home > about cfr > leadership and staff > helene d. gayle > The Challenge of Global Health [Rush Transcript; Federal News Service]
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| Authors: | Laurie A. Garrett, Speaker, Senior Fellow for Global Health, Council on Foreign Relations |
|---|---|
| Helene D. Gayle, Speaker, President and CEO, CARE | |
| Susan Dentzer, Presiding, Health Correspondent, Head of the Health Policy Unit, "The Newshour with Jim Lehrer" |
February 8, 2007
The Washington Club
Washington, DC
The Washington Club, Washington, D.C.
February 7, 2007
SUSAN DENTZER: Good afternoon, everyone. Please go ahead and take your seats. We'll begin shortly.
Welcome to this terrific conversation that we'll have today on the challenge of global health. I'm Susan Dentzer from The NewsHour with Jim Lehrer on PBS and also a Council member, and I'm delighted to be here today with two of my colleagues to talk about this very important issue.
Many of you are council groupies so you know the drill at these sessions, but let me just go over briefly with you how we proceed. We will begin with introductions and conversation among us for about a half an hour. I ask you, please, in deference to all of us being able to hear the conversation that you take a moment now to turn off your cell phones, your Blackberries, your other wireless devices. Reminding you all also that this session is on-the-record. It is being recorded. Anything you say may indeed be used against you.
And we invite -- we're going to invite all of you, after we have a half an hour of conversation among all of us, we will open it up for questions and answers. Comments are always welcome, speeches are a little awkward, so we'll ask you to confine your remarks, if you would, to comments but also, of course, questions for our two terrific speakers.
Let me take a moment now to introduce them. Of course, they need no introductions in front of an audience such as this one. But first of all, on my right is Laurie Garrett, the enior fellow for global health here at the Council on Foreign Relations. Truly an unparalleled expert with just, again, unparalleled knowledge and expertise in the field of global health. And Laurie, we're delighted to have you with us.
Laurie, for those of you who read the Council publications, know Laurie has a current article in the magazine, which is, I believe, available outside, correct? Yeah. So please feel free to take a copy with you when you leave today.
And also on my left, in many respects -- no, just kidding, Helene. (Laughter, laughs.) No, that's a cheap, cheap joke. Cheap joke. (Laughter.)
Helene Gayle, president and CEO of one of the nations, and indeed the world's leading relief and humanitarian organizations, CARE, but also, as many of you well know, an alumni not only of the Centers for Disease Control and Prevention, where she led the HIV/AIDS response for many years, and also a name you also know, The Gates Foundation, where she also was until just this past year. Correct. So we're delighted to have her, again, with unparalleled expertise and knowledge in the field broadly, and now increasing operational experience in how you address the problems of poverty and health, not to mention relief and humanitarian concerns around the world.
So with that, ladies, let's open up our discussion today. And let me ask you, Laurie, we've been through really an unprecedented era of growing awareness of global health, of just a phenomenal commitment of funding now among donors of all stripes to the questions that face us in terms of not just attacking individual diseases such as HIV/AIDS, but also more broadly childhood immunizations and so forth and so on.
But we don't really have a keen sense that there is a single source of leadership in global health. So let's start with the question: Where is the leadership, at this point, in global health?
LAURIE GARRETT: And that is THE question. That's the paramount issue, I think, right now.
You know, it's interesting because I recognize a lot of the people here. And I want to thank each and every one of you for, I guess you say in Washington, braving the dusting of snow. (Laughter.) And some of you will know exactly what I'm talking about. For others, perhaps it's a little fresher, a littler newer.
But you know, five, six years ago we were scrambling to raise attention to these issues. We were scrambling to get -- you know, $100 million grant was considered phenomenal in global health. And there was a sense that it was all right that we were operating like a series of cottage industries because that's all the money there was and the scale of the operations were comparatively small.
Now we're in the billions. We're in real chunks of change. But we're still operationally hampered with the same sort of structures and chaos of health leadership. It's absolutely essential that there be a groupthink moment of collectively the major figures in the global health panorama to really consider, what is leadership, how should it be exercised, who's in charge here?
It's hard to escape that, for all of its flaws -- and there are many and there are probably in this room enough people that could list them that we could go on all day -- with WHO. It's hard to escape that they are the logical leaders of global health. So then the question becomes, how on such a paltry budget can Margaret Chan, the new leader, director-general of WHO, exercise sufficient authority in the world to guide this new multibillion-dollar mission to set appropriate strategic goals, and I think very importantly to set a kind of code of ethics and understanding of how the players should and should not behave on the playing field?
And just as a side -- quick note on that -- what I mean to declare that is that now that there's real money on the table, we're seeing a lot of poaching behavior between NGOs, between actors on the ground -- stealing each others doctors, nurses, translators, what have you, and a lot of backbiting. And I think it's very, very important that we have a sense of common, shared mission and some rules of the game that everyone will agree to try to play by, which includes consideration for the ministries of health in desperately poor countries that tend to have no capacity to pay their own employees -- their doctors and nurses in particular -- at levels that are commensurate with what the same individuals could make by jumping ship from the government and going to work for a local foreign-financed NGO, faith-based organization or external government agency effort.
DENTZER: Is the WHO, though, capable of drawing up that code of ethics, and more important, getting anybody to follow it?
GARRETT: Well, if they're not, then we're really in trouble. Certainly WHO's flaws are many, as I said, and their budget is minuscule. You know, the core annual budget of WHO is less than the core budget of the New York City Health Department in a given year. And while they have a lot of earmarked additional funds from donors, they are earmarked -- I guess everybody here in Washington knows what earmarking of funds means -- and that greatly limits their ability to exercise the power of the purse. But there's other kinds of power and there's other ways of corralling forces.
I think we're going to have to see, since she's so new to the job, what steps Margaret Chan takes in the next six to eight months in terms of trying to consolidate operationally how WHO functions and figure out how she can exercise greater power in this very new, very fresh, well-funded global health world.
DENTZER: Helene, how do you see it? Where is the leadership from global -- in global health? Where does it have to come from? And do you agree with Laurie's assessment that WHO has to take the lead on many of these issues, notwithstanding the difficulties in doing that?
HELENE D. GAYLE: Yeah, well, I think -- I mean, think WHO obviously has a strong leadership role to play. It was the technical organization created within the U.N. to provide health leadership. But I think the fact that we're searching for where THE leadership is shows that global health has really become more than just a health concern, and the fact that other agencies are very engaged, whether it's the U.N., whether it's the NGO community, whether it's bilaterals.
And so I think, you know, we're looking at an arena and a time where it's not going to be one localized authority, but it's going to be the better coordination of the different actors within the global health arena. And that, you know, again, I think we're recognizing that global health is a development issue. It's a foreign policy issue. And so I think expecting that a technical health agency is going to be the lead I think is just not where we are anymore.
But trying to figure out, how can we do a better job, how do we really look at the different actors who are on the scene and look at what's the right blueprint -- what's the right role of a health agency, what's the role of a development agency, what's the right role of a foreign policy agency when we look at these issues of global health, because it really has become more than just an endeavor that one technical agency can focus on.
So you know, I'm actually hopeful that with all of this increase -- the increased resources and the increased attention -- that we are going to be able to have a more coordinated response. But it's, you know, things like the article that you wrote recently, Laurie, and this kind of discussion that I think will get us there. Maybe there ought to be some kind of a focal point within the U.N. that looks at coordinating across the different agencies now that we, you know, know that it's more than one agency that has that responsibility. So you know, I think we're in a very different phase than we were when WHO was first created.
And I think the other big piece that is very different than when WHO was created is that leadership from the countries themselves -- you know, the African nations, the Asian nations -- we're not at a point where it is the northern countries who need to provide that kind of leadership. And more and more, we're having strong health voices from the south exert their own leadership. So I think that's really where the leadership needs to come from. And we've got to figure out, how do we support the institutions, like a NEPAD, that has a strong health focus within the African Union. How do you really strengthen the capacity for the leadership that comes from the countries where the issues are greatest?
DENTZER: As you said just a moment ago, Helene, we increasingly understand that global health is not just health per se, but fits into the broad array of issues around poverty reduction. How do you see that playing out in the future? And again, other than some of the mechanisms you've just described -- having the U.N. coordinate across all manner of agencies interested not just in health, but these other issues -- how do you see that developing going forward?
GAYLE: Well, I think the recognition is clearly there. That's why -- you know, people think I jumped ship when I left, quote, "being a health professional to work in international development." Well, I see the two as being the same. If you aren't looking at issues of access to clean water, we're not going to be able to focus on reducing diarrheal diseases. If we don't have literacy and education, we're not going to have a strong health response.
So I think, you know, more and more looking at this more integrated approach and looking at who are the different actors who are involved in that, you know, whether it is the U.N. system, again, or development agencies. But I think that's where we've got to really take this response and recognize that, you know -- and again, it goes back to a lot of the things that Laurie said in her article -- if we keep doing this in a stovepipe way that looks at the disease of the decade, we're not going to make a real impact on global health. And so while I'm thrilled that we have PEPFAR and we've got billions of dollars now going into HIV, it's at the cost of maternal and child health programs. It's at the cost of building the infrastructure -- the basic health infrastructure. It's not taking into consideration the human capacity needs.
And so, you know, we're really good at, you know, the disease du jour and thinking about the issue of the day, but not thinking about what's the long-term -- what do we want in 10 years to say we've helped to create, and how do we do that? And how do we look at some long-term goals in a much more integrated approach?
DENTZER: Just on this theme of building up the public infrastructure of various nations, Laurie, you wrote a great deal in your article about the fact that we just lack global capacity and health care delivery, and are short probably on the order of 4 million workers in the health care sector around the world at minimum. How do you see that particular problem being addressed? And again, in the context of who takes the lead on that -- how is that coordinated among U.N., at the individual country level, et cetera? And not to mention, of course, policy here in the United States, which is siphoning off a lot of these workers from around the world.
GARRETT: You know, the problem we have is that the wealthy world is aging, and as we age, our health needs increase. So the United States is becoming an older society. This is even more obvious in Europe and Japan and China. And that means that there's a need for more intense, hands-on health care, nursing care -- not just physicians; all the way down the line -- lab techs, orderlies, home-care people, the entire infrastructure.
At the same time, Congress has systematically ignored every bill that has come forward for several years on, through at least three administrations, to try to improve funding for our own domestic health training and education for physicians, nurses, medical technicians, the whole gamut of health care providers.
And so as our -- you know, any demographer in this room -- I know there's at least one in the room -- can tell you, you know, here's the curve: we're short this many now, we're going to be short this many in 2020, we're going to be short this many in 2050. What are we doing about it? And the answer, apparently, on the Hill is nothing.
Meanwhile, we're watching -- we're watching our medical infrastructure decrease, shrink. Simple example: In nursing schools today we're turning away more than 100,000 nursing candidates every year. The irony is that a state like Michigan, where as the auto industry collapses, they're actually telling former autoworkers to go into nursing training. But what happens? There's no ability to get into nursing school. Why is there no ability to get into nursing school? Because you can't hire nursing instructors. Why can't you hire nursing instructors? Because they make more being nurses than being a full professor of nursing in a nursing school.
And so literally, because the federal government is not helping a beleaguered state like Michigan, which can't from its own resources amply subsidize the salaries of would-be nursing faculty by augmenting would-be salaries, we are grabbing nurses from The Philippines. And if you go and look around the world, you can see this massive brain drain going on. Yesterday in The New York Times we learned that the brain drain even includes wealthy countries like Germany, that are losing their doctors and nurses where we benefit.
So what's the big picture here? If we don't come up with strategies that include saying that wealthy countries have a moral -- and I would argue foreign policy -- responsibility to adequately train their own domestic workforce of health care providers rather than poaching from poor countries -- if we can't take that first step, then we're on a sinking ship because everyone of the programs that we're all so excited about that are suddenly getting billions of dollars -- and I would add, jumping off something Helene said, all the development programs that require expertise -- you know, a water system requires somebody who knows how to do a water system -- if we're not understanding that we have a responsibility to train the personnel that handle those jobs domestically rather than poaching from overseas, then every program we're funding, whether it's PEPFAR, whether it's the U.K. DFID programs, whether it's the Gates Foundation programs, they're all going to sink for lack of human resource capacity. That's the limiting step.
DENTZER: Helene, do you see this at an operational level at CARE, just this shortage of capacity of people to do this work around the world?
GAYLE: Yeah. Well, not only in CARE, but you know, in the other areas I've been involved in I think, you know, we are seeing this. One of the biggest impediments -- when I was at the Gates Foundation, we funded the project in Botswana to bring -- to help bring universal access to antiretroviral therapies for poor people in Botswana. The biggest rate-limiting factor was personnel. The drugs were there. The resources were there. The commitment was strong. But it took us -- we were a year behind the anticipated start date just because we didn't have people.
Now Botswana has people because it was one of the first countries that made that commitment; you know, it's getting staffed up. But it's getting staffed up from doctors from Zimbabwe and from Malawi and from Kenya. And so as those countries now start to ramp up their access to antiretroviral therapy, they don't have any doctors there. And so, you know, that's not helping either. So even within the -- within Africa and within different regions, this issue is the critical rate-limiting factor.
DENTZER: How do you see it being addressed?
GAYLE: Well, I think it's not. And I think it's not being addressed -- I think it's being addressed in a patchwork way. And again, it's one of those areas where there needs to be some coordinated thinking about what's the best way. And as Laurie said, I think a lot of it starts with, what are we doing in our own -- in the source countries, if you will, that are taking skilled workers from developing countries? What are we doing to not have that kind of sucking effect? And then what can we do to provide environments back where people are working so that they are working in decent environments?
A lot of times it's not even -- it's not even the salaries, but it is, you know, I was trained as a health worker; I want to save people's lives, I don't want to contribute to worsening their health. And a lot of times, the health facilities that people come to are in such poor conditions, lacking in basic infrastructure, that, you know, it's hopeless and it's depressing. So I think we've got to do more both on our side, but also making sure that in the countries there's the equipment, there's the infrastructure, and that we can look at what are some of the ways in which we can be creative about salary support.
DENTZER: Laurie, as you said in your article, we are now pumping unprecedented amounts of money into global health. And surely, if we were looking back 10 years ago, we'd be surprised at how far we've come, notwithstanding how far we need to go.
Yet, as you also noted, a 2006 World Bank reported estimated that about half of all the funds donated for health efforts in sub-Saharan Africa never reach hospitals and clinics at the end of the line, that they get siphoned off in padded prices for transport, payment for ghost employees, other forms of corruption. How do we deal with that?
GARRETT: I think we have to step back and ask: How have we in the wealthy world viewed this whole question for the last umpteen years? I think we viewed the health of people in poor countries as a charity operation. It's a big, huge charity operation where they are intended to be on their knees with their hands out begging year after year after year after year. It's never going to be sustainable because it's all about begging, and nobody is ever going to be allowed on the ground to build a business that's related to health that makes money, that therefore is sustainable.
So here in the United States, every single aspect of health is a profit center. You have to really comb your mind to think of any aspect of public health or health delivery that isn't a profit center for somebody in the United States. But in countries in Africa, much of Asia, much of Latin America, just the opposite; it's all an endless poverty operation with everything being about a charitable position.
So what does that mean? It means if I'm a doctor, I've gone through just as much training as any American doctor to obtain my degree, but I happen to be living in a desperately poor African country. My salary is not going to be enough for me to live on. It's not going to be enough for me to feed my kids. I'm going to be filled with resentment because I'm also, as Helene said, working in an environment in which it's under resourced, I'm acting more like a funeral parlor than ability to heal and cure people because I don't have the tools, and we're not dealing with the prevention piece on the public health side, so I've got people coming in with things that never should -- they should never have been sick with in the first place.
So what do we have to do about that? I think in the very short term, obviously, there's a lot of talk about trying to raise the salaries of people working in developing countries in the health sector. And I do think we need to raise salaries, but I also am very cognizant of the inflationary pressure that that will produce, and I do think that's a concern.
In the bigger picture, I think the answer is to get away from this charity model and to say, why can't we be looking at community health workers operating on a franchise model? Why can't we build in business-reward models that allow the individual to earn a real living and take care of their people?
And also, a final piece of this is to ask, what are people dying of? And I'll just give you a quick example from a recent trip to Haiti. Being in a town where doctors are being trained to treat people, it's terrific. But 75, 80 percent of the patients are coming in with the same set of problems. What's the source of all of them? The drinking water, and the drinking water is contaminated with a whole host of different microbial diseases. What would it cost to fix the old drinking water system that existed during the Duvalier "Papa Doc" days? Well, about $250,000. Well, guess what? We don't have a funding stream in the U.S. government where we will to pay for that $250,000 to stop that 75 percent disease burden that we're training these doctors to take care of, and no other agency seems to have that funding stream to go in and fix that water supply.
So part of this is asking, are we really approaching and tackling the right problems? It goes back to leadership. It also goes to Congress. You know, right at this moment we were talking about, how do we set the priority that we're here to train our own health workers and not poach health care workers from overseas? Well, gee, which subcommittees is that about? And how do the people who are on the Foreign Affairs or foreign ops committee tell the people that handle domestic medical affairs spending have a conversation that says this is a foreign policy issue, we want you to spend more over here to solve this problem. We don't have an apparatus and a leadership here domestically.
DENTZER: Let's put this in the development context for a moment, Helene. We have a system here in the U.S., such as it is, where a dollar of everybody's health expenditures is a dollar of somebody else's income, and so we have thriving -- sort of thriving health care business sector. Certainly 16, 17 percent of the GDP would constitute thriving health care sector.
How do you think through that in the development context? Could we build thriving health sectors in these low-income and middle-income countries as a means of helping to address these problems?
GAYLE: Well, I think we can, I think, and that's one piece of it. And I think looking at -- as Laurie said, not seeing this as just a charity function, but really looking at ways in which good business principles can be used for how we look at health and health as a business endeavor and as a part of an economy, and look at much more innovative ways in the way that we do it.
You know, we've gone through these models where we -- these periods where we say, well, the best model is, you know, give everything free. We can't charge. They're poor people; you can't charge for health. Well, poor people spend money for other things that they think are of value. And if something is of value, people will pay for it and they will also value it more. And so I think we have to think about ways that are realistic, given income levels, but that do put some costs and incentive in it and look at doing things in a business way.
But I think, again, it's not looking at health in a vacuum, and recognizing that it's by having a longer-term approach of building strong economies that ultimately we will make the health industry more viable in these countries as well. So we have to look at the kind of wraparound services, looking at, are we also looking at policies that are going to enable growth in those same countries that we're looking at improving health? And if we aren't, then our health efforts are going to be short term and are not going to be able to take hold in the context of a crumbling economy. So I think we, again, need to step back and look at this in a much more holistic way.
DENTZER: From your experience at CARE or at Gates, is there any example of a country that is making moves in that direction -- inroads in that direction?
GAYLE: I can't -- you know, I can't say one -- you know, again, I think Botswana's a great example of a country that because of economic growth are looking at things in a much more comprehensive way. But I think it's hard to say country by country. And it's more looking at, what are our approaches to it? How are we looking at our foreign assistance in a way that really looks much more comprehensively? What are models of even within the health sector? I was looking at Andy McGuire who is with GOBI. I mean, GOBI is an example of looking, at least within kind of the child health domain, how do you look at different streams and harmonize those and look at ways in which you can do the kind of bulk purchasing that will drop the prices of purchasing immunizations?
So you know, I think we are seeing models of different ways of doing things, more innovative ways of doing things. And a lot of it has to look at what -- having the country, again, drive some of these issues. We tend to look at these things so top down and think that we can up with some mega scheme that is going to be THE answer for the developing world.
Well, each country is so different -- the country's needs, their ability to say, "My highest priority is not your new idea about, you know, be it malaria, HIV or whatever. Our highest priority is that we want a good water system and a good latrine system. That's what we need the resources for. And if you would help us to do that, we'll also be able to work on some of these other issues." And we're just not letting countries lead in finding the solutions.
GARRETT: That's absolutely true. And it also goes -- it goes right to -- you know, one of the things I asked in the article is, where's the diarrhea celebrity, right? (Laughter.) So it's really easy to stand up and say, you know, I want the AIDS drugs to be available to everybody who needs them. That's the politically cheapest health money at this moment, is money to deal with treatment for HIV/AIDS.
But you know, where's the lobby that says, you know, what about diarrheal disease in kids -- top killer in children? What about maternal health, where we're going backwards; in country after country more women dying in childbirth? Inexcusable. There's no new technology there, you know. It's called a Cesarean as in Caesar-section. It really is a marker for whether or not there's any health infrastructure, and whether or not that health infrastructure is built with the concerns of women and children in mind.
DENTZER: All right. So the floor is open for nominations of which celebrity should be named the diarrheal spokesperson -- (laughter) -- of the year. I'll invite your contributions.
GAYLE: (Laughs.) Well, there are a lot of them that are, well -- (laughter).
DENTZER: (Laughs.) Don't go there. Don't go there, Helene. (Laughter.)
GAYLE: We're going to keep this clean.
DENTZER: But we would like to open this up to questions and comments from those of you in the audience. Again, I would simply ask that you identify yourself by name and affiliation for the benefit of our guests.
Yes?
QUESTIONER: Peggy Hamburg, NTI Global Health and Security Initiative.
DENTZER: Wait, there's a mike coming.
QUESTIONER: Just as you were talking about leadership and response to problems, it struck me that XDRTB in South Africa could be an excellent real time arena for us to galvanize and try to really apply existing knowledge and resources to a problem that if we don't deal with it now is going to spin out of control and, you know, clearly have global implications that are very serious. So I was wondering, you know, if you could comment on number one, what you think is the state of the problem, and what are the opportunities for us to work cross-sectorially and through what mechanisms to really make a difference because we can.
GARRETT: That's a perfect example and --
DENTZER: And say a word -- I think everybody knows what XDR --
GARRETT: Yeah, I will. This comes from somebody who really knows what she's talking about. Peggy Hamburg led the New York City response to multi-drug resistant tuberculosis in the early 1990s. We now have seen emerge noted in the late spring of '06, a strain of tuberculosis in KwaZulu-Natal that is being dubbed XDRTB because it is not responsive to any available drugs. And the death rate in the initial group was 98 percent. And it was rapid death.
Now of course, this is associated -- it's piggy-backing on the HIV epidemic. People who are HIV-positive are much more likely to contract active tuberculosis. But the fact that this multi -- I mean truly drug-resistant strain exists in the world is a reflection of the failures of tuberculosis treatment, the failure to make the necessary antibiotics available and to monitor their use appropriately. So that's a marker really for the public health infrastructure.
I think that there is substantial evidence that it's already well beyond South Africa. There are XDRTB cases being picked up in Swaziland. There are rumors of cases in Zimbabwe. I think it would be unrealistic to think that it's all -- and certainly in Mozambique.
Furthermore, survey -- recent surveys are showing a steady increase towards XDR, meaning multi-drug resistant to, say, eight antibiotics, all across Siberia, from the Tomsk region, once again, which appears to be where the New York strain came from in the early '90s. And so clearly we have a serious, out-of-control problem where tuberculosis could become a major global killer again on a scale currently roughly 1.5 million people a year -- we could see it skyrocket to claim five (million), 10 (million), 20 million people a year.
What do we do about it? Now, WHO did step in that role that Helene was underscoring in the technical expertise role, very rapidly trying to pull together, you know, the essential expertise to address the problem. But what do we see right away? We see, A) where's the incentive for drug development? There isn't one. Why? Because the people who have TB are dirt-poor. So what drug company right now wants to spend X-hundreds of millions of dollars to invent a whole new tuberculosis regimen? None.
DENTZER: Even with three billion people in the world walking around the latent forms of the --
GARRETT: They're in the wrong countries. They're in the wrong countries.
The second part of the problem is that the true revolution at this moment would be a rapid diagnostic, would be a way that you could just like that test and know, this individual has active tuberculosis, and furthermore, it's drug-resistant. Again, sadly, where are the market incentives? There actually are some interesting tests that have been invented, but getting them into operational production and distribution right now is proving horrendously difficult.
So you've picked a perfect example where the vacuum in global leadership is obvious. Yes, it cuts across sectors. This isn't just a WHO technical support. It goes right to, what are we doing funding the PEPFAR program to do AIDS treatment if everybody in a family that's affected by HIV is going to get XDRTB and be dead before they can get their antiretroviral drugs?
GAYLE: Just to add, you know -- as you know when you were in New York City, the billion-plus that you ended up having to put into TB control because the infrastructure was eroded is -- I think it's a similar sort of issue where TB, you know, has fallen off the radar screen to a large degree in people's mind because HIV, which is obviously very related to TB, but that's taken higher priority in people's minds. And HIV treatment has taken such high priority without people realizing that treating TB in HIV-infected people would in some ways be a more wide-scale effective approach, understanding that antiretroviral therapy will help people with HIV and TB as well.
So again, I think it's one of these areas where we -- by not looking much more comprehensively and thinking about how do you keep the whole infrastructure up, we're letting the infrastructure for TB erode. But you know, on the other hand, it's also an example where better coordination of all the different actors -- I mean, the Gates Foundation is putting lots of money into developing new TB drugs and new TB diagnostics. That needs to be factored in, and as soon as that's available, making sure that we've got the systems in place to get the drugs out to those who need it most. So you know, we've got a lot of the different pieces, but we're not putting it together in a system that really will act on behalf of where the needs are greatest.
DENTZER: That's it. I mean, Helene, let me ask you point blank: If at this moment Dr. Brown comes forward with an unbelievable rapid diagnostic that's like a litmus dipstick -- you just lick it, cough on it, it tells you you've got tuberculosis and that it's drug resistant -- what would it take us --
GAYLE: Where are the systems? And that's a -- yeah --
DENTZER: The number one mass-manufacturing, you know, to get it where it needs to be.
GAYLE: Yeah. We're not there yet.
DENTZER: Okay. Let's take a question back here, please.
QUESTIONER: Thank you. Rehana Ahmed; I'm a board member with Population Services International. I live in East Africa -- Kenya.
I heard both speakers with great interest, and I would go ahead and say that global health is a development issue, as mentioned by Helene. And we have the Millennium Development Goals which begin with eradicating extreme poverty. We find that in villages where we can help increase productivity, whether it's agricultural or whichever other form of cash crop they can grow, health is something that comes in second -- food security being the first.
GARRETT: Right.
QUESTIONER: And when NGOs and international NGOs walk into the slums and offer their pet services, whether it be for water or child health or whatever, the community in turn is asking for food security.
GARRETT: Right.
QUESTIONER: So it cannot really be isolated. And I think we are halfway on the MDG calendar, and we do need to look at it in an integrated way. So just specifically one example -- HIV-AIDS has been mentioned more than once -- the new trust is to integrate HIV with reproductive health -- maternal and reproductive health. So the money is in HIV, but again, the people affected are the same -- they are in the reproductive age group. So integration is, I think, one of the key way forwards, whoever -- whatever the leadership comes from, on the ground, we're looking for integration to get results.
GARRETT: Yeah, no. And I think your issue of food security is an important one, and of economic livelihood. I mean, the PEPFAR program is hopefully going to be able to start incorporating, for instance, for reducing women's HIV risk, the notion that micro-lending and allowing women to start small businesses so they're not economically vulnerable and put themselves at risk for HIV is HIV-prevention. And I think it's by looking at what are some of the underlying factors -- and you know, the Haiti example is a good one. You've got, you know, doctors treating people's diarrhea over and over again when the real issue is water. So if we don't start looking at these issues, then I think we're not going to have the impact. And then, you know, the obvious integrating things like reproductive health along with HIV and STD treatment, et cetera -- you know, we have to do that if we're going to have a real impact.
DENTZER: All right. A question here in the back, please.
QUESTIONER: Hi, I'm Matthew Connolly of Columbia.
As an historian, I'm really struck by how it is that -- it seems as if people in the field are trying to make this up as they go along. When you talked about how it is we might think about where we want to be 10 years from now, how come there isn't more discussion about where we were 20, 30 years ago? Because so many of the problems that you're talking about have historical precedents and parallels, whether it's earmarking funds for stovepipe projects -- that's what malaria eradication was all about; whether it's about poaching among NGOs and international aid agencies because they can't spend the money fast enough -- that's what happened with family planning in the 1970s. So why aren't people learning from this history? Is it just that they're too busy?
GAYLE: Well --
GARRETT: I don't think people aren't learning from the history. You know, I think we've got systems that in some ways doom us to repeating the same efforts over and over again. You know, we have a funding system, for instance, that is extremely short-term and often shortsighted. It's difficult to do the kind of long-term endeavors when you are funded in three-year funding cycles. And so just as you're about to develop a strong infrastructure, your program money runs out and you've got to start all over again. And if the only resources are resources that come in stovepipes, it's hard to knit those together when you're told that you can't spend, you know, money for HIV to help somebody who has malaria if that's what they come in with.
So I think -- part of it is the nature of our funding and the way in which funding is done, and I think some of our broader -- our overarching policy constraints. So I think those are the things that -- oftentimes it's not that people don't understand these things, but I think we're often compelled based on the structures under which we work.
DENTZER: Question here, please.
GARRETT: And by the way, I mean, I am not anti-disease-specific funding. You know, I think that sometimes campaigns or big pushes or major focus on key priority issues is critically important. You know, there are emergencies that emerge, like an XDRTB and other things, where it may need that extra funding. But I think it's -- to have that as our only funding and to not have bases of support that support core infrastructure and human capacity development is where I think we make our mistakes by not having that foundation to really improve the overall health infrastructure, and then lay on top of that the disease-specific funding that is critical for key priority diseases.
QUESTIONER: Thanks. I'm Louise Holly Wise, and I'm affiliated with Georgetown University.
I brought my checkbook today, and I have two checks. So the first check, for Laurie, is for $100, and I would ask how you would spend that between domestic and international spending and on what specific things.
And the second check I'm going to write to Helene, and I would ask you to spend that in Kenya. And what would you spend it on there, please?
GARRETT: Whew, boy.
DENTZER: And I assume this hundred-dollar check is a symbolic check which stands for larger global resources. Right. Okay.
GARRETT: That's tough. I never really put it that concretely in my mind.
I would say that the health -- human resources crisis is so acute that I'd be willing to spend about 40 percent of it on trying to make America and other key wealthy countries -- Canada, U.K., and so on -- domestically self-generating in all of its necessary health personnel so that we all collectively cease poaching health care workers from poor countries.
And the remaining 60 percent -- I think the one place where I have a little difference with Helene is related to the leadership question. While perhaps from her perspective I overemphasize WHO's role -- and I do agree with her that we need to see more sectors engaged -- we still don't have some individual or agency of some sort that coordinates all these little meowing kittens into a corner and says, "Let's all try to be on the same page. Let's have some shared vision of what we're trying to accomplish." And without that, we have really remarkable problems.
Let me give you a real quick example. One of my idols, Dr. Andrew Spielman, passed away around Christmastime, sadly -- one of the great medical entomologists of all time at Harvard University. And Andrew had figured out that malaria was actually not just a problem of blood-feeding by the mosquito on humans and other primates, but also that the introduction of corn to the African continent was the key factor responsible for accelerating malaria all across Africa; that when the colonialists brought corn, the mosquitoes were able, between blood-feeds, to feed on the pollen of corn. And when they did so, they became more aggressive, much stronger, and took -- were much better carriers of the parasites. So he said, "Gee, well then let's try a little experiment. Let's go to a village and get everybody to move the corn crops to the furthest distance and bring the cassava and other crops closer to the village." Sure enough, malaria rates in the kids plummet.
So then he says, "Well, all right, let's make a corn that's a transgenic GM corn that has an agent in it that sterilizes the female mosquito." He devises this thing, goes around seeking funding for it, boom, he comes up against the anti-GM forces, comes up against the food security forces, comes up against one thing after another -- whole effort drops dead.
If it is really that simple, if we could really dramatically reduce malaria rates in Africa simply by attacking the corn piece of it, wouldn't that be a revolution, and wouldn't that be easier than waiting for the mythological malaria vaccine that we would mass-use all over Africa, right? But it's all these difference pieces that we try to bring together that -- where we lack some kind of a leadership that says, "This is a good idea -- this, this, and this. I want all you guys to stop screaming at each other, and let's try to figure this out."
The other example would be DDT home use and all the different forces that all mean well -- everybody thinks they're on the right page for their issue. We don't have a way of corralling it all into one focused assault.
DENTZER: Let's give Helene her chance to spend her hundred bucks.
GARRETT: Yeah, what's your hundred bucks going for? (Laughs.)
GAYLE: I would go to the Kenyans and ask them. (Laughs.) You know, and I think it would be a mixture of core infrastructure, water, agriculture, along with education and probably some health things. But I would go to the Kenyans and ask them what they thought they needed those hundred dollars for the most.
DENTZER: What a novel idea. (Laughter.)
Okay, let's take a question here.
GAYLE: And I was just -- I was just saying to Laurie, I mean, I actually -- I don't disagree with the need for leadership. I just don't know that WHO is well -- is best-placed, given the fact that health has now become much broader than the technical piece that WHO is mandated to do.
GARRETT: But who is?
GAYLE: But they have to be -- I think they have -- I don't know that it's there. I think we have to create it.
GARRETT: I'm with you.
GAYLE: I don't know if we need a health secretary within the U.N. that really helps to coordinate across the different actors or something. But I think you're right -- we need that leadership. We need somebody to help us develop that blueprint so people have their -- you know, their playbook, if you will. But I don't think that we -- I don't know that WHO leadership is any longer the leadership. And that's -- there's nothing -- that's not to say that WHO doesn't have a strong leadership role and we shouldn't be doing more to empower them, including a better -- a much stronger budget for WHO and its activities. But I think if we believe that health is beyond the medical, technical piece, then it has to be beyond WHO.
GARRETT: Right. And you know, if I may just add on that that the best indicator of what you're talking about is when in the last two years, concern about pandemic influenza and in particular H5N1 escalated, what did we end up doing as a global community? We created a special office within the secretary-general's office at the U.N. as the "flu czar" to coordinate all the various agencies, all the responses, for flu. And that may be a model for us to consider.
GAYLE: Right. Or even AIDS or -- you know, I mean, we've don't similar sorts of things. But then -- you know, then we've got to be clear about what the mandate of that entity is and have it appropriately resourced.
DENTZER: All right. Let's take a question in the rear, please.
QUESTIONER: Ms. Garrett sprinkled her remarks with several comments about incentives, and I wonder if you might spell that our a little more systematically. That is, this is a group that has historically been oriented I think toward public health and therefore public spending on health.
And just to give you a brief example of one case that I know well, the Robert Wood Johnson Foundation has now taken the lead in research on systemic lupus, for example, and introduced a business model into its funding which, instead of the usual NIH procedure of continued funding indefinitely for research that may go nowhere, now rewards researchers by continuing to sponsor their research only if it leads to new developments and new cures and new prescriptions and so on. So when you talk about incentives, what do you mean, and how would you build that into an international system of health care?
GARRETT: You're speaking about the sort of push-pull mechanisms for R & D and for getting products out of pipeline. I was actually speaking more about at the ground level. But I'll be happy to take on both.
At the ground level, the best example would be to just think about the water issue. For the last -- well, since Bretton Woods, the way we have approached the water question was to say that the wealthy world would give, you know, poor country A X-hundreds of millions of dollars to build a dam and some giant piping systems and so on. And what has always been discouraged and pooh-poohed was anything that would involve small-scale water purification and small pumping systems and so on at the village level. And even more importantly, I would argue, where those have been put in place, there's never been any incentive to maintain them. So some -- you know, the old Bob Dylan line: "The pump don't work 'cause the vandal took the handle."
What I would love is a model that says, "Here, you buy a franchise and you have, you know, water purification equipment tools and all that, and you go around and you charge a reasonable amount of money to the village, to a community, to a household, and this is your business," the way it would be here. It's somebody's business.
On the mega-scale of pharmaceutical incentives and biotech diagnostic incentives for getting things out of the R&D pipeline and into real production, there are mountains of papers, studies, and recommendations, and without going through all of them, it boils down to push-and-pull mechanisms. I think Gordon Brown's idea of creating a -- you know, a huge purchasing pot of guaranteed purchase for specific, targeted innovations is probably one of the better ideas out there right now.
GAYLE: Could I -- just to add to that, you know, in a very simple way, I just visited a project not too long ago in Haiti -- a water project that we helped to repair the water system after the hurricane -- Hurricane Jeanne a couple years ago. We went back to that project -- that's a project that the community keeps up. It pays small fees that the community collects. We're not even maintaining that anymore. That's being maintained by the community itself. Simple project, simple water system, but it's still there two years later because the community is paying for it. They collect fees. They have incentives to keep it up, but the also -- you know, it's helped the community come together.
Same in Afghanistan -- a similar water project that we helped to repair the original damage, but it's being kept up by the community. And there are fees, and it still works. It's no longer maintained by an outside source.
And so I think there are a lot of examples from the very, very grassroots to larger, you know, grander examples that if you get communities engaged and have people actually putting fees and have the sense that "this is a business and I have an obligation to keep it up," you know, it works. It's sustainable.
DENTZER: Let's take a question here. And we are approaching the end of our hour, so I'll take this one and then we'll try to work -- bundle a couple of these other questions together for our two guests.
QUESTIONER: Yes, hi, I'm William Courtney. I'm a retired diplomat.
Before coming in here today, I would have imagined that a number of people in our Congress would be proud that the United States has devoted a lot more resources to international public health recently than was the case in the past. But listening to the conversation today -- seems like a bit of a downer; that rather than achieving a significant amount, that we've created so many unintended byproducts of -- some of those I would raise a question with -- in particular, devoting a lot more resources to health care internationally would seem to make health professions more attractive for people in poor countries and other countries and would encourage a lot more people to come into the health care industry. And I would think that would be a good thing, even though some of them do come to the United States.
If your purpose is to mobilize more political support for international public health, wouldn't it be better to focus on the achievements that have been made, the corrections that should be made -- new directions and things like that -- but rather than making things seem so negative, try to build on the momentum and push things in a more positive direction?
GARRETT: I'm sorry if --
GAYLE: Oh, that's our job. (Laughter.)
GARRETT: Yeah. (Laughter.) I'm sorry if you think we're the "Bad News Bears," but I'll put it all -- I'll give you a positive spin.
We have this -- what ultimately is going to be a $15-billion PEPFAR program. It's focused on HIV-AIDS in 15 countries. A template has been built. Why stop there? Why not say, "All right, we've built something of a set of infrastructures involving multiple players on the ground in 15 countries. We've created a set of partnerships that involve the Gates Foundation and a host of other organizations -- WHO, et cetera." Why not say, "All right, we've started to build a template. Let's add on the malaria piece, the TB piece, the maternal mortality piece, the child mortality piece." Let's really say that what we're aiming at now is to learn from what we've done with PEPFAR -- now let's build health systems. Let's go the whole nine yards.
I think that the generosity -- the generous spirit that's been displayed by the American people in response to the tsunami and in the president's call for PEPFAR originally is spectacular. There's no other nation in the world that donates to the tune that America does. What we need, though, is to be more focused about what we're trying to do with it, be willing to take on the bad news and say, how do you go beyond this bad news -- how do we take this generosity and make something much more meaningful out of it?
DENTZER: Let's -- let me just quickly survey a couple of you. If you would just briefly articulate your questions, we'll try to bundle all these together for our final question.
Go ahead, please.
QUESTIONER: I'm Ed Altendorf, World Bank retiree.
I just wanted to comment very briefly on the hundred or $100 million that might be spent. I'd like to suggest that it should be spent in the first instance on some form of global public goods -- often research, particularly operational research, and particularly information dissemination. The same might apply at the level of Kenya -- at the level of public goods in Kenya. That's something that can be done with that free hundred or hundred million dollars -- can't be done with USAID or other tied money. Thank you.
DENTZER: An important comment.
Let's see -- let's go over here. There's a hand up over here, and then one in the rear, as well.
I'm sorry.
QUESTIONER: My name's Rebecca Hooper. I am the program examiner for both PEPFAR and Child Survival at the Office of Management and Budget.
And I had a question for Laurie and maybe Helene as well on funding. As I was reading the paper, I was trying to figure out exactly what you would advocate for differently. And my question is, are you unhappy with the bilateral funding? It sounds like you're very happy that we have it now and it's much more increased than it has been in the past. But would you advocate a sector-wide approach? Would you prefer to see money going more to the multilateral organizations such as the Global Fund, or is it just more is more?
GARRETT: Oh -- go ahead.
DENTZER: Let's take -- we have one here, and then we'll come back and we'll wrap up this last one here.
QUESTIONER: I'm Susan Weld. I've worked on China.
I don't know if this is -- (off mike) -- but I wanted to -- in China what's happened since the beginning of the -- (off mike) -- (opening ?) program is that they've built the health care (profit ?) sector for the rich people, as you know, Laurie. So they have some really wonderful facilities for the very rich. But what's happened is the central government stopped funding public health in the poor areas, so there's a huge gap in China now. But they do have this for-profit -- so I heard you say what we need to do is build up the for-profit health sector in some of the countries. Is there any way to do that in a more balanced way and avoid the problems that China now recognizes it got into by making that choice?
DENTZER: Okay. And then we have a final question here in the front. We'll bring up the microphone here for you -- coming from this side.
QUESTIONER: I'm not sure it's worth the mike, but thank you. Just a quick word of support for the market model that was mentioned earlier -- the small-scale, fee-based market model. Just an example from another area -- my experience in Bangladesh where the cell phone service has exploded. Poor people will pay for service that they need, and people are -- ladies that were doing micro-finance are now doing cell phones and they're making profits and all the rest. It's a model that can work as long as the benefits aren't so diffusive that people have an incentive to receive but not pay. If you can make it -- if you can package the benefits somehow, then you've got a market model that can work, even in the poorest area.
DENTZER: Great.
All right, let's take the two -- the PEPFAR question and the China question.
Helene, did you want to want to say something on the PEPFAR -- the bilateral funding?
GAYLE: Yeah. Well, I would just say -- you know, again, I think, you know, it kind of gets to the earlier comment. I don't think we're saying that we're negative about what's going on, but more needs to be done and it needs to be done in a fashion that doesn't pit one account against the other, that, you know, doesn't fund PEPFAR to the exclusion of maternal -- child health programs and that looks at the infrastructure needs. And maybe there needs to be a separate account that's just an infrastructure account, along with some of the specific focused accounts. So you know, I think it's not that these are bad by any means, and I think we should feel good about the fact that these resources have increased, but we've got to think of them in a more integrated way -- not have one take away from the other -- and look at some of the very core basic infrastructure, as well.
And I would just say -- you know, on the China, you know, I think what they did was to totally let go of public health and to only let it be a kind of a free market endeavor that focused on the needs of a few. And I think public health has always got to think about how do you have a safety net and how do you do the things that only public health can do that assure certain basic needs for all the population, and then mix that with a way of looking at increasing incentives so that everything isn't free and we're looking at ways in which you can have a more market-based approach to health services and really figure out how to integrate those two and not totally let go what was, at one point, a very good public health system that did assure certain basics for the whole population. I think that's what they've done is to just move so far away from that without looking at how to integrate those two.
DENTZER: Final comment to you, Laurie.
GARRETT: Okay. I'm going to go really fast. Operational research -- I'm with you all the way. We need health administrators. We need people who know how to run health systems. And particularly in poor countries, it's virtually nonexistent.
Let's see -- China. Hey, you don't have to tell me. I was there during the SARS epidemic. It's all about who do you bribe to get a sterile syringe. China definitely needs to rethink their entire health structure. But what China shows is not that it's a bad thing to have a private sector in health but that it's a bad thing to abandon the public sector and that the American model might not be the best model to apply to all the rest of the world. Our health -- our health chaos -- (laughter) -- extraordinarily expensive, and what do we achieve for it? The lowest markers of the wealthy world.
The market model, however -- I am all for it. And Bangladesh -- I'm glad you raised that. BRAC is the perfect example of what local-level financial incentives can accomplish for health. And if anybody here is not familiar with BRAC -- it's the acronym "B-R-A-C" -- I urge you to just go online, Google it -- you'll -- it'll blow your mind.
And then finally, health diplomacy -- what is health diplomacy? And are we in a situation where we're on a sticky wicket, if you will, when we start walking down that path? Certainly PEPFAR is a piece of grand, extraordinary health diplomacy and it deserves praise. But health diplomacy is a double-edged sword because if your provision of health is perceived as nothing but a piece of diplomatic effort and does not show a willingness to expand to a far larger perspective that takes in the totality of health needs; that listens, as Helene has stressed over and over again, to what the people locally want and need, what their priorities are -- then it becomes very shallow.
And the final example I would give of that is, you know, as long as Palestinian mothers wake up every morning knowing that their children may die of diarrheal diseases and measles but nobody across the border in Israel gets either one, there will never be peace between those two countries. And if we as a nation are providing some way of reconciling that difference, we see genuine health diplomacy in action. Take that model, expand it globally -- you start to get to where I'm thinking.
DENTZER: Thank you.
GARRETT: Thank you. (Applause.)
DENTZER: We have heard some very important -- we've had a very wide-ranging discussion today obviously, ranging from leadership and coordination to human capacity and incentives, issues perhaps on the table, as was noted before, 30 years ago -- issues probably on the table for the next 30 years, if not beyond. But I think we've had an extremely important articulation of them today. And join me now in thanking our two guests for this very provocative -- (applause).
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