub-Saharan Africa in particular
to move out of syndromic treatment,
diagnosis and treatment being something
that needs to have a laboratory support to carry out
so you are making a specific diagnosis
that has a specific treatment
is what I hope we are starting here.
This will look at curriculum, focus on clinical teaching,
develop preceptor relationships
as you move in to your first clinical experiences
that have a more senior experienced clinician,
be it a physician or a nurse
who are there to consult with you on those patients,
not put you in a position over and over again
where you, as the provider,
are not sure if the patient is dying
because of the disease
or because of something you didn't know.
Our colleagues in Africa are put in these untenable situations
right out of medical school, right out of nursing school
that any of us would not be able to sustain.
So, we hope that this will help that.
The civil-society-and-community piece is critical.
I think that our ability
to maintain and sustain these programs
is best supported by creating a voice
that is coming out of the individuals
who are using these services,
going back to those who are making allocation decisions
and planning and implementing programs,
to allow for corrections to occur over time,
for an element of accountability
to be part of the infrastructure that allows this to sustain.
We cannot expect or hold everybody accountable
from Atlanta or from Washington.
We need to create that capability internally
so the self-reflection
that our medical colleagues and country go through
creates quality controls and systems
that allow them to know that they are on or off track.
This, I hope, will make a contribution
to our ability to make it better,
make it run more efficiently,
but also have that level of accountability
that stays in the face of power.
Finally, the focus on women, girls, and gender
is something that is --
anyone who's worked in this arena and these settings,
it's dominated by women, girls, and gender issues.
It's not a choice we've made. It's who comes in front of us.
And we have very aggressively tried to bring to scale
a response that increases the understanding
of how gender plays itself out
in the societies that we're working in
to give safe islands of safety
for individuals, MSMs,
injection-drug users, women in general,
so not just for only women, but also for men.
It plays out in the same way.
But I think having these safe areas
to allow people
to not have to stay in horrible situations
but where options are present are what we've tried to create.
A post-exposure prophylaxis treatment,
diagnosis and treatment of sexually transmitted diseases,
diagnoses of pregnancy,
family-planning considerations around spacing and contraception
are all part of what the whole package should be.
And in partnership with countries,
we are working very aggressively
to try to make that a self-sustaining expectation.
So, the emergency response
moving to a more sustainable response,
the country ownership being the critical backbone of that
for sustainability
coupled with a voice from those who use these services
to, again, give that feedback.
The global shared responsibility
is something that I think the United States specifically,
in that we do play a significant role
in donor resources globally
for HIV/AIDS, for TB, for malaria,
really for many disease processes
that go undiagnosed and unresponded to --
We believe that it is time
for the global community in health to look --
because of the successes that we've seen
with entities such as PEPFAR and the Global Fund --
to look now and ask ourselves, "Can we do this differently?"
Can we and you in this room carry this further
to put a basement of healthcare
available to those individuals on the planet
who, right now, do not have access to it?
Can this be something that, as a basic human right,
we can now push more aggressively,
knowing that it is achievable
with a chronic progressive disease
that is as complicated as HIV/AIDS and/or TB.
I think that that is the question at hand.
I think we are positioned as a major contributor to this effort
as the United States
to maybe present this as a dialogue
that moves forward,
and we're hoping that we can, over the next couple of years,
move this agenda globally.
PEPFAR has a unique relationship
with the Global Fund.
We are the main kind of USG representative
in the Global Fund dialogue.
We sit on their board.
We are able to share the responsibility
of this global burden of HIV/AIDS and malaria, TB,
with the global community.
I think that the distribution of resources that go out here,
the United States takes the lion's share of it.
Other countries -- U.K., 13%,
but you drop off rapidly
as you move through the rest of your European countries.
It's time that we look at this,
that we ask ourselves and each country asks itself,
"Is this the contribution that we can make?
Is it the contribution that we should make?
And what can we do to increase our ability
to impact by converging these resources in a different way?"
I think both the Global Fund and PEPFAR have shown
that there are advantages to that convergence,
and we need now to demonstrate it more aggressively.
We believe that if there is this call to action,
that the United States, I hope,
will take the leadership role in pushing,
that we will increase the collaboration,
the resources will become, with already at existing levels,
more efficiently spent,
and we will demonstrate that and reflect that
by saving more lives.
So, I just want to end
with the challenge that Mark really put out to you.
This is a moment in time
that I'm old enough to say is unique.
The convergence of the science
that has happened over the last 30 years --
HIV is a remarkable --
one of the unique examples
of science informing policy, informing program.
We see a direct reflection of the scientific discovery
immediately incorporated into large global programs
through the efforts of those bilateral programs
but also through WHO and the U.N. system.
Holding our colleagues accountable
in WHO and in the U.N. system
to play that role of convener,
of consensus driver, and of resource sharer,
to call it like it is
around the efficacy of their effort,
to say that it is good or bad, we need to change it,
or, if you cannot do it,
we need to say that this is a serious enough issue
that we need to find an entity that can.
If we didn't have the U.N. or WHO,
we would have to create it.
Each of us here have had extraordinary interactions
with those entities over time,
but I think we would all agree
that the role that is carved out
for that international effort,
the forum that is presented in that international discourse,
is not reproduced anywhere else,
and with just bilateral efforts,
I don't believe you can stop or move
to that vision of, really, putting a basement of healthcare
on the planet.
So, I challenge you to be part
of that getting across the finish line,
carrying that dialogue further to be more specific and concrete
about what the elements and bricks are
that are needed to build that road.
So, I thank you very much.
[ Applause ]
I just want to thank all of you for coming,
and if we can thank our speakers again
for making this trip down here,
really, to share their time with them --
with all of you, and I...
[ Applause continues ]
Wanted to thank, again, Emory and the CFAR
and Professor Carlos del Rio,
who has graciously provided
a reception that immediately follows this
that you'll be able to speak with the panelists and speakers.
And that's another reason
why we didn't have it at the CDC,
'cause I do believe that there could be wine out there.
So, thank you again, and thank you, Emory, for hosting this.
[ Applause ]