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Rethinking Maternal Health [Rush Transcript; Federal News Service]

Speakers: Nils Daulaire, President and CEO, Global Health Council, Paul Fife, Director of the Global Health and AIDS Department, Norwegian Agency for Development Cooperation, Sheila Tlou, Botswana Parliament Member, Former Minister of Health of Botswana, and Representative Nita Lowey (D-NY), Recipient of the Global Health Council's 2008 Congressional Award for Global Health
Presiders: Laurie Garrett, Senior Fellow for Global Health, Council on Foreign Relations, and Isobel Coleman, Senior Fellow for U.S. Foreign Policy, Director of Women and Foreign Policy Program, Council on Foreign Relations
June 11, 2008
Council on Foreign Relations

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LAURIE GARRETT:  (In progress) -- global health at the Council on Foreign Relations, typically based in New York rather than here in Washington.  I'm very glad that we were able to make it here from New York yesterday.  It was iffy all the way.  And I appreciate every one of you that managed to join us this morning.  And I want to thank you all very much for being here.

We're here to talk about maternal health and maternal survival.  And I think this chart, for those of you who can see it, summarizes the problem that we're here to discuss.  It is demographically adjusted for deaths in childbirth.  It shows you where in the world this phenomenon dominates and where in the world it has basically been conquered, so that that little skinny sliver that is North America is us versus that massive, bulbous space that is India, that is the Indian subcontinent, and that is sub-Saharan Africa.

With us today is an absolutely stellar group of individuals.  You couldn't ask for a better group to discuss this with you and to lay out the key issues.  We're going to focus on policy, and we're going to do so thanks largely to Judith Helzner and the MacArthur Foundation, which has taken a very deep interest in this problem, to our many collaborators that have assisted in bringing this together, especially the Global Health Council, which most of you are probably familiar with, based here in Washington, D.C., and, of course, in Vermont, in Senator Patrick Leahy's backyard, I think.

I want to just briefly tell you about our format and then introduce our first commentator.  We're going to try and have our comments today very short, in the ballpark of seven, eight minutes for each speaker, so that there will be a lot of time for your questions and your comments and discussions.

The most important thing to accomplish here today is to make sure that everybody leaves this room understanding what the issues are and how U.S. foreign policy can address this problem and why it should, why it is in our interest to do so.

Dr. Nils Daulaire has been running the Global Health Council for all the time that any of you have really heard of the institution.  You've heard of it largely because of Nils's extraordinary energy and efforts and the fantastic staff he has built around him here in Washington and in Vermont.  We have been delighted to work with them and want to thank them for all their efforts in helping to bring this event together and a similar event we will be convening tomorrow in New York City at the Council on Foreign Relations headquarters.

The Global Health Council is an umbrella organization, really, that encompasses almost all the organizations that work overseas and receive USAID funding or foreign aid funding from the United States budget.  So you're really -- you're speaking to the implementers, as it were.  And we are here speaking to the funders.  Putting implementers and funders together is always a good idea.

One last comment about Nils Daulaire, besides that he's brilliant, fantastic, witty, all those things.  (Laughter.)  He just married off his daughter this weekend.  (Applause.)

NILS DAULAIRE:  I'll do my best to stand up after the weekend.

Let me make a couple of notes before I start.  First of all, let me note that 10 years ago, when I joined the Global Health Council, I spoke to a reporter and was asked what would be a real marker of progress in terms of Global Health's position.  And I said, "I would say if the Council on Foreign Relations ever gets engaged in global health and brings the mainstream of foreign policy thinking into this arena, I think we've made enormous progress."  And I think we owe Laurie and the Council -- Council on Foreign Relations, not the Global Health Council -- an enormous vote of thanks and confidence for having really engaged in this.

I also want to thank a number of old colleagues from many, many years who've been struggling in this arena of maternal health, who are here today from Family Care International, from the White Ribbon Alliance, from the International Women's Health Coalition, from Ipas, from EngenderHealth, and from the International Center for Research on Women.

And for those whom I didn't mention, forgive me, but I just did want to make sure that these organizations that were very instrumental in putting the Women Deliver conference in London last October together.  This is really the movement for women's health around the world, and they're vital members of the Global Health Council.

I'll keep my comments short, because, looking around this room, I realize that there's enormous background and experience here, and we'd rather hear from you.  But let me just lay out some framing points here.

Every second of every day, four women around the world give birth.  And every minute, one of those women dies.  Those are statistics that we're all familiar with.  What is perhaps a little less known is that, for every woman who dies, another 30 women suffer lifelong consequences as a result of complications of their pregnancy or delivery.  That has huge and devastating impacts.

So we are talking about not just the more than half-million deaths each year.  We're talking about 15 million women each year who enter the realm of handicapped and whose lives and communities are forever changed by that.

Now, I live in a state, as Laurie has just commented, Vermont, where this was commonplace a century ago.  In fact, on the little farm where I live, there's a family burial plot about 50 yards down the hill just for that one household.  It's filled with headstones from the period from about 1812, when the house was built, until the 1860s.  And you wouldn't think that one little house and a neighbor house would be able to fill a cemetery, but it has.  And what's striking there is that two of those headstones are from women -- actually wives of the same man, both of whom died in childbirth and both of whom are buried along with their infants.

So this is not a remote issue, but it was something which, as a medical student, I thought was a historical issue rather than one present.  And as I started my career in international health 30 years ago, I was shocked to personally watch women die, to be the last point of referral, as they were brought in, in -- (inaudible) -- sepsis, and literally to have them die under my care and in my hands.

This is all too common.  And what is really inexcusable about this situation is that saving women's lives is not rocket science.  It does not require Massachusetts General Hospital and high tech and people trained at the best universities in the world.  And, in fact, some of the work that's been done by the organizations that I just referred to has really clarified how important three vital steps are for the -- can you hear me in the back?  I was just told this isn't amplified.  So I'll speak up, in any case.

The three vital steps to massively reduce the number of deaths and the number of lifelong complications from pregnancies and births, and those are that every birth, every birth, needs a skilled attendant; that all complications need immediate access to emergency obstetric care; and that all women and girls who are at high risk or who do not wish to become pregnant at this point need reliable access to family planning.

Now, we know that those three things work, and they work in concert.  They're not stand-alone things.  I was trained as a family physician, and I wouldn't just take care of colds.  If somebody came in with a bladder infection, I'd have to deal with that.  All of these things fit together, and they fit together in the larger context that I'll talk about in a minute.  But let's talk about those three things.

What about the skilled birth attendants?  In Sri Lanka, we know that Sri Lanka, back in the 1950s, made a commitment, a national commitment, to assuring that every woman had skilled birth attendants.  At that point about 30 percent of all women did.  Today it's about 97 percent.  It's still a very poor country, wracked by conflict and all kinds of problems.  But in going from 30 percent to 97 percent of skilled birth attendants, they also took their material mortality rate from 600 down to 60, so an enormous impact there.

Secondly, emergency obstetric care.  One case in point:  Matlab in Bangladesh.  It's a very poor area.  Everybody knows the conditions in Bangladesh.  And Matlab, which is a field station of the International Center for Diarrheal Disease Research, started referring women into their field hospital for emergency care back in the 1980s and have, during the subsequent 20 years, in their immediate community that they monitor very carefully for mortality, they've reduced maternal mortality by somewhere between 55 and 65 percent, almost a two-thirds reduction from the access to emergency obstetric care.

And thirdly, family planning, an issue which sometimes is seen as something different than maternal health and maternal care, but we all recognize it's part of the same package.  In Egypt, when USAID became very actively involved there in a range of health programs, maternal and child health as well as family planning, one of their emphases was assisting in family planning.  And during the ensuing 20 years, the number of children born to each woman in Egypt dropped from 5.3 to three.

Now, what does that have to do with maternal deaths?  Well, I said before, high-risk deaths, women who are too young, too old to have had recent pregnancies or who have had too many pregnancies, are at much higher risk of death.  And, in fact, by cutting fertility by almost half through the widespread availability of high-quality contraceptives, maternal deaths in Egypt dropped from 5,000 to 1,000 during the same period, so an 80 percent reduction.

These things make a difference.  And when they work together, they make an even bigger difference.  But what's clear -- and I'll end with this -- what's clear is that we can't do this as a stand-alone kind of effort.  We require the health system to be on every minute of every day if we're going to save women's lives, because they deliver at enormously inconvenient times for us doctors. 

(Laughter.)

And what that means is that we have to support robust basic health care systems in countries around the world.  We can't just do it by a one-shot intervention, as nice and as easy as that would be.  And we need to do it in the context of a continuum of care in which we look at women and children not as sort of discreet packets but, in fact, a woman who is just becoming pregnant or considering becoming pregnant needs access to family planning services.

If she wants to delay that, she needs good pregnancy care.  She needs that skilled attendant at childbirth.  She needs means to be transported to a facility which can provide her with emergency obstetric care, because you can't anticipate most of these complications.  And all of these things need to be put together into a package.

So the Global Health Council and our membership have called on Congress to devote greater attention to this very important issue of maternal and child health and family planning by increasing U.S. government spending from its current level for this spectrum of activity, currently $1.3 billion, to increase it in the next year by a billion dollars to $2.3 billion.  That's nowhere near enough in terms of the long-term picture, but this has to be ramped up, just as we saw in the early years of PEPFAR, that PEPFAR had to be ramped up.

This is hugely important.  This takes a vast toll in terms of lives and families.  We haven't done well enough.  But we've got a good start here.  And it's very encouraging to see, this early on a Wednesday morning, this many people packed into a hot room in the basement of the United States Congress.  But we hope that those of you who are staffers will go back up and work with your members to make sure that this becomes not only rhetoric but policy.

Thank you very much.  (Applause.)

Now it's my pleasure to introduce our next speaker, who is an old friend and colleague, Paul Fife.  He comes from Norway, another country that I have fond connections with, and is at NORAD, the Norwegian aid agency, the director of the Global Health and AIDS Department; has been deeply involved not only in AIDS but in the MDG 4 and 5 efforts of the Norwegian government.

Paul. 

(Applause.)

PAUL FIFE:  Thank you, Nils, Laurie, Isobel.

It's a pleasure and honor to be here.  One can wonder why a Norwegian should come here and talk to you.  I mean, the brain power in this room -- just imagine 4 million people, four and a half million people, the population of Norway.  We represent only 3 percent of total aid and total health aid.  So we're minuscule.

Speak up?

GARRETT:  Yes.

FIFE:  I'll speak up.

So what can I contribute?  And basically what I can contribute is give a snapshot from what's been happening in Norway the past five years, in particular in relation to MDG 4 and 5, child and newborn and maternal health, and also represent some of the international initiatives that are working on this.

As Nils -- very clearly, it is down at the local level where action needs to take.  Maternal survival, maternal deaths are very clearly global issues as well.  And this is also why I think it is on the radar screen for the Council, but it is not a local problem.  It is a global issue, and it's something that we all need to be worrying about.

Also maternal deaths represent the tip of the iceberg.  We really see the 500,000 women that die each year and girls that die each year -- I mean, 20-30 more are maimed.  And also there is violence.  There is a breach of their rights, which happens.  So it's an immense problem.

And in particular, we can say why MDG 5 or the AIDS Millennium development goals is the one that has basically fared the least well is actually a failure of our societies to protect our girls and women.  And I'm 42 years old.  I'm a male and I'm a doctor, and I come here particularly from the field of vaccines or vaccinology.  And it's totally -- I cannot understand why it hasn't been on the radar screen of the political level of communities, and also of all the different rights movements.  Why is it happening?  Why do we allow it to happen?

So I have a prime minister, Jens Stoltenberg.  And when he came on board in 2000 and signed the Millennium Declaration in New York.  On the plane back he thought, "Okay, possibly in 2015 I'll still be around."  He's young.  He's 47, 48.  And he said, "Okay, I'll look at one MDG and I'll try to do something about."  And he picked MDG 4.  He's an economist, and he could just see the potential, I mean, all the right reasons for basically to work on child survival.

What's happened since then, he started with vaccines and basically committed to $1 billion for the -- (inaudible) -- for improving introduction of new vaccines and coverage.  And then, of course, he saw the link to maternal health.  So now he's really behind the maternal, newborn and child health continuum of care.  And he has put one billion additional dollars on the table, up to 2015.  And this comes on top of the regular contributions from Norway to the U.N., to the World Bank, to the multilaterals, to NGOs, international NGOs, and to countries.

So that was the first point.  What is needed now?  What is needed now?  Political commitments delivered.  That's my first point.  Okay, we need it delivered, of course, in action, but also in funding.  Countries, OECD countries, need to pay for the 0.7 percent of GNI.  This is important.  This will fund basically what we need to do at local and country level.

Even as important as that, all countries in Africa and Asia need also to increase their share of spending to health and to the social sector.  African countries have committed 15 percent to health.  This needs to happen.  Only a few countries are doing this, although it is increasing.  So it's a mutual accountability.

A third thing that Stoltenberg did was actually to say, "Okay, we need committed global leaders."  He engaged, on a personal level, a network of global leaders for MDG 4 and 5.  And these are President Bachelet of Chile, President Johnson-Sirleaf from Liberia, President Wade of Senegal, the presidents of Indonesia, Tanzania, Mozambique, the UK and Brazil.

And basically they don't meet often, but they communicate.  And now they also write letters to the presidents of the G-8, to the government of Japan, to say, "Look what we've managed to do on MDG 6, on AIDS, on malaria," the important things which are happening now.  We need to have the same for maternal and newborn and child health.  And look at what you did in Japan after Second World War.  This now needs to happen -- primary health care, delivery of services -- at local level.

After political commitment, the second message I have is that we need to improve coordination and basically make aid more effective at global level.  This is also why it is a global issue.  It's great, the political commitment.  We have many new initiatives.  We need to harmonize them.

We have the Global Campaign for the Health MDGs, which is a no-brainer.  We have the International Health Partnership, which is very much working for improving aid effectiveness.  Let's spend the dollars better in countries, and let's build on national plans.  Let's reduce transaction costs.

We basically need to work at international level so that we reduce both the transaction costs between our agencies, but in particular country level.  Ministries of health, ministries of finance, cannot spend their time meeting with delegations and dealing with individual project proposals.

The third thing, which also was a point that Nils made, was that we need to focus, yes, on interventions.  We need what needs to happen.  But we need to do it in a way which is systems-oriented.  We need outcome-focused health systems strengthened.  This is what is going to make it sustainable and this is what is going to build ownership locally and in country.

Special focus should be on children and women.  And we cannot ignore anymore the human resources crisis, which is extremely complex.  But there are budding solutions in countries.  Some countries are really attacking this head-on in terms of training and retaining; and the role of non-state providers, both at delivery of services and also for participating in demanding services.

Norway has, together with the World Bank, tried out a new mechanism on results-based funding to look at how can one link incentives to results.  And we do it in a new program in the World Bank of $150 million over four to five years.  It's not large amounts.  Each country will get about $12 million, but we link incentives to maternal survival.  And countries are basically eager to come, and there are two regional workshops to see how one can design contracting out performance-based deals for human resources, and also the demand side, incentives for safe deliveries.  Importantly, we need to follow this with evaluation, research, for learning, both for better policy and for implementation.

My last and final point relates to civil society and citizens.  We are not going to succeed unless the forces are harnessed.  We've seen it in AIDS.  We have seen it in AIDS.  We haven't done enough yet in AIDS, but we have seen really what civil society can basically move in terms of forces.  It is key to accountability -- accountability to the service provider in terms of quality, in terms of the ministries, in terms of also parliaments.

And to be able to do this, in addition to all of the wonderful international NGOs at the large NGOs that we need meet around, we need to be able to harness the local civil society organizations.  And that is a question we have:  How can we do it even better than today?

My final point is I think we get to succeed if we manage to frame MDG 5 as the indicator for health systems performance and as proof of tangible action for delivering on equity and on women's lives.  So let's do it together.

Thank you.  (Applause.)

ISOBEL COLEMAN:  Hi.  I'm Isobel Coleman with the Council on Foreign Relations, also in New York.  Thank you for bearing with us.  I know this is a very tight room for this size meeting.  And thank you for accommodating on the floor and everything else.

It's my pleasure to introduce our next speaker, Sheila Tlou, who -- Tlou, I was told this morning -- Sheila is from Botswana -- Tlou means "might of an elephant."  (Laughter, applause.)  You will see that this is true when Sheila comes up to speak.

Sheila has been the health minister in Botswana for the past four years; just recently stepped down.  She is currently a member of Parliament and has also been -- she's a Ph.D. in nursing, has been a trained nurse, working on the front lines of community health in her country, in Botswana, for the past quarter century, and has also got the distinction of having started at one of the most important civil society organizations in her country, the Botswana chapter of the Society for Women and AIDS in Africa, which has over 3,000 volunteers and has been a key partner of the government really working on a critical range of health issues relating to HIV.

Thank you, Sheila.  (Applause.)

SHEILA TLOU:  Thank you.  Thank you very much.

Good morning.  And good morning, floor people.  (Laughter.)  I like you.

Okay, let me -- I have what?  I have 10 minutes.  Okay.  I mean, my story is a week long -- (laughter) -- but I'll compress it in 10 minutes because we'll have questions and answers anyway.  So let me start by thanking the two councils, the Council on Foreign Relations and the Global Health Council, for inviting me, especially at a time when I really needed to get back to my original mission in life.  I mean, I've been a politician for the past four years.  And, you know, politics is politics, but I'm an academic.  I went to -- (inaudible) -- an academic environment, and I really miss the research.  And I'm seeing one of my colleagues here, people that I used to work with, you know, around the world, really looking at especially HIV and AIDS issues.

So thank you very much for -- this is like one of the first engagements I've had.  So I know, from now on, I am an academic.  I'm a member of Parliament, but Parliament is something that's part-time.  (Laughter.)  (Inaudible.)  The real stuff is here, where people are.  So it's great.

I'm talking about a country where I guess one of the major messages to any funding or to PEPFAR is that, okay, I come from Africa, but, you know, each country is unique.  We each have our characteristics, our unique needs.  And sometimes donors tend to say, "Here you are, and these are the conditions -- no exceptions."  And it usually doesn't really work.  You need to be able to assess what is the situation in each country.  And in a way, I'm glad to be representing a country that has been that unique, and I'll tell you how.

This is a country that, before the advent of HIV and AIDS, was the model country in terms of implementation of primary health care.  We saw primary health care as it was stated -- (inaudible) -- 1978, you know, implemented such that by 1990, we had 80 percent of the population within 10 kilometers of a health facility -- and, I mean, fully staffed with people, from basic to complicated hospitals, but all the same, proper access.

Where we had primary health care workers even at community level, people were able to motivate women to go for antenatal care, to motivate women to deliver at health facilities, to motivate women to ensure that the children are immunized, so that 90 percent of all our children were immunized against childhood illnesses.

Now, the infant mortality rate at that time was around 88, maternal mortality around 140, and we saw a total fertility rate go down from 6.8 all the way to 4.3.  Now, we had quite a lot of gains, but they all got crashed down when HIV/AIDS really took its toll.  And it took its toll at a very wrong time for the country.

This is a country where we used to have donors -- NORAD, (CIVIDAR ?), whatever.  And we were then classified as a middle-income country, whatever that means, because we never felt it.  You know, somebody out there in the World Bank decided this is a middle-income country.  But in country, we knew we were just as poor as everybody else.  However, that meant that donors then left, and they left at a time when the impact of HIV/AIDS was being felt.

So we saw our whole -- all the gains that we had really disappeared, and we saw AIDS really coming up in Botswana, where, by 2004, 32.5 percent of pregnant women were infected; okay, mother-to-child transmission around 40 percent.  So you knew that you then were losing mothers as well as their children.

And, of course, its impact on health care also affected quality, so that we no longer had that 90 percent skilled care.  We now had health care workers even infected, and infant mortality rate over 90; maternal mortality anywhere between 250 and 300.  Nobody was counting, but we knew it was -- -

What happened then was where we should have had comprehensive health care, the issue then became crisis health care.  Everything shifted to HIV and AIDS.  I guess we had no choice, because if your whole society is faced with extinction, you have to act.  And fortunately we had leaders at that time where the political will and commitment became necessary, and it was there.  So we saw that -- (inaudible) -- approach.  And indeed, our country was the first country to budget, to include in its own budget, budget for HIV and AIDS.

So when the leaders in Africa in 2001 stated that they were going to devote 15 percent of their budget to helping AIDS, ours devoted 22 percent.  And it's been like that under my -- when I was a minister, I ensured that at least 22 percent went to helping AIDS, and the rest to, about 27, to education, because education is also important, especially empowerment of the girl child.  So that got 27 percent, and health was next at 22 percent.

And the great part was that, unlike other African countries, the military got only 5 percent.  Now, the reverse is sometimes true in other African countries.  The military gets the lion's share, and the money is channeled away from where it ought to be.

Now, I would say that the U.S. funding, PEPFAR, also came in at that time, and, you know, some of the donors, especially ACHAP, the African Comprehensive Partnership, which is made up of Bill and Melinda Gates as well as Merck.  So we had the drug companies there.  But PEPFAR really was our major -- became then our major partner in the sense that we were able, with technical and financial support, to increase access to health care.

Now, the great part about AIDS care is that it's a crisis, but at the same time, if you are doing it as well as we thought we are doing, then you are also including overall health care, so that we now have 90 percent access to antenatal care, to post-natal care, to whatever, but also almost 100 percent immunization, because then we are able to strengthen the health system.  Then we are able to have access to HIV/AIDS prevention, treatment, care and support for women and children, especially orphans, because we now have 66,000 orphans to take care of.  In a country of 1.7 million people, that's quite a lot.

So the results have been phenomenal.  We are seeing -- we saw mother-to-child transmission go down from 40 percent all the way down to 3 percent.  So now it is, like, around 3 percent.  And the main aim is that we should really be having zero transmission.  We are seeing ARV uptake; 90 percent of people who need ARVs are on ARVs.  And most of them are women, which is true, because in any event, most of the people who are infected are women.

So what PEPFAR is also helping us do is to really now look at how we can improve this.  For example, we're slowly losing some children; much as we've saved them from transmission from the parents, at the same time there are some who fall in the cracks because of lack of implementation of our policies, specifically the infant and young child feeding policy.

How you counsel women not to breastfeed but ensure that they have the adequate means to ensure that the children receive good hygienic formula, so we give free formula to people for formula feeding and give the education.  But then you really don't know what happens to that woman in the middle of the night when she has to get -- (inaudible) -- and she can't be able to make proper formula, so maybe she resorts to breastfeeding.

So those are the nitty-gritties that we are now grappling with.  I will be able to answer any questions we would be having on that.  But basically, even the total fertility rate has now gone down to 3.1.

Now, really, how can you more impact -- I guess to me the most important question that I have to answer now is what more can be done?  How can U.S. funding have more impact?  The first, of course, is to leverage that political will and commitment.  You know, we don't want to have a dependence on donor funding.  But at the same time, we should be able to sit down as countries with donors to be able to say, "Look, this is the 15 percent that we are giving," and see what else can be done.

I attempt to sometimes get this message, that donors must do this.  And as an African, I'm thinking, "Yeah, but what are the African countries doing?"  So it should be a real partnership where our commitment, especially the Abuja Declaration, we are able to do that.  And then we can sit down with donors and be able to say, "When we put our 15 percent, this is where it takes us.  Now this is how we can help."  So you find that it becomes a whole lot better.

Now, the strengthening of the health system -- he's already mentioned that -- policies.  We need, you know, how policies can actually be made into better practices, but also the supply systems.  You know, we're in a situation where you can have access to drugs and all that, but the supply chain management of those is always a problem.

So it's really sometimes that kind of technological support, and also the related technologies like delivery packs; just simple things, as he said; and, of course, access to sexual and reproductive health commodities.

We still have situations where women are having pregnancies that they have not planned for and that they did not want, so that even with the total fertility rate of 3.1, we are still having problems in terms of access to sexual and reproductive health commodities.

Human resource development is a thorny issue throughout the world.  I serve on the Global Health Worker Migration Advisory Council, whatever that is.  But we now are sitting down to really come up with a solution that can be discussed at the World Health Assembly where developed and developing countries can all sit down and agree that, look, we all need health care workers, so let's ensure that we train them; we train and retain them in each country, but ensure that we produce enough that the supply and demand can at least meet each other halfway.

Right now the demand is just too much throughout the world.  And with globalization, I don't care what we do; you know, if we don't ensure that we retain our people, they will go.  So it's really there.  But that is one area where we can be helped with in terms of training and ensuring that we retain people in country, because in the ultimate, most people do want to work in their own countries, especially when the climate, economic climate, is good and there is peace and stability.  But they are forced sometimes by circumstances to go and work elsewhere.

So let me conclude by simply saying that maternal health is an urgent priority in the fight against poverty, which is another MDG.  But it is also affected by poverty, especially right now with the current food crisis.  I don't know how we're going to tackle that one, but it is something that we need to also look at.

Thank you very much.  (Applause.)

COLEMAN:  Laurie and I are each going to make just a few short comments to wrap up today.  But let me just start by saying that I'm Isobel Coleman and I direct a program at the Council on Foreign Relations called Women in Foreign Policy.

And Nils earlier was talking about how getting the Council involved in this issue is a sign of progress.  And, in fact, in the last five years the Council on Foreign Relations has started two new initiatives.  One is the Global Health Initiative and the other is this Women in Foreign Policy Initiative, which I direct.

And Laurie and I collaborate on a lot of intersecting issues, because so many global health issues actually come back to the role of women in society.  And the work that I do at the Council on Foreign Relations really takes and looks and examines the role of women in society and makes the argument that women's empowerment is really a key foreign policy issue for the United States for a whole variety of reasons.  It's key for promoting democracy, for economic stabilization and growth.

Women's role in society is critical for stabilizing fragile states.  You can go down the line.  There are a whole list of reasons.  One of the most critical, of course, is the very central role that women play in developing.  The data is extensive on the role of women in driving the education of the next generation.  Women play a much more central role than do men; and women's role in the health of the family and of the community broadly.  And Sheila has just been talking about worker migration, and Sheila is trained as a nurse.  We know that there's a global nursing crisis, a nursing shortage in the world.  And 95 percent of nurses in the world are women.

But this -- what we're talking about today is not just a personal tragedy, a family tragedy, when a woman dies in childbirth, and a community tragedy, but it is an economic tragedy for the country.  We have half a million women dying in childbirth a year.  But we heard earlier that the impact is actually more like 15 million women when you take into account disability.

And women play such a crucial role in the family's economy, in the microeconomy and in the community's economy.  They are the backbone of the informal economy in many parts of the world, particularly sub-Saharan Africa.  And in many of these -- almost all sub-Saharan African countries now, women make up the majority of the labor force in agriculture.  And in some countries it's upwards of 80 percent.  And when you have women who are dying in childbirth, it is destroying the fabric of the family, of the community and of the local economy.

Women's rights as human rights has been a very key element of U.S. foreign policy for the last several administrations.  And it has been emphasized, women's empowerment, as I said earlier, as a key driver of several different U.S. foreign policy objectives.  Women are critical not only in the development equation, in educating the next generation, but also in stemming the tide of HIV/AIDS, which is now really a women's disease and is affecting women.  And it's no coincidence that when you look at this map, where maternal mortality is greatest is in countries where women's lives are valued the least.

The MDGs recognize that women are so central to the development equation by making two MDGs specific to women -- women's empowerment and maternal mortality.  And we really cannot talk about women's empowerment when we don't start at the most basic element, which is ensuring that women don't die in childbirth.

I hope that -- there will be a new administration come November, and that whoever that might be will look at this issue as an opportunity for the United States to really take up and drive home the role that the United States can play positively that we've heard earlier from our various speakers on really addressing the issue of maternal health.

It's no news to anybody in this room that the United States is not viewed very positively around the world.  In fact, in some of these areas, I mean, some of the biggest countries in maternal mortality -- Afghanistan, Pakistan, some of the sub-Saharan African countries -- the United States has an opportunity to take on this issue as a public diplomacy issue, as a major health initiative, to say, "Look, we stand -- a value of America is we stand for women's rights.  We stand for human rights."  And one of those key rights is that women do not die in childbirth.

I think I'm going to turn it over to my colleague, Laurie Garrett, now.  But just in closing, I'd like to say I think it's important that we see this opportunity for women's health, women's maternal health in particular, as a marker for progress that we're making in health generally and health systems specifically.  Thank you.  (Applause.)

GARRETT:  Well, you can see why, at the Council on Foreign Relations, I have a fantastic situation being there with the Global Health Program, in large part because I have this fantastic, stellar colleague, Isobel Coleman, to work with.

We will shortly be joined by Representative Nita Lowey.  But I want to give us a few more comments and then an opportunity for everybody to engage in this conversation that we're having here today.

You've heard the numbers.  You've heard what they mean on the ground.  You've got the sense of how Norway is trying to approach a strategic way of looking at the maternal health question.

And I want to argue that this is totally doable, that one of the things that's held back progress in the maternal health question for quite some time -- in fact, ever since the Safe Motherhood Initiative was announced in 1987 -- we've barely seen the maternal survival numbers budge.  In some places they've worsened since then.  And the main reason is because there's a tendency to see the issue as overly complicated, as just too many factors contribute to maternal death; too many factors need to be in place to save mothers' lives.  How can any funder make a difference?  How in the world can we have metrics that determine success and determine that we're getting somewhere and U.S. taxpayer dollars are saving lives?

I'm here to tell you we know enough now.  We know what that strategy should look like.   We know what needs to be done.  Terrible as the situation is, this map, which some of you may be able to see at this point, shows you the tremendous disparity in maternal mortality around the world.  It's the biggest gap differential of any of the major health markers.

It's a logarithmic differential between maternal death rates in the wealthy world, in Latin America and Europe, on one side, where we're looking at about somewhere between 17 and 25 women dying per 100,000 births, versus sub-Saharan Africa, where we're looking at roughly 920 women dying per 100,000 births, and parts of India and Indonesia exceed 1,000 women dying per 100,000 births.

We have an expectation period opening up.  The world, to a degree that those of you who have not traveled recently overseas cannot imagine, is sitting on tinderhooks watching our elections.  The expectation is very, very high that, regardless of which of the two candidates becomes the president of the United States, that there will be spectacular change.

In truth, it's going to be hard to fill those expectations, regardless of which candidate becomes president.  But we can manage some of that expectation by picking the right targets that will really make a difference in world public opinion and in saving lives.  Maternal health is precisely that target.

And here's what we know.  We know that spending has been rising, that there's a global commitment.  It's not just Norway.  We've seen that in 2003, total spending for maternal survival was around $2 billion.  Today it's around $3.5 billion, and the United States contributes roughly a billion of that.  That's maternal survival and infant survival combined.

We also know and have new data that tells us a lot about what's killing women and what we need to target.  Consider this:  In Mozambique, an amazing study just published recently, they actually performed autopsies on 179 women who died in childbirth in Moputu.  And what did they find out?  Fifty-two percent of them died of hemorrhage.  In other words, they bled to death.  So that boiled down to, A, they didn't get to a physician fast enough; B, somebody didn't do the right things fast enough; and C, there wasn't a safe blood supply.

Okay, those are three targets.  We know what to hit.  But 48 percent of them died of infectious diseases.  And of the infectious diseases, half of it was HIV.  Almost all of it was vaccine-preventable disease, other than the HIV piece.  Those also tell us what we need to target.

UNICEF has shown us that if you implement tetanus vaccination at a cost of a mere $1.20 per pregnant woman, three rounds of tetanus vaccination, you radically reduce tetanus deaths and infant deaths due to tetanus, so dramatically that they estimate that in 10 years of implementation of widespread tetanus vaccination, 1 million lives have been saved.

We can do this.  Stunted babies -- we know that a woman who was growth-stunted as a child and continues to be malnourished into adulthood is far more likely to give birth to a stunted baby, and that baby is far more likely to die.  About 20 percent of the burden of maternal mortality can be directly attributed to acute malnutrition.

Now, you may say, "Wait a second.  Is it America's responsibility to put food on the table of every single poor person in the world?"  Well, it turns out it's easier than you might think.  First of all, you could solve it in part if the mother is just healthy enough that she can produce decent breast milk.  Guess what:  A breast-milk-fed child has 14 times greater probability of surviving to age one.  So right off the bat you've solved part of that problem.

But Indonesia has shown simple vitamin and micronutrient supplements costing about $3 over a nine-month period of pregnancy, a 25 percent reduction in the mortality of those babies.  So simple interventions can make a huge difference.

Ethiopia -- only 10 percent of all births in Ethiopia are currently attended by anybody who's trained to catch a baby properly.  But where they are getting community health workers trained and midwives trained and getting them on the spot, they are radically reducing the maternal death rates.

Ethiopia currently has the largest rate of fistula, the thing that has been referred to many times as the crippling, handicapping injury that occurs to women who simply go through labor too long without anybody doing a C-section or intervening on their behalf.  Well, they are beginning to attack that problem as well.

In India, one out of five maternal deaths occurs in India.  And of those, the key reason for that is 60 percent of all births in India take place in a home without any professional attendant, any trained helper.  So that's a target.  We know what it is.  We know where we need to go.

The other piece we know is that one of the most vulnerable population groups to dying in childbirth is teenage girls.  Their poor little bodies haven't developed sufficiently to carry a child to term.  And here they are at age 13, age 14, pregnant.

I would just note that we in the United States had that problem at one time.  We had a huge -- what was then called the epidemic of teen pregnancy.  We have reduced our teen pregnancy rates by 38 percent over the last 15 years.  They've started to do an uptick, which needs to have attention paid to it.  But the point is, we found a tool kit, and some of it may be transferable.

It's all about, in the end, health systems, transportation, getting where you need to be for the right help that's available 24 hours a day, seven days a week.  People don't need to bleed to death.  People don't need to die of vaccine-preventable diseases.  People don't need to die of HIV.  These are interventions we know how to do.

And finally, I just want to emphasize once again, and without any hesitation, I think that we've lost ground on the maternal mortality question because we got bogged down in too many little details about a problem that has complex contributors.  The truth is, we know how to keep women alive.  The C-section is after Caesar.  This is not a new technology.  We know how to do it.

And America can lead the way, or at least stride alongside the bold leadership of Norway, to act as donors that make this a top priority, see it as a piece of our foreign policy, and recognize the tremendous benefit we will accrue politically when we make the achievements that make sense.  It's 500,000 women a year dying in childbirth right now.  It should be an American target to bring that down to at least 100,000 within the next five years, and we can do it.  (Applause.)

We're going to take questions now.  And I know that some of you in the back have been squeezed back there and feeling a little hot and have had trouble hearing, and it is our apology.  It's just too small a room.

COLEMAN:  Not to mention the hallway.

GARRETT:  And the hallway out here.  We're going to take some questions right now.  If you could just raise your hand, stand, identify yourself, and speak as loudly as possible since it is hard for those who are standing out in the hallway to hear.

QUESTIONER:  I'm Dr. Mary Carnell from John Snow.  I'd like to ask several of you -- we're probably a roomful of maternal health and child health experts and interested.  The comment you made, Minister -- member of Parliament Tlou -- -

TLOU:  Tlou.  (Corrects pronunciation.)  (Laughs.)

QUESTIONER:  Tlou.  Sorry.  Thank you.  If the economic climate is good and there's peace and stability, our people would like to stay in our countries and work, in terms of the human resource crisis.  I'm just wondering, in the balance of things, we have to put more money into maternal health, but we have to put less money into war and more money into peace and stability.

I'd like some comments from all sides what our countries are doing with the country budgets.  I'm very happy to hear about your 5 percent military budget.  You know, that's not the case here in the United States.  It's not the case -- -

TLOU:  (Inaudible) -- countries, that's right.

QUESTIONER:  Where is the balance, and how much do we have to put into democracy?  Or is it democracy?  Is it something else than what we've been calling governments in democracy to have peace so that some people can stay home to work and other things can have the monies they need?

COLEMAN:  I think it's to Sheila.

TLOU:  It's to others too.  (Laughs.)

GARRETT:  Before you start -- -

TLOU:  Oh, okay.

GARRETT:  -- there are a couple of seats here if anybody wants to try to -- oh, you're just going to the bathroom.  Sorry.  Okay.  (Laughter.)  Don't take those seats.

TLOU:  (Laughs.)

GARRETT:  We are going to take a break in about 20 minutes, before Nita Lowey arrives.  So I just want to give you that sense of timing, for those of you who are standing and are thinking about a break.

TLOU:  Let me simply stand.  I'm not giving an answer, but I'm, I guess, complicating the thing even more, because, you know, people have sometimes said, "How come Botswana was able to achieve so much in terms of progress in HIV/AIDS prevention, you know, treatment, care and support?"

And basically I'm seeing four ingredients:  Political will and commitment at the highest level; prudent spending in country -- that ensures that the money goes to where it's targeted; zero tolerance for corruption; and a good governance that ensures that we involve civil society in everything that we do.

I think we're one of the few countries where, when we go to international meetings such as the U.N., we are talking the same language and sometimes have the same paper as our civil society.  Now, if you take civil society as a government watchdog, you know that's usually not the case.  But we try by all means to ensure that we speak the same language.  And when we have any fights, we fight at home.  But by the time we leave home to go to whatever meeting, that we now have the same agenda.

So I would say it takes quite a lot of other things.  But I think we also need to concentrate on that, because that will then ensure that our health care workers don't get enticed to go to other places.  I mean, right now, as I'm talking to you, most of the health care workers from Zimbabwe are in Botswana and in South Africa.  You can't blame them.  They have to survive.  So it's really that kind of thing.

FIFE:  Thank you very much.  I think it's a very important question.  I come from a country where few people, in principle, stay in the northern parts.  It's quite close to, I mean, where it gets dark half the year.  And so we've had to think the past 30 years about incentives.  And each country is different.  But for many African countries, there needs to be a two-step process -- one fast in terms of just deploying basic frontline health workers.  Ethiopia has been doing it.  Malawi has been doing it.  Ethiopia is showing increasingly great results.

The people, the health workers, need to be able -- that's their home place.  They need to be recruited from the place where they're going to work, and they need to receive some dignified pay and recognition.  It's not going to solve all problems, so one needs really to work on the second phase, which is the long-term higher education.

I mean, basic education for girls in particular has been very successful.  We need to do it with secondary education.  We need to do it with higher education.  And that's, I think, what is very important in particular for the United States.  It's very closely linked to research and to rewards.

So to have good managers in capital cities, in the big cities, there needs to be some professional rewards to be staying in health.  The rewards are not there today.  They are increasing some places where actually one can do decent academic work and actually get recognition, which is not only related to pay.

So we need to look again at these research systems also as a way, not only to have people to stay and feel that they can professionally expand their career, but also to work with ministries and others to know exactly what is working, what is not working.

So the whole issue of implementation research, evaluation research is something we need to look into.

COLEMAN:  Nils has a comment.

DAULAIRE:  Let me be brief.

Mary, an awful lot of ships have been dashed against these rocks.  And the challenge, of course, is framing a set of arguments that makes sense to the people who make the decisions.  That's why it's terrific to have the Council on Foreign Relations who have among their membership some of the key leaders in the foreign policy community.

But I think that the two arguments that need to be framed and made repeatedly and thoughtfully are the arguments about security and the arguments about responsibility.  And in security, we have been trying, but we need to do better than we have today.  We've been trying to make the argument that areas of high deaths and high levels of disease are a culture medium for chaos and violence, as we've seen with Afghanistan and Somalia and other places.  And that, in fact, it's not just a matter of humanitarian response --- although I suspect a majority in this room would probably see that as the principal reason we should do it, because it's right.  But it is also for our long-term benefit.  That's the way we need to make the case to U.S. policymakers.

Responsibility is an argument that is inadequately heard -- and I much appreciate Sheila Tlou's comments about this in the context of Africa.  This is not just a developed world or a donor world issue.  It's an issue that needs to be addressed by responsible governments around the world.  And in order to make that case, we have to help mobilize civil society in those countries.  It can't be from the outside.  It has to be from the inside. 

     The Global Health Council has members in 146 countries at this point.  We've been working our International AIDS Candlelight Memorial and other vehicles to start putting together national networks to push --- White Ribbon Alliance that's been doing similar things in the context of maternal health.

But these kinds of movements need to be supported from outside, but really led from the inside to tell their policymakers, their politicians and national leaders that they have a responsibility to deal with these issues.

COLEMAN:  Thank you.

QUESTIONER:  Hi.  I'm Ann Starrs, from Family Care International, which was the organizing partner for the Women Deliver conference that has been mentioned a couple of times today.

I have a question that's probably primarily for Paul, although others may have a thought on this. 

Paul, the Global Campaign for the Health MDGs and the International Health Partnership have created a real momentum around --- one of the elements you talked about was performance-based financing. 

     There's an initiative that was launched at the Women Deliver conference called The International Initiative for Maternal Mortality and Human Rights.  And there was recently a visit to India, which looked at some of the results of the performance-based financing, and in particular the initiative of, in essence, paying women to deliver -- come to health facilities to deliver.

And I don't know what the numbers were, but there were documented cases of women who were in labor, were essentially forced by their husbands to walk two-and-a-half hours to a health facility to deliver.  They were given the money that the Indian government has agreed to. The husbands pocketed that.  And then, you know, a couple of hours later the women were walking home with blood pouring down their legs.  So there's a real risk, I think, of having that kind of mechanism, obviously, have results that we really don't want. 

     So I wondered if you had any comments on how the rights framework can really be married and help influence and help shape the way things like performance-based financing and results-based approaches can be implemented to ensure that incidents like that, which as I said, may not be common, but for them to happen at all I think is certainly something that we want to avoid.

     So if you have any comments on that from the international perspective.

     FIFE:  It's a very important question --- a tough one. 

     First of all, the government of India is putting in $30 billion for that national overall health mission.  It's an investment for the people.  And we see an increasing number of countries -- also Ethiopia -- that really for the first time are doing this.  So it's a sign of national leadership.

     The issue you raise is, I guess, referring to the Circle GSY program where the government of India has put in incentives linked to delivering in facilities.  And some of the early figures which are coming up are amazing in terms of a doubling and more of actually the proportion of pregnant women coming to the facility.  So there are several issues around this.

     One is, okay, so what's the quality of care in the facility?  Some of these facilities are possibly more unhealthy than being at home.  But is it good to have that -- will that demand spur, basically, action on the service delivery side? 

     I think the issue you raise is really, we need research.  I mean, both in terms of before implementing policy, what are the good practices?  What is the evidence?  And then we always know, when there is a policy introduction, there will be unintended effects.  There will be side consequences.  They might be positive/negative.  This needs to be followed.

     So again, it refers back to my first point of really being very, very careful in following -- setting aside funding and brain power locally, also with support from the external academics in order to build up the rigor and really follow this very carefully and adjust.

     One of the good things -- one of the many goods things with the global initiatives -- has actually been to implement policies, work with countries and adjust.  And it's that flexibility we need to reclaim.

     We also need to learn from the past.  We can go 30 years back in India and the program that referred to sterilization -- also where there were incentives.  So we also have to learn from the future -- from the past -- (laughter) -- from the past, also from the future.  (Laughter.)

So issues you are raising really point to the need to be very careful in this World Bank program we are supporting.  And we would love to have -- it's a multi-donor trust fund.  We have established a working group that is co-chaired by the Center for Global Development to look at learning.

We know performance-based funding, which is also used in my country and your country as an effective way to improve services, is not the answer to everything.  When it comes to developing country settings, it's only going to be a tiny portion at the top.  It's not going to represent the full funding that the health sector needs -- long-term, predictable funding for salaries.  But to see the good examples, the evidence coming up and also to learn from what is not working in the context.

So I think you made a very good point.

COLEMAN:  I just want to, first of all, point out now we have a little bit of seating here.

I also wanted to remind you that -- underscore one little fact piece -- and that is that children whose mothers die in childbirth have a 75 percent greater probability of themselves dying before reaching the age of one.

And noting that, I would like point out in the hallway among our many illustrious guests here today, Charles McCormick from Save the Children has joined us. And I know that the issue of maternal survival for Save the Children is child survival.  The two are absolutely linked.  They don't see any separation between these issue sets.

Can I pick somebody from the back?  How about way in the back there.

QUESTIONER:  (Off mike.)

COLEMAN:  A little louder, please.

QUESTIONER:  (Off mike) -- from the International Women's Health Coalition.

I'd like to add a point to this immediate exchange and then also ask an additional question.

The point to add, I think, is Paul: I'm very glad you referred to the earlier experience that we had in family planning programs with incentives schemes. And to say that as we struggle with overall financing for health care, it may really behoove us to think about how we finance access to care rather than paying people in this kind of way to generate demand for care.

In the Bangladesh setup on a nationwide level -- Nils had referred to the -- (off mike) -- specific effort.  In the mid-'90s, we worked with governmental donors to ensure emergency obstetric care down to the district level.  And in five years, maternal deaths came down by 26 percent, simply by making a relatively -- (off mike) -- quality service available.  Women and families will go when they know that care is there and that they won't go there simply to -- (off mike).

The question I want to ask is that -- I hope I heard you correctly -- that Norway is trying to make the MDG-5 the indicator of success in the health system strengthening.  Perhaps you even said "the" indicator of success.  We would love to see that happen and I would like to hear from you:  What do you think are the possibilities?  Because frankly, in the International Health Partnership Initiative, I think we're very far from seeing that.

FIFE:  I mean, I think the task that falls on all of us is to allow for diversity and at the same time, be very outcome focused.  So whether I said "the" or "and," I cannot really recall.

COLEMAN:  It was "the."  (Laughter.)

FIFE:  It was "the?"

COLEMAN:  Yeah.  I made a note of it.  (Laughter.)

FIFE:  I mean, we stand by that as a measure of health systems performance.  But it is extremely important here -- both in terms of all the different subcommunities in health, AIDS, rights -- that we don't continue to, shall we say, decrease the value of the case we put forward by, shall we say, not being able to stay on message. 

     And what is really important here, first of all, the debate that has been going on the past few months in terms of too much funding for HIV and AIDS and malaria and not enough for this.  We know that more funding is needed for everything.  And it's really important not to battle for what are insufficient resources at local country and global level for today.

     So we really need to have some common messages in terms of our resource envelopes and what this consists of.  I think The Partnership for Maternal, Newborn and Child Health has been doing a very good job in terms of the bringing together the child, newborn and maternal communities.  That we do see that one of the main challenges we have today is the divides -- the gaps between the AIDS response and the health system response.

     And a message from our side is very clear that we shouldn't look these -- shouldn't increase divide.  These are basically extremely powerful forces that need to come together through national health strategies, meaning good country plans, health sector plans, where in countries where HIV is a public health problem, HIV and AIDS components are well aligned and the same as the national AIDS plans.

     So it is a tremendous challenge to us all to basically be on track when the best thing we can do is really to talk about the outcomes.  And that's where the MDGs -- the MDGs are not very strong in systems.  They are strong in results and that's really what we should be working for.

     So when it comes to a main challenge, how to reconcile this tremendous political commitment that we see now, it might not be there five years from now.  We need to deliver how to link this to results and in a way which builds systems and institutions.

     QUESTIONER:  I'm Joan -- (off mike).

     Can you give us a five-minute primer on U.S. policy now on this issue?  We know that funding, according to the Council on Foreign Relations, is gone.  Basically -- (off mike) -- since the '60s.  Where does -- how's that funding structured and how does that relate to the new initiatives that are emerging for resolutions in some of the investment acts?

     COLEMAN:  Nils and I can probably take that.

     Let me just say, in basic terms, one part of the problem on maternal and child -- maternal and infant survival is to carefully separate the language -- child refers to up to age 5; and infant, first year of life.

     One of the problems is that they're in many different streams and they fall into lots of different bureaucratic boxes.  So it can be difficult to figure out how much money you're really looking at and who's doing what initiative.

     But basically, U.S. funding has -- for maternal and infant health -- has not significantly increased when adjusted for inflation for many years.  And the White House proposal was for a significant decrease.

     Nils, do you want to add anything to that?

     DAULAIRE:  Yeah.  And it would take far longer than five minutes and I won't do that to anybody here -- (audio break) -- that spending is about $1.3 billion, of which approximately 425 million (dollars) is for family planning and $900 million (dollars), more or less, is for, broadly speaking, maternal and child health. 

We were successful this year in getting a $100 million increase in maternal and child health appropriations.  And that has been enacted into law and is currently being programmed.  We anticipate a significant increase again this year but, as I noted earlier, we're looking for a $1 billion increase.  Right now we've got promises on the table for $100 million.  Half a loaf or, in this case, one-tenth of a loaf is better than none.

But in any case, we're happy to talk to you about it, and look at our website. 

COLEMAN:  (Inaudible.)  You. 

QUESTIONER:  My name is -- (name inaudible).  I work for John Snow and the USAID/DELIVER PROJECT which focuses on supply-chain management.

Many of the speakers have brought up transportation as one of the key challenges to healthcare access -- I'm bringing it back to Afghanistan again.  The health clinics can be fully stocked with supplies, you can have health workers who are experts in emergency obstetric care, but if the roads are bad or nonexistent, women still won't be able to access the services.  So how can we work more closely with the Department of Transportation and the Ministry of Interior, the people who are building the roads, to actually have a greater impact on maternal health than drugs or -- (inaudible)?

TLOU:  Well, the question -- she mentioned the how.  In the case of Botswana, let me say that we are very lucky in that the discovery of diamonds in the country enabled us to really have a very good network of roads.  So that when we say access, we know we have almost every village you can reach it by tarred road.  And right now, almost every major village and some small villages are electrified.  So that at least when we are talking families with access to refrigeration and all that, you know that you are talking about electrified villages.  So it's different from other countries.

And I know what you are talking about because a colleague of mine in Malawi was able to make these tricycle-type vehicles to transport women to facilities so that they don't have to walk.  But then she had to now negotiate with the ministry that's responsible for transport to say, can the road be better?  Because then what's the point of giving this particular vehicle is you cannot, you know, take it across?

So it's a question of really how everything is (contrary ?), the various ministries are able to collaborate with each other.  And of course, to get money from the Ministry of Finance which is the ultimate domain in this, yeah. So that's -- yeah.

DAULAIRE:  Just another small note, and that is we've got to expand the way that we look at this.  I've worked in probably 55, 60 countries and some of the most remote places in the world.  And there were lots of places where I couldn't find drugs or medical supplies and virtually none where I couldn't get a Coke or a beer.  Those are heavy, they're labor intensive, there is a lot that we can learn from and benefit from partnering with the private sector that figures out ways to get things out there.

TLOU:  Mm hmm.  Especially Coke.

COLEMAN:  Let me just make a specific comment about Afghanistan.  It doesn't, unfortunately, have diamond mines right now, but it does have other mines.  And the Chinese have just invested $3 billion in the north in a big mine.

And I was in Afghanistan in February, and there's a lot of talk right now about how to piggy-back off of some of these private investments to further specific not just maternal health but other national needs to improve water, sanitation and roads, in particular.  And if you can do it in a framework that brings in those actors that are working specifically on something like maternal health as, again, a marker for the whole national health system, it becomes really important.

But it needs to be up front in the negotiations.  And therefore, it needs to be a national priority from the very beginning.

We'll go to the front again here.

TLOU:  Well, there's someone who's been up there.

COLEMAN:  Well, we only have time for just a few more questions.  Maybe we can take them together.  If you could make --

QUESTIONER:  I'm Charles Llewellyn.  I'm the USAID health officer in the second or the bottom pink country there, Tanzania.

And I want to thank everybody here for all of this interest.  But I want to point out something that I can't address the people that work in this building, the ladies and gentlemen that control our resources, because that's against the law.  But perhaps some of you can.

In Tanzania, we have a very good health portfolio and health budget.  We have $300 million in PEPFAR money coming in, and that's wonderful, that's great.  We have $35 million coming in for malaria control.  As one of the president's malaria initiative countries, I manage the program.  We're very proud of what we're doing, and we are reducing maternal mortality and early childhood mortality by controlling malaria.  I have $10 million now, it's doubled in the time I've been there, for family planning, which is not nearly enough in the country of 40 million people.

TLOU:  That's right.

QUESTIONER:  But it is making a difference and is saving women's lives.  And I'm very, very pleased that we have recently, because of this $100 million we talk about for maternal and child health, doubled our maternal and child health money which handles all of maternal mortality and childhood mortality.  And maternal mortality in Tanzania is 536, I think, deaths per 100,000.  That's a very high level.  We have doubled it, and I'm very proud of that.  We got $5 million this year for a country of 40 million people. 

So if there's any way that you can use any of that information to get us more money -- (laughter) -- than we can -- because we know what to do.  We've heard here -- and all of us work in public health, I'm sure.  All of the people in this room could help design a program which could drastically reduce some maternal mortality and neonatal mortality in Tanzania, but resources are required.

And if you have $300 million in PEPFAR and $5 million for maternal/child health, I think there's an issue there.  I don't want to take any money away from PEPFAR, I want more money for the other program.  Thank you.

COLEMAN:  Let me just say in response to the comment which, of course, was not directed at any seated political official -- (laughter) -- I think you could talk to USAID or health officers, embassy officers from almost any one of the poorest countries in the world and get similar breakdowns in what seemed to be the funding priorities versus the kind of frustration about what are the disasters on the ground.  And I will speak here very personally, not on behalf of any organization, and say that this has been an ongoing struggle as PEPFAR has grown that a disease-specific program devours so much attention and resources, especially in countries that lack healthcare workers, that are desperate on an infrastructural level and are compelled to skew the handfuls of trained doctors and nurses and so on to a single problem.

It would be a big mistake, I think, to pit one issue against another.  I think it's interesting that Adrian Germain from the International Women's Health Coalition raised the issue, what is our marker for success in investment?  And certainly, if the goal is to build health systems, which it certainly ought to be, the best marker, without a doubt and, I think, one that you would find agreement across the scientific establishment on, is maternal survival.  Because maternal survival tells you, is there somebody there 24/7?  Is there a facility?  Are there trained personnel in the facility?  Is there an infrastructure at the village level, or is it all just in the city and in the capital?  That is the target that tells us whether our taxpayer dollars are really in a position to save lives. 

And I don't think that we're here to try and pit one set of foreign policy, global health programs against another but rather to talk in an additive fashion.  And I think that's the best way to view it.

And if I may, I think we need to take a break.  Is that right?

DAULAIRE:  Can I add one thing?

COLEMAN:  Nils wants to add one brief comment.

DAULAIRE:  One brief comment.  A fellow Vermonter Alexander Sojenitzen -- (laughter) -- wrote in -- I don't know if it was "The Gulag Archipelago" or "A Day in the Life of Ivan Denisovich" -- he wrote about one of the prisoners getting an extra potato in their thin gruel one day and how angry everybody else was.  I think we need to be careful not to get into that situation. 

The entire field of global health has been grossly underresourced.  Ten years ago, it was under $1 billion, today it's $6.5 billion.  It should be, from the U.S. side, no less than 10 (billion dollars) and would look more like $15 billion a year as part of a much larger foreign assistance package because it can't just be health.  I think that's what we need to keep our eyes on is to grow the package rather than wondering whether we can steal part of that potato back.

COLEMAN:  I know we have a lot of other questions still out there.  Let's just take two more quick questions.  We'll answer them together, and then we'll take a break.

Okay, here, and there was one --

QUESTIONER:  (Inaudible.)  How are you planning to listen more to what the countries have to say so that if we decide to take the stressor indicator with your -- (inaudible) -- countries are also interested in doing?

COLEMAN:  Okay, and there was one other over here who was quite patient.

(Off mike commentary.)

No?  Okay, then we'll just take this question here.

QUESTIONER:  I just wanted to note for the record that a major contributing cause of maternal deaths and disability is unsafe abortion.  It hasn't been mentioned here, but I think we see evidence when safe abortion care is made widely available and accessible that, in the case of South Africa, maternal deaths plummeted by 91 percent and maternal morbidity decreased by 50 percent. 

COLEMAN:  Paul, do you want to take this question?

FIFE:  Listen to countries, yes.  And I mean, it's hands-off as much as possible.  And that's why the IHP and (Germain ?) -- I was not able to answer to the question about the lack of focus on outcomes in the International Health Partnership.

The International Health Partnership basically gives the process to countries to sort out the priorities, the national plans and basically have a national plan that is robust enough and with indicators that external parties feel able to invest in.  That there is a validated (plan ?) which is outcomes or results focused and where basically performance, in terms of indicators, also can be evaluated and independently basically assessed.

And so we are working with eight countries in particular -- not Botswana, but Zambia, for instance -- to look at how this could work out.  If one has a national health plan that the country, the parliament, the civil society and donors feel comfortable with, then we can reduce the number of projects that basically are per today taking up resources.

But at the same time, we need projects.  All systems have projects once in a while.  And one of the learnings in the Norwegian administrations on gender and women's rights was that we did away with projects 10 years ago.  It came back four years ago because mainstreaming did not work.  We need an additional focus on women's rights and on gender equality.  So we're doing both.

On unsafe abortions, I mean, we have the figures here.  There are 200 million pregnancies per year.  Seventy-five million are unwanted pregnancies.  And of them, 50 million are induced.  And of these 50 (million), 20 million are unsafe.  These are staggering figures.  And we know that in some countries, half of maternal mortality is actually due to unsafe complications of unsafe abortions.

TLOU:  Okay.  I'll talk about the unsafe abortion simply to say really we've answered the theme.  But let me say that one of the things that we did when I was the chairperson of the African Union Ministers of Health was to come up with a framework recommend and plan of action on sexual and reproductive health.  And it was real interesting that the mention of that, especially among my male colleagues -- I mean, most of the ministers of Health in Africa are males at that time.  There were 53, there were, I mean, maybe seven females.  And these men, it was like they've never heard of the ICPD.  (Laughter.)  We had to start reeducating them. 

So we're hoping, we have the plan of action.  And it really does take care of, you know, what to do in terms of unwanted, unplanned pregnancies but also even post-abortion care.  But whether it will be implemented is a different story.  But then, hey, you are Americans.  You've seen how Roe and Wade has been going up and down.  So I guess it really depends on who is there.  But let's keep on pushing it.  At least now we have a document that's there.  Thank you.

COLEMAN:  Thank you for your patience in this crowded room.  We have Congressman Nita Lowey who is joining us in a few minutes.  She's just finishing up voting on some bills right now.  She should be here in about 10 minutes.  We're going to take a 10-minute break, stretch your legs.  For those of you in the back, they get first priority on the seats up front.  Please, do some shuffling here.  There are refreshments in the back.  We will reconvene in 10 minutes.

(Break.)

TLOU:  (In progress) -- and make sure that we achieve all of them.  And in the ultimate, we will find that we've gone a long way.

COLEMAN:  Paul.

FIFE:  My prime minister just received a letter from President  Balkenende in the Netherlands.  And he said I want to join MBG 4 and 5 and I will particularly work on MPG 3.  That's basically what he said.  (Laughter.)  And we cannot forget either the malnutrition or the nutrition of MBG one, 20 percent maternal mortality, 35 percent -- (inaudible). 

So again, the MBGs are there, and they will be there.  We need some common messaging.  The health MBGs which include all of these are not that bad, actually.  These are pretty strong messages.

COLEMAN:  There is a very strong overlap between -- the World Bank has done a gender empowerment measure.  There's a very strong overlap correlation between a very low gender-empowerment measure and very high maternal mortality.  We see it in the map.  The two areas of the world that have the lowest gender-empowerment measure based on a whole range of statistics from female survival from birth all the way up through nutrition, education, everything, they go into this measure.  The lowest GEM scores correlate with South Asia and Sub-Saharan Africa, also the Middle East.  And they do have, even though they are wealthy countries in the Middle East, disproportionately high maternal mortality rates.  Low gender empowerment, high maternal mortality, it's not rocket science.

Sorry, there's a question right here.

QUESTIONER:  (Carmen Morose ?) and the question is for Paul.

Paul, I really like what you said about the need for specific projects because mainstreaming works only to a certain point and systems are good.  But I mean, this special attention to certain issues.  And I'm so glad that your government and other European governments have paid attention to unsafe abortion and have created the Safe Abortion Action Fund organized by IPPF.  And it had a tremendous response.

What I want to know is whether -- what's your strategy with regard to this neglected problem?  Are you going to continue having specific projects on unsafe abortion?  Or are you going to inject the whole initiative with this problem?

FIFE:  I mean, again, countries need to take the lead.  And I know for my country, if an external power would come and dictate or mean very strong things, I mean, there would be a backlash.  So we are extremely aware of the context of the sensitive issues.  And at the same time, we have decided to basically have as foreign policy development policy the same as we have domestically.  So it's very clear that the example you had from the Safe Abortion Action Fund is a very interesting mechanism because it's application based.  And basically, organizations, institutions working in the global south and others can apply to get support.

So we need diversity.  We think that the key thing is to have strong, national health plans which basically are designed, developed, monitored earned by governments.  And that civil society has a very strong role.  We want really parliament to be -- we don't want ministries of Health to be accountable to donors.  We basically want the ministries to be accountable to parliament.  So this needs to basically be local processes.

And again, when I say that or we say that projects are needed, in some ways, we are in a big change management process in our countries, all countries, in the global architecture.  So how do we work and change the systems to improve them?  And then we know that we need the broad-based actions, and then we need specific projects to advance specific issues.

GARRETT:  One thing I would say to those of you that are here that are really coming from an advocacy place, are not actually members of a congressional staff or agency's staff, I do think that you have a big challenge in the coming nine, 10 months.  And that challenge is to figure out how to create a coherent, foreign policy agenda around health and development that builds coalition, that is serious, that has no one health issue, no one development issue pitted against one another, and that comes to a new president and a new administration as a coherent package that can compete against a vast array of financial competition that will face the White House and Congress in 2009.

Without coherence, without building those bridges, without bringing that kind of a package forward, you will all fight individually for your own pieces, and almost all of you will lose.  That's it. 

Now, who's bringing that coalition together?  Who's making that happen?  Right now, nobody.  And it would be perhaps a bold step for the maternal health advocacy community to step up to the plate and challenge the rest of the development and health communities to follow suit.

And I can't think of a better way to segue to somebody who has indeed taken on all these issues, coming down the hall, we think, at this moment, after voting on homeland security -- (laughter) -- there she is, Nita Lowey.  (Applause.)

DAULAIRE:  There's really no better way to conclude this morning's event than by honoring one of the most passionate and effective voices on the issue of maternal health.  As we all know, the work at Global Health takes place in the communities and clinics of poorer countries in the world.  But the work that takes place there doesn't happen in a vacuum.  Those of us who are or have been on the front lines of implementation know that policymakers can be our greatest assets.  At times, unfortunately, they can also be our biggest barriers, depending on the issue and political climate.

Too often, though, we are quick to point out what policymakers have not done or what they've done wrong and not so quick to congratulate them for doing what's right, what makes sense and what will make a genuine difference.  And that's why the Global Health Council initiated the Congressional Leadership Award for Global Health several years ago and are today presenting the third annual award.

Congresswoman Nita Lowey is a policymaker who is doing what's right, what makes sense and what will make a difference.  And for that, we're here to celebrate her today.

Representative Lowey's commitment to health has been evident since she arrived in Congress in 1999.  Simply put, Nita Lowey gets it.  And to global health's benefit, she puts this understanding to work through tremendous legislative efforts. 

Viewing a robust U.S. foreign policy as a key national interest, Representative Lowey supports the role of military presence in action and development.  Importantly, she places equal emphasis on the role of aid in a comprehensive foreign policy platform.  I think she just came from a homeland security markup, so she gets it from all the perspectives.

Notably, as chair of the Foreign Operations Subcommittee of the House Appropriations Committee, Representative Lowey has had the unenviable task of identifying priorities in tight budget environments and amidst an ever-expanding menu of competing international demands, as we talked about a few minutes ago here.  Understanding the central role that good health and healthcare plays, Representative Lowey has navigated the investment trade-offs with grace, dignity and beauty, I'd say, ensuring that global health programs are well and appropriately resourced.

But she hasn't stopped there.  As we know, money is only as good as the programs it supports.  And Representative Lowey has complemented the scale of global health spending with strong, clear policy language about how funds should be used and to what end.  Thanks to her thoughtful policymaking, global health is in a time of great support, high activity and increasingly evident impact.  The U.S. has demonstrated tremendous leadership through PEPFAR and PMI, the Global Fund and other international initiatives to which this nation contributes. 

So we celebrate global health's progress, and we thank Representative Lowey for her central role in that progress.  But as we discussed today, we have an unfinished agenda.  We heard today about the part that relates to maternal health.  If we are to see true progress, defined as longer and healthier lives for the world's poorest, we cannot undermine sound policy with ideology.  Policy must be driven by evidence and the realities of the lives that they are intended to improve. And we thank you, Congresswoman Lowey, for working tirelessly to weed out counterproductive policies and to assure that good ones are in place. 

We also cannot pick and choose which health threats and diseases will pose the greatest threats to global health in the coming years.  Most people in communities are not affected just by AIDS or malaria or TB.  They're also affected by multiple conditions.  The most vulnerable, as we've heard today, are often women and children who are also fighting for basic health and access to services, such as skilled-birth attendanTS, emergency obstetric care and immunizations that can protect them from the leading and preventable causes of death.  We need a comprehensive, thoughtful approach to global health.

So we look to you, Representative Lowey, to continue to fight the good fight for global health, to lead, as you have done, and to do that with particular care and concern for the world's women and children, as you have for so many years.

The Global Health Council and our members from 146 countries around the world and from 46 of the 50 states present you with this award to celebrate all that you have done for the cause and all we know you will do.

If you'd please come up. (Applause.)

And this bowl -- there have been jokes about my home state of Vermont this morning.  This was made in Vermont by Simon Pierce, a glass maker who is my neighbor by the way.  (Laughter.)  And it states, "The 2008 Congressional Award for Global Health, presented to the Honorable Nita Lowey in recognition of her efforts to improve the health of the world's poorest people."

Representative Lowey, on behalf of the Global Health Council and the global health community, I'm honored to present you with this leadership award in global health and thank you for all you've done and all that your wonderful staff, particularly Nicia Vesai (sp) and Michelle Senoras (ph) have done on behalf of this cause.  Thank you.  (Applause.)

REPRESENTATIVE NITA LOWEY (D-NY):  I think I'll put it here.  (Chuckles.)  Thank you.  Good morning to all of you.  And thank you, Nils, for your generous -- is that Charlie back there?  I've known Charlie McCormack.  There are many good friends in the audience.  But I've known Charlie for a long time.  And thank you for your good work.

And Nils, it really is an honor for me to receive this award from such a distinguished group because you're really there, and you're in the ground, and you know what this is all about.  So I have always felt that your work is a lot harder.  Although sometimes -- (laughter) -- the Hill can be a challenge these days.  And we're all busy thinking about our bills knowing they're probably not going anywhere this year.  But it is a challenge, and you never know.  Sometimes there are surprises.

I'm sure you have similar, similar situations in Botswana.  Is that correct?

TLOU:  That's right.  (Laughter.)

LOWEY:  In fact, I was in Botswana not too long ago.  And it was an incredible, incredible visit.  And there was a great deal of progress being made.  At one point, they had back-tracked a little bit.  Now I understand you're back on track again.

TLOU:  We are again, yes, yes.

LOWEY:  So I look forward to talking with you.

But I want to make it clear that the work that you all do makes my job easier.  And I, too, want to thank my wonderful staff for the hard work and Nicia (ph) and Michelle and Lucy, they do all the work.  So I am very, very appreciative.

My husband, Steve, and I have three children, eight grandchildren.  They've been healthy and happy and have had the opportunity to make choices in their lives.  And I must say, I wake up every day, and I'm grateful for these blessings.  And we know and I'm committed every day to every parent, wherever they live, to every person, whatever their circumstance, because they wish the same for their children.

And unfortunately, for so many families in the developing world, these wishes do not come true.  Well, we realize, together, that wishes don't always make it so, whether it is diarrhea or HIV/AIDS, TB, malaria, malnutrition, unsafe drinking water, the threats to children and their parents are daunting.  And yet so many of the challenges facing these families today are preventable and treatable if only they had access to the affordable health care they needed.

That is why today's focus on maternal health is so crucial.  More than 500,000 women die each year from complications associated with pregnancy and childbirth.  This number, half a million women or one death every minute, has stayed stagnant since the time we began measuring them.  If I weren't addressing experts, I would say that this must mean that we have yet to discover ways to prevent or treat the complications from pregnancy and childbirth.

You know that isn't true.  You all know better than that.  We know that the reason half a million women die yearly is not because cost-effective and life-saving treatments don't exist.  It's because too many women lack access to them. 

So what does this tell us about the state of global health?  It says we have a lot more work to do together.  Reducing needless maternal mortality and morbidity should be a priority of the highest order.  There is an inseparable link between the well-being of mothers and that of their children.  A healthy woman, as we know, is more likely to give birth to and raise a healthy baby.  And nations that recognize and meet the needs of mothers and girls have healthier, more successful children. 

Hard to believe this is my 20th year in the United States Congress.  I started when I was 11 or 12.  (Laughter.)  I know Charlie won't believe that.  And throughout these two decades and before, I continue to fight with many of my colleagues for the rights of women and girls.  And as chair of the Subcommittee on State and Foreign Operations -- and I must say it's much better being in the majority than in the minority -- we have worked together to help ensure that our yearly aid package funds initiatives to educate girls and women, keep mothers health, immunize children and enable poor women to start their own businesses.

These are some of the most effective and efficient uses of our development dollars.  And while I'm pleased that we were able to provide close to $1 billion for maternal health and child-survival programs in the fiscal year 2008 bill, the need continues to exceed what we are able to provide.

And it's not always the fact that it's not legal in the country.  I remember a trip not too long ago to Cambodia.  And we'd see one woman after another thin, gaunt with eight, nine, 10 children.  And family planning is illegal there.  So we just have to keep doing more.  Addressing maternal health will require that we use all of the tools in our toolbox.  And that is why it is essential that we continue to insist that women have access to the family planning services they desperately need and desire.  And many of them don't even desire it because they don't know how badly they need it.  So that's why education is so key.

For these reasons, I sought to exempt contraceptives from the global gag room in last year's state and foreign operations bill.  (Applause.)  It's extraordinary to me.  I think the number was about 180 people voted against the bill because we were sending contraceptives to Ghana.  I mean, that's what that was all about.  And we should let them know and not let them off the hook because it's unacceptable, and they have to hear from constituents in their own district as well.

So I remain committed to a repeal of this terrible policy.  It is past time to put the health of women and children ahead of politics and ensure that families around the globe have the information and the opportunity to make choices for themselves. 

So I truly want to close by commending the Global Health Council, the Council on Foreign Relations for today's briefings.  Your commitment and leadership to improving health worldwide is invaluable.  I'm proud to say I'm with you today in support of programs to help shape a healthy world.  I look forward to continuing our partnership in the months and years ahead.  And I am truly honored to receive this wonderful award.  Where in Vermont?  I'll have to -- (inaudible).  (Laughter.)  Where is this?

DAULAIRE:  Quechee, Vermont.

LOWEY:  Oh!  I know QuecheeQ: 

DAULAIRE:  Well, there you go.  (Laughter.)

LOWEY:  My children live --

(Cross talk.)

-- Quechee.  So I am nearby, and I remember that.  (Inaudible.)  I'm not ready to move there full time from New York, but it's a beautiful place, and look what comes out of it.

Thank you again for all your efforts and all your hard work.  You are the true heroes and heroines.  I really appreciate this. (Applause.)

COLEMAN:  As a lifelong New Yorker, we're not allowing you to move to Vermont.  (Laughter.)  You're not leaving us.  Thank you.

Thank you all for your patience, again, in this small, tight, close room and for staying with us for these two hours. 

Thank you to our panelists, Paul who traveled from Norway, Nils who traveled from Vermont, and Sheila who came all the way from Botswana.  Thank you for coming.

Thank you to the Global Health Council and to the many different organizations that have assisted us along the way, the International Women's Health Council, Save the Children, CARE, Family Care International -- I know Ann is here someplace, there she is. Thank you to Nita Lowey and her staff.  And thank you to Betty McCollum and her staff who helped arrange this room for us.

And all of you are invited and encouraged to attend tomorrow's meeting which will be similar but a different format in New York at the Council on Foreign Relations headquarters there where we are going to have several back-to-back sessions looking at, again, this topic of maternal health in the global and strategic context.

So thank you all for joining us today.

And again, a special thanks to the Global Health Council.  (Applause.)

Just one final thank you, a very special thank you the MacArthur Foundation and to Judith Helzner who has made today and tomorrow's meeting at the Council on Foreign Relations possible from the very beginning.  So thank you to Judith.  (Applause.)

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