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A Conversation with Ambassador Ebrahim Rasool

Speaker: Ebrahim Rasool, Ambassador of the Republic of South Africa to the United States
Presider: Yanzhong Huang, CFR Senior Fellow for Global Health
November 4, 2011, New York
Council on Foreign Relations

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YANZHONG HUANG: OK, I guess we'll get started. This is a council rule. You start in time, end in time, you know.

Welcome to the Council on Foreign Relations. I'm Yanzhong Huang. If you have problems pronouncing my name, just call me Yanzhu (sp). This is always -- this is my illegal, unofficial name. (Laughter.) I'm a senior fellow for global health at the council. And this is actually the first meeting of our new Emerging Powers in Global Health Governance Roundtable Series, which actually builds off our Global Heath Governance series the past year.

And this series will feature Ambassador Rasool. And his excellency has a very long history of -- involved in the anti- apartheid struggle, but his official title now is the South African ambassador to the United States. And he has had a very long, distinguished career in government, having served in the ministries of health, welfare, finance and economic development, and as also premier of the Western Cape from 2004 to 2008.

You actually included in the -- in the program these bios, so I won't repeat that.

And after the ambassador's remarks, Ambassador, you're going to speak for 15 minutes -- 15 minutes only -- and -- because this is, again, the council rules. I had this experience last time in -- you know, I was asked to moderate a panel of NCDs, noncommunicable diseases. I told every speaker to have, like, seven or eight minutes, you know, talking. It turned out, everybody wants to talk more. They're like 20 minutes -- (inaudible). So I apologize, because it's rude for me to interrupt and say stop, right? (Laughs.) But -- so this is an experience, you know, I had, but I'm sure that the ambassador's going to keep this 20 -- 15 minutes limit.

So -- and also, after the remarks, we will open up the floor to questions and discussions. And I want to let you know that this meeting is on the record. So feel free to use and quote today's discussion. And please also turn off your cellphones and BlackBerrys -- and I'm going to do the same thing. (Laughs.)

The -- and Ambassador Rasool today is going to talk about the role of South Africa in global health governance. Ambassador, you have 15 minutes.

AMBASSADOR EBRAHIM RASOOL: Thank you. Thank you very much, Yanzhong. I can detect that you are desperate for success in timekeeping -- (laughter) -- because it appears that if -- the length of time you've spent on admonishing me to stick to 15 minutes meant that the last experience was a hard one for you. So --

HUANG: (Chuckles.) But don't worry. I mean, I am going to talk after that. (Chuckles.)

RASOOL: So basically I would be very happy if, with five minutes left, you could just tap me on the shoulder (or similar -- I don't know ?) --

HUANG: OK, I will.

RASOOL: -- so that I could have an elegant wrap-up to whatever --

HUANG: I will.

RASOOL: -- I am basically saying.

But thank you very much, through you, to the Council of (sic) Relations for not only inviting me but hosting such an important discussion at such a transitional moment in health governance globally. I think that sometimes when we are in the midst of a change, we don't see it until -- we don't recognize what we're in and we yearn for what we left behind. And so I think that maybe in the midst of this change, it's good to take stock of what it's moving from, where it's moving to and how much continuity we want and how much this continuity is desirable in a global health system.

And I'm honored that South Africa has been asked to anticipate in such a debate, because I think for the -- for a long time we have been at the center of health, either through contention or through achievement. And I think that we would be grateful if there was a happy balance between the amount of contention and the amount of achievement, because I think that imitation is often pain-free but not always desirable.

MORE And so in a real sense, I think that it's a good thing that South Africa is trying to kick off such a discussion.

And really it was in 2007 when South Africa and six other states convened in Oslo to discuss health but from a completely different angle. Foreign ministers convened in Oslo to discuss how foreign policy should have health as a lens through which, (amongst others ?), to do diplomacy and to do foreign policy and to deal with threats. And that was completely left-field thinking that brought South Africa and six others together in Oslo to discuss where health governance was going to and where it needed to go to.

And so the objectives of that Oslo conference of foreign ministers was to find a new lens through which to view health -- unbiasedly. Development and poverty was central to the kind of countries that were -- that were together, that it needed to discuss what to do about new partnerships, some of which were emerging and some of which were not emerging, that you needed a new partnership for health governance.

And most importantly, it helped global governance on track. And that wasn't to say that we didn't know that the World Health Organization was there, it was just how relevant was its (toll ?) in the changing global scenario. And so that conference in Oslo was a recognition that health was undergoing a significant change, a significant transition from an old international health system to a global health system.

And international is the coordination of nations to do health. Global was saying that there was a certain transcendence of nations that was needed in governing health. If we can understand the subtle difference between the two, we're beginning to understand the transition that I think we all find ourselves in in managing health.

And this change from an international health system which was multinational, needing coordination for certain things, to a global health system in which nations had to cede some autonomy and take on transnational responsibility was driven by the impact of globalization on health at that point; that suddenly the tension between the nation state and the globalizing world needed to be dealt with.

It had to recognize the mobility not only of goods but of people and of health issues like disease; that there was no longer borders which could be shut; and thirdly, that the definition of threats had changed, because threats up till that moment, and particularly after 2001, was threats emanating from wars and from terror, which were largely external, from the outside in, and suddenly you're now having to deal with -- at the hand of avian flu, H1N1, et cetera, internal threats or threats from the inside out.

And if we understand that, we could then begin to understand that some of those threats or at the core of those threats were health threats, whether you're dealing with bioterror, whether you're dealing with lifestyles (driven by ?) tobacco crossing borders where they'd never been before, or whether you're dealing with disease that could start in one place but cause contagion across the world.

And so the definition of threats itself had changed to begin to say that you can no longer manage health from an international perspective. You've got to govern health from a governance perspective.

And so in response to all of that, many new actors had entered the scene. In the previous era, it was countries and the World Health Organization. In the new era, there were now many. So suddenly, in addition to countries, in addition to the United Nations family, you had philanthropies springing up all over, each one driving the disease of choice and the health fetish of the moment and so forth. But also, you've had a plethora of NGOs and civil society and everyone getting involved. And the system was now truly multipolar as we were going on.

And there was a fast-shifting global health governance architecture. It wasn't recognizable any longer. The question that everyone asked was, was the World Health Organization relevant? Was it being eclipsed? And certainly, in a fast-moving, fast-changing transition like that, the World Health Organization appeared ponderous. It was bureaucratic, it was technical.

And 80 percent of its funding was earmarked. So some people were giving the money to the World Health -- but say I want you to use it for this. No one could sit at the World Health Organization, and say, you know, it's better if we invest in systems, but you want to give it to this disease, let me take you to this disease.

So there was a conduit, but not a leader.

And so those were the kind of questions which forced this new debate onto -- and countries like South Africa were overwhelmed by vertical programs. People wanted to come in and fight malaria, and people want to come and particularly fight HIV, and people want to come in and fight TB, and people want to fight this disease. But no one was mindful of whether the center could hold, whether the health infrastructure could do what they wanted to.

And so some of them came, and they said, no, we'll form our own NGOs to drive it. And so the system was in serious tension. And new sources of funding like the philanthropies who were coming up, the Gates Foundations, et cetera, all came with a -- with a project. And all of them were worthy. You couldn't argue against someone wanting to come and fight malaria or HIV. You couldn't argue that (no model had applied ?) to it. And so sometimes the pushback from -- (inaudible) -- of Africa seemed obtuse and obstreperous in the context of the need that existed for intervention.

And new directions were being set by NGOs, single-issue NGOs who had no other business except to make their issue the primary concern of everybody, catching the attention of funders, pressurizing government, putting strain on health systems. And so health was being pulled apart not by a central idea of what the priorities were, but by a multiplicity of actors, each with well-meaning and sometimes well- achieving agendas.

But distortions were exacerbated.

Distortions of inequality in health was still fairly large because you had an inadequate mix between vertical programs that -- for diseases and horizontal programs that strengthen health systems, health capacities and health infrastructure. The gap just grew wider: lots of money for HIV, very little for systemic capacity-building. Research was skewed. The developed went to where people had money to pay for the latest drugs to fight diabetes, not doing the research.

And that's where the 90/10 distortion came from: 90 percent of the burdens of health out in the development in the world, 10 percent of the resources for research in some of those issues. And we had distortion in the -- (inaudible) -- between dealing with the determinants of health and dealing with the symptoms of health. There was a lot of money flowing into dealing with the symptoms of health and very little in dealing with the determinants like tobacco advocacy, alcohol abuse, et cetera, et cetera.

And so (Oslo ?) sought to respond to this. And this was the core of the emerging market response. And if you consider that (BRICS ?) consists of about 40 percent of the world population, then that was a very good forum to start coming together to deal with the health profile of that 40 percent who carried massive burdens of diseases within 40 percent of the population, largely emerging, largely developing and largely ignored except for some vertical programs that came in.

And so the need to shift to a broader front of operations was important. That's why foreign ministers met in the recognition of this. And so the understanding was that you needed whole government -- whole-of-government interventions at home, meaning not just health ministries, but agriculture, trade, justice. Everyone needed to be in on dealing with health.

And that's some of the new imperatives coming out of that Oslo meeting: whole of government at home and whole of society everywhere else, that it was no longer just that -- health that needed to do it. Trade regimes were going to be absolutely critical if you're going to drive down the price of devices, drive down the prices of drugs, drive down -- drive away tariff and nontariff barriers, get a better mix between generic and (ethical ?) drugs coming in, push back on intellectual property rules, manage TRIPS a lot better, et cetera, et cetera.

So we understood the centrality not only of trade, but of the World Trade Organization in being important in health. And suddenly health, in the new era, emerges as a fundamental human right and health provision as a global public good. And that, I think, is an emergent paradigm that needs to come out in the time that we're -- that we're in.

And so just to mention a few things in the last minute is that this rethink that is happening of global governance means that it is shared governance. It's no longer exclusive governance. Secondly, that you need a better integration between vertical programs and horizontal programs.

Some call it diagonal, some call it a matrix, some call it holistic, but you are going to need something different from the old -- (inaudible) -- because for the short term, you need vertical interventions; for the long term, you need sustainable systems and capacity.

There is a need within this for a new master plan as well as a new conductor of the orchestra. Who is this? Can the World Health Organization be remandated and strengthened in order to become again the conductor of the orchestra? Or do you need a new instrument?

I think that from our purpose -- and I end up on this -- in September at the United Nations General Assembly, you had a glimpse of the possibilities when only the second time the high-level meeting of the United Nations considered noncommunicable diseases. And you began to see the preparation. In South Africa, for example, you had a whole-of-government Cabinet meeting discussing how to fight NCDs. Then we convened our NGOs and our civil society so that all of society came in. Then a national strategic plan looking at trade, regulations, health, all of those kinds of things kicked in to support what you were going to vote for at the United Nations. And then on the sidelines of the U.N. General Assembly, the BRICS countries convened to say what is a uniquely emerging market response to noncommunicable diseases. And then we went into the U.N. to vote in support of the political declaration on NCDs.

And I think what it all says is that something is emerging. It's challenging governance. It's challenging the paradigm of health. But I think that we are going to be in a better place than where we come from.

Thanks very much. I hope I didn't give you too much grief.

HUANG: Thank you. Yeah, it's exactly 20 minutes. (Chuckles.) Very much appreciate it.

Ambassador, thank you for giving us that excellent introduction of the changing landscape of global health governance.

And you mentioned the role of BRICS, the emerging powers. And I actually have a relatively more specific question. You know, the BRICS health ministers met in Beijing this past summer, right? They had this Beijing declaration focused heavily on access to essential medicines. I'm curious, what is the role of South Africa in particular -- maybe BRICS in general -- in ensuring that the poor in the developing world have the access to essential medicines? Or does that put the emerging powers at odds with the West, you know, the OECD countries, which (are) focused about this intellectual property right issue?

AMB RASOOL: I think potentially it does. I think if you go back to the -- to the late '90s, early 2000s, South Africa was leading a fight against pharmaceutical companies simply to find parallel imports to loosen up intellectual property rights for essential drugs in the fight against HIV.

It was a costly battle because in the time of that fight we were in a complete moral dilemma because, literally, people were contracting the disease, people were dying, and we needed to sort out the principle that would sustain whatever interventions we could be having. And so I think that that's the battlefield we come from.

I think that we are probably now at a better place, where pharmaceutical companies themselves understand the need to be less rigorous and less dogmatic about things like intellectual property rights, where I think that the possibility exists if you have the BRICS countries and other emerging economies standing together and pushing, because these are not going to come on a -- on a platter to us.

It's going to be one of those things that we're going to need to fight for, and that is why I think the battle of governance is going to be a -- largely a battle about the redistribution of power within a new governance arrangement, a new distribution of votes within a new governance arrangement.

And the possibility exists that the superpowers, who had been the bilateral donors in the relationship, had previously done favors to people struggling with disease. The mobility of disease now means that winning the battle against HIV in Africa is preventing it from reaching the U.S. Winning the battle against H1N1 elsewhere is to prevent disruptions in the global trade and from bringing it home.

So I think there is a bit of balance. The table is laid for a great dialectical process to take place, especially as the BRICs countries and the emerging economies are more organized in the way the governance arrangements will have to reflect that. And you may get fundamental -- (inaudible) -- decisions coming up.

HUANG: Well, thank you, Ambassador -- (inaudible).

The -- so I'm now opening the floor up to questions. We should have 35 minutes, I think, for discussion. So if you're interested in asking a question, please identify yourself and your affiliation before responding. And also, please flip your tent card to indicate that you have a question. This -- we also allow, of course, the one- finger rule. So if you have any quick follow-up remarks, please feel free to do so.

So I'm going to start with my -- (laughs, inaudible).

QUESTIONER: OK, I'm Katherine Marshall, Georgetown University.

I have two questions. First, I'd be very interested in hearing a little bit more on where you think -- what the fate is of WHO and the direction that it might take. And second, building on sort of threads in your own past, I'd be particularly interested in your view of where the Muslim world sits on this and the interfaith, particularly OIC and the Islamic Development Bank as actors in what's emerging, but also the sort of interfaith dimensions at the African or even South African level.

RASOOL: I wonder if we should take -- (inaudible) -- yeah, OK.

HUANG: Well, I think currently -- yeah, we can do one -- maybe -- (inaudible) -- if we have too many questions, then we can do this collection.

RASOOL: Yeah.

OK, I think -- I think that there is a strong body of opinion that says you've got to continue investing in the United Nations family, and you've got to strengthen the secretary-general's office in order that the World Health Organization is freed up of being technocratic, bureaucratic and a repository and a conduit for earmarked funding, that it should play a far better role. It's going to be up to the World Health Organization to see whether it is able to do this. Others will be saying that you've got to shift this responsibility to the G-20. Others are saying that maybe the -- a different formula is going to be required for global governance in the world.

The good thing is it's all in the debate. The inside track is being held by the WHO. It has the first right of refusal, and the refusal isn't going to be about what they (declare ?). It's about how they change. It's not about business as usual, but in recasting the internal power dynamics within the WHO.

And most importantly, it's about whether the World Health Organization can find synergy with its other siblings in the U.N., who also compete for -- UNAIDS and children and all of those kind of things -- whether it can find synergy amongst the siblings of the U.N. in order to be able to play the role.

With regard to challenges in the Muslim world, I think that very clearly the Muslim world has enjoyed itself while, from the rest of the world, it enjoyed a triple bypass -- a triple bypass of democracy, of freedom and all -- and the rule of law. It could very much do what it wanted to do because there were other priorities that the world wanted from the Muslim world and were prepared to do that triple bypass. So we didn't have a sense -- it was a fairly closed society -- didn't have a sense of great disease in all of those countries.

But it's a society that is also beginning to feel the migratory patterns. It's also opening up, and the more it opens up, it becomes -- it becomes candidates for health profiles that they may not have had.

I think that if the Arab Spring does lead to a strong basis in democracy, of integration globally and freeing up of the voices that have been suppressed, such as women's health and so forth, then I think that a lot of these things are going to come to the fore within the OIC; that the OIC for the first time will say: No, we have -- our religion doesn't allow for extramarital sex, and therefore we are not going to have problems of HIV and STDs and all of those kind of things.

They've swept things under the carpet. I think it's going to come out.

On the interfaith, I think the greatest challenge for the faith communities, given not only the challenge of poverty but, more specifically, the challenge of health, is where the faith communities could make their own transition from competitive religion to collaborative religion; that that I think is the major challenge facing the faith community.

We are so busy competing for adherents that we are forgetting to do good. And we need to be able to mobilize all that good will that sits within the churches, the mosques, the synagogues and the temples and so forth, mobilize the resources that's there waiting to do God's will. But it's been frittered away because we are busy with competitive religion. And by and large, we are -- we are forgetting that we're probably in the greatest battle for faith itself. And that's where I think we're missing the mark from a religious community.

HUANG: Julie.

QUESTIONER: Is that working? Good. Thank you, Ambassador, I'm Julie Fisher from the Stimson Center, and I'd like to follow up. You've described very eloquently South Africa's role among the other emerging economies in leading a change in global health governance. But could you describe a little how you see South Africa's role as a regional leader in bringing about the kind of health governance reforms that could lead to cooperative capacity building and less of the siloing effect that's even more pronounced in some of the less well-resourced countries in the region?

AMB RASOOL: I think that that's probably -- the African agenda is, in a sense, the primary foreign policy component of what South Africa does; that a lot of the things we do globally are even, I would say, at the service of an African agenda.

And so to a large extent, we have been engaged thus far in driving sub-Saharan Africa, particularly, away from autocracy and single-party state and non-democracy and all of those and establishing the institutions of democracy, primarily elections.

And we have been engaged largely in resolving conflicts and post- conflict reparations and reconstruction and all of those things, and that's why the Oslo declaration by the seven countries had a large component on how to protect health systems in conflict situations, how to ensure that one of the first things you reconstruct in a post- conflict situation is the health system and health infrastructure and how you find a balance between those who directly die in conflict and those who are incidentally the victims of conflict, because when water goes and all of those kind of things and sanitation is out of the window, where disease (then lurks ?).

So I think we're still largely, I would say, in emergency mode in dealing with our responsibilities on the African continent, and slowly but surely moving in a far more constructive, forward-looking, long- term mode. And so I think we speak with a lot more authority now that we have learned so many lessons from the fight against HIV and AIDS so that other countries in sub-Saharan Africa don't have to make their own mistakes and do the same experiments that we have been able to make. I think we have a good sense of what works, what doesn't work, what the health system requires.

And so we are -- also one of the biggest and immediate contributions that Africa can make is not to keep the Zimbabwe health workers and the Congolese health workers and the Somalian health workers in our country too long. It's not because we have stringent immigration laws. We don't. But the fact of the matter is that South Africa can't be the hospital for sub-Saharan Africa. You've got to get the health workers capacitated and back to their countries of origin. So we have imposed on ourselves a non-poaching rule in relation to the rest of Africa.

So I think that we -- we probably would emerge as the regional leader for health systems, but it's a responsibility we'll carry fairly lightly, and by suggestion rather than instruction, by example rather than through force.

HUANG: I'm sorry, just a quick follow-up. Does that mean that the administration of the South African government is sort of, on the international front, retreating from a leadership role on the (issues ?) of development, governance and health, and reaching out for commercial diplomacy and international partnership, particularly BRIC countries? Is that the case?

RASOOL: I don't think so. I think that we see South Africa, for example -- on that array of BRICS, it's at this point got a 3-percent growth rate compared to what China, India, Brazil and others are having. So we don't really see ourselves as economically in the same company as BRICS. But BRICS knows -- or if you leave out the "S" for a moment, BRIC knows that if it does not have a credible presence from Africa, then it is not a credible emerging-market institution.

And so South Africa, to a large extent, comes there and flies the flag for Africa and is a conduit for lots of the ambitions that BRICS and that emerging economies would have -- is a conduit for Africa in such a conversation in much the same way that I -- we go to the G-20 as South Africa, but we ensure that we have an interregional discussion on the agendas, for example, of the G-20 within Africa so that we can better represent some of the continental trends, as opposed to just what the South African agenda is. And I think that that's the kind of approach we would generally take.

So it's not an abdication of leadership. And I know that the U.S. is going through its own debates about the merits of leading from the back, but the fact of the matter is, better to be a determined beloved leader than a (needed one ?) but often scorned and invoking jealousies and envy as opposed to gratitude and cooperation as we go on.

HUANG: Thank you.

The gentleman over there.

QUESTIONER: Yes --

HUANG: Sorry.

QUESTIONER: Witney Schneidman, Schneidman and Associates. Ambassador, thank you for a great presentation. I was struck by the tension that you posited between the WHO and its agenda and, as you put it, the need for a new master plan. And I was going to ask a question similar to Katherine, which you answered well.

Just to make a comment: The work -- I've done a number of projects recently, certainly with the Africa region of the WHO. And it's pretty clear to me that in the near term, at least, the need for investment, the need for more capacity is quite central. And given the important role that the WHO plays in partnership with governments in advancing agendas, I don't think we'll change any time soon.

But my question really goes to the master plan and who's going to drive that. Right now, the G-20 is meeting in France as we know. And I'm just curious, from your perspective, is the G-20 a vehicle for creating that new master plan? Are health issues on the agenda there right now? And is that something that either developed or developing nations can look to -- to moving forward on a new health -- global health agenda?

RASOOL: There's -- in all the debates and the options available for a new master plan and a -- or maybe I should (quote ?) -- a new symphony and a new conductor of the orchestra, I think that one school of thought says the G-20, largely because you're dealing with ministers of finance, and that if you can make health a priority in a G-20 agenda, that you begin to manage more equitably the allocation of resources. So I think that that's the one school of thought that is very strong on this.

I think the school of thought that says that the World Health Organization, that it's better to reform something than to create something, is as strong: You just need to free it up from the impediments that makes it ponderous.

So again I will say that the challenge is really at the door of the World Health Organization, whether it can catch up with a shift from an international coordinator to a global coordinator. And it's going to be around for a while. But even the World Health Organization will say that there is no synergy in the world; there's no coordination in the world; we are largely driven by the size of philanthropies; we are largely driven by the voices of NGOs; we are largely still driven by the directions that national governments take; we are still a vertical, interventionist organization, as opposed to the one that can do both bold systems and intervene in diseases.

And so that's -- I think we are right in the midst of that debate. And it would be too early for a country like South Africa to pronounce itself one way or the other on it. But I certainly think that with countries like BRICS, with the Oslo agreement, with the Beijing Declaration and all of those kind of things, we're certainly lobbying very hard for something new to come out.

HUANG: Just for your -- (chuckles) -- information, that the WHO just ended a three-day -- (inaudible) -- board special session focusing on the reform of WHO -- (laughter) -- the governance program, adding priorities, in fact.

The -- so our next -- Jim (sp), yeah.

QUESTIONER: Thank you, Andrew Yanzhong Huang.

HUANG: Thank you. (Chuckles.)

QUESTIONER: Ambassador, thank you for your very stimulating remarks. I have seen firsthand -- I work for WHO, by the way. (Chuckles.) I'm a senior adviser for the prevention and control of chronic diseases in the Pan American Health World Health Organization, and I had pleasure to help organize the high-level meeting in New York.

I've seen first-hand how this verticalization can break up a country's system. In my previous job, HIV response in Guyana, and the ministry was just getting a nice team, in comes a PEPFAR project, in comes a Canadian project, in comes a world Bank project, and they each hire one of the people from the ministry, and you break up. I was so sad. That was about 10 years ago.

I have two questions. One, in talking about the plurality of the global health situation, you mentioned the philanthropists, the NGOs. I agree. You did not mention corporations, and transnational corporations. I mean, perhaps it's implicit. But you take a group like IFBA, the International Food and Beverage Alliance, they control 20 percent of the world's calories. A major externality to their way of operating, the combined operation, is the obesity epidemic that we face. It's not the only cause of the obesity epidemic.

But I wonder, in this shared governance future that we have to create, how you see the management of transnational corporations. Even the U.S. cannot manage them alone.

The second question is on the rebuilding or the retooling of WHO. How do we get the investment to do that? WHO's total budget is about three or four months earnings for Pfizer. It's about the size of running one big U.S. hospital.

RASOOL: General hospital in Massachusetts.

QUESTIONER: Yes. And so you have all this debate and agonizing, and yet the core budget is so small. It really is undercapitalized for the job it's so supposed to do. So it's OK for you, and I agree, to saying, you know, what WHO wants to do, but you guys are the owners. You have to help and support and make the investment to reform the organization and help it to do its role with the rest of the U.N. system.

We're trying in the Americas region to establish for NCDs a Pan American Forum that makes a platform for government, for companies and for civil society to engage and try to take joint action, because you cannot just point to the companies -- civil society has and people have a role and government has a role -- so to create a platform where you can take joint action and not just government alone, the whole-of- society approach.

But those are my two questions. Thank you.

RASOOL: Well, thanks very much. I anticipated that there would be such a curve ball. That's why I said we could take a few questions at a time. (Laughter.) But the fact of the matter is that, look, I think that in your first part you describe exactly what I think is going wrong, and so we've all agreed on it.

I think that certainly the reason that I didn't mentioned explicitly corporations as part of this plurality is because of the ambiguity about whether they are essentially a determinant of health factors or part of the -- part of the cure. And I think that certainly there are some great efforts being made by certain corporations. I just -- I don't want to mention anyone, but we have a friend working at one of the major beverage companies who is absolutely determined to really drive down the kind of calories and sugar levels and all of those kind of things within it, and different marketing techniques.

So I think -- let's take the point that corporations are a major part, and pharmaceutical companies also, I think, have the potential to do all of that. But part of this overhaul of the global governance system would require, amongst others, a stronger regulatory regime, a global regulatory regime. And that is not going to be at the whim of whoever governs a particular country.

I think that that's going to be -- and you're going to find many corporations on the receiving end of some of those regulations, and so two turkeys (out for ?) Christmas or for Thanksgiving. So we're going to have those kind of tensions as they exist.

But the retooling of the World Health Organizations, with its small budget, is absolutely critical, because one of the things that we are saying, especially from emerging economies, is that part of the retooling is not just to give the WHO the ability to synergize that regulatory regime but to give it the enforcement mechanisms that may be required. And that's where I think it's really going to challenge the budget.

And maybe part of the overall horizontal investments that we need to get back to as part of a more integrated way is to say that whoever we have to have as the conductor of our master plan needs to be invested in a particular way that makes it independent of a single donor, that makes it able to do what is right and not do what is prudent, that allows it to enforce without fear or favor. And that requires a completely different set of funding and financing norms.

And maybe, I think, we could be having -- if this Oslo meeting were to have effect, maybe Oslo has to be able to say that BRICS countries, while a lot of their health budgets have to go into their national situations and they have very little to use as donor funding itself, but maybe part of the investment has to be in a global conductor like that. And so those, I think, are the emerging debates at the end of the issues raised in your question.

HUANG: thank you, Ambassador.

Well, I'm going to collect the questions from Deepa Pria (ph) and then Chris (sp) and Rubatta (ph) and Katie (sp).

(Cross talk.)

QUESTIONER: Good morning, Ambassador. I think that cuts my time to one minute, I think. I have to formulate.

If you see -- like in your talk you have told about what global health -- it has been -- I think it is -- (inaudible) -- initiated with the globalization. And so the underpinning is strongly economic. And as you see, like that's creating a different type, often, dividing the governance of things like -- you know, just an example, like the economic aspect has shifted the drug manufacturing to India. But recently when there -- some of the MNCs wanted the price of the life- saving drugs, government has to wake up.

So as I see, there is a strong local or the national need and at the same time there is a big international, global requirement, which is economic.

So in these situations, there are many cofactors which is related to these governance aspects. So how do you think that in these situations the global health governance will go ahead? And particularly I will like to comment (sic) you on the climate change issues.

QUESTIONER: So -- Chris Decker from the National Intelligence Council. Ambassador, I had a quick question in terms of -- you said that the Oslo agreement or -- was looking -- part of it was that countries need to cede sovereignty, and later on you said a little bit about intellectual property rights, that developed countries need to cede sovereignty there. I did wonder if you can help explain, though -- within the WHO, the debates on pathogens has very much been developed countries then turn around and claiming sovereignty over the pathogens. So there's this apparent disconnect, if you can comment on that.

QUESTIONER: My comments are probably similar to ones that have just been made, but I'm wondering if you define health simply as the absence of disease or if you define it in terms of status of physical well-being. And if it is the latter, such things as environment and agriculture loom very, very large in creating a healthy population. That complicates the global governments issue -- governance issues tremendously and puts new demands on the World Health Organization or a successor agency. I'd like your comments.

HUANG: Katie?

QUESTIONER: And I'm Katie Callahan from Global Health Strategies. And I -- earlier you were speaking about South Africa's role and responsibility in acting regionally in sub-Saharan Africa, and the other big emerging player in sub-Saharan Africa is China, and I was wondering if you thought, in this BRICs era, if you thought there were opportunities for South Africa and China to collaborate in terms of leadership around health in sub-Saharan Africa.

HUANG: We also have, actually, (if you could have ?) -- (inaudible) -- has --

QUESTIONER: (Inaudible.)

HUANG: (Chuckles.) Well, yeah.

QUESTIONER: Hi. Erin Hohlfelder from -- (inaudible).

HUANG: Yeah.

QUESTIONER: Just quickly your thoughts -- I think governance and financing issues at a country level are obviously interrelated, so your thoughts on sub-Saharan African countries hitting their Abuja targets for health financing and what role that plays in --

RASOOL: Which targets?

QUESTIONER: The Abuja targets for 15 percent -- national budgets for health and how that plays into this discussion. And also, from the U.S. government perspective, we also often hear that they don't hear enough demands from African countries -- so this interesting tension between wanting to better manage programs at the country level but then also, from an advocacy perspective, the need to hear more general demands and how you feel that balance is met.

RASOOL: OK. Thanks very much.

I think, Deepa Pria (ph), that certainly the issue of economics is probably the central reason why we are speaking the language of whole of government, whole of society, and that the new global governance system that should emerge should have trade at its -- at its core. And part of where I think that this debate around WHO, G-20 and so forth comes -- and the World Bank and so forth come in is because if you -- the further you go to the left of that spectrum in the debate, people see health as having to be protected from your (liberalism ?).

And so, in a sense, I think that the question is, who can exert influence over the World Trade Organization when Doha, et cetera, et cetera has not been able to deliver much to your developing world?

And so it's building up these blocs that can also manage TRIPS, that can manage intellectual property, that can manage all the economic and trade-related issues and money flows within the global health system.

So there's very clearly at the center of all of these debates is also the economic questions. That's the one major addition to the architecture that I think is being -- is being looked at.

And on the issue of climate change, I think at Copenhagen one felt very painfully the absence of a global health voice. And so it goes to both questions that you're -- that you're asking, that within the global governance more generally there were dyssynergies. We didn't see the national connections between the conference of partners coming together and health. And yet, we were seeing all these floods on one side of the world decimating populations and leaving in its wake disease-ridden people. On the other side, you've had desertification at the end of drought creating absolute food insecurity and poverty and starvation in its wake.

And this is where the metaphor of the conductor comes in, because it's a conductor that in a sense understands the entire script and is able to understand how the violins are related to the percussions and the percussions to the -- to the wind instruments, et cetera, et cetera. And that's what I think is the missing center in all of this debate that is able on the one hand to speak to the WTO about the trade and economic-related aspect; at the same time, is able to understand where the projections are going to take us for health, because it's well-being. And it's part of this new conversation that opened up in Oslo about fundamental right(s); it's about well-being, it's dealing with the determinants of health as opposed to just the outcomes and the -- and the symptoms of it.

So I think we're in a sense beginning to get there. But the architecture and the financing -- the nuts and bolts of it -- has not in a sense caught up with the new paradigm and the new conception that is -- that is beginning to emerge.

And, yeah, I have not been following entirely the debates on pathogens and so forth, but I think that there is a language that is being spoken about that balance between the respect for sovereignty and the need to cede sovereignty to a greater good. And one is really -- yeah, I think that the tone of debates after the U.S. election and after Greece is going to be very, very important. Are we going to throw the baby out with the bath water? That really is -- because Europe began to achieve something that is a regional good, if we cede national sovereignty.

For the first time, you're not only having Greeks asking themselves, "Should we even have the euro, should we even be in the EU?"; you're now having Europe saying should they be in it. And you are having other Europeans beginning to say: If we want to forestall what's happening in Greece, shouldn't we be opting out -- (inaudible)?

So, yes, I am -- I am answering your question far more generically, and maybe you should put up -- use the one-finger rule, and give us an opinion on where you think the pathogens issue is going to. But I think that we're in an era where the tension will come again between global governance and -- or regional governance, and national sovereignty.

I think that the China-South Africa collaboration and leadership on health in Africa, I think that to a large extent it's going to be mediated far more through BRICS and other mechanisms, multinational mechanisms, as simply opposed to very bilateral ones. I think that my own reading is that China is at a phase of its own development where even what it does in Africa is at the service of what it needs for its population.

There's some good that accrues to Africa. You're getting infrastructure going. You're getting economic growth rates. But it's still far too much extractive, as opposed to constructive and productive for Africa.

I don't think we're at the stage yet of seeing a Chinese USAID or AID presence in Africa. And that's part of the message that I give on a regular basis to investors in the U.S.A. who raise the kind of China question. I'm saying China is looking after itself. And Whitney (sp) has been in other forums where I say that. There's a very lovely U.S. song, if you can't be with the one you love, you love the one you're with. (Laughter.)

And it's the absence of the U.S. --

MR. : (Careful ?).

RASOOL: -- that is -- that is -- that is really creating an unfettered condition for the presence of China in the -- in the U.S.A. And Africa is benefiting from it, but I think that, as I say, if we had choices between an investor who develops your own human skills, who creates a plant and productive capacity, versus one who doesn't, there's very little choice. We know who we'll choose.

But I don't think China is there yet in our relationship.

HUANG: South Africa -- I'm sorry to interrupt -- South Africa says that it will launch its own development aid agency, right?

RASOOL: Yes, SADPA. So -- and that becomes an adjunct for us because we're understanding that we could either have a hundred thousand Congolese in South Africa or have a fund that creates capacity in -- we could either do all the key health surgeries in South Africa, or we could be helping to develop capacity in sub- Saharan Africa. And that's why our Parliament now for the first time has approved -- has begun to fund a South African development agency for sub-Saharan Africa. So I think we're getting there.

The last thing is really the Abuja targets. I think there's good news across Africa. But again, if you look at, for example, the Abuja targets and the MDGs, those are vertical stuff coming on a very bare horizontal platform. And so you can't expect wonders to launch a -- otherwise, you're going to have to get the U.S. volunteers coming in to administer even some of those -- some of those drugs and some of the immunizations and the vaccines and all of those kind of things because you're landing vertical programs on a very horizontally bare infrastructure. And I think that that is why this other part of the debate, about the diagonal versus the matrix versus the holistic, is a very important one that I think we need, so that the two could happen together.

So the issue is that I think Africa is making demands, but it's not making the sexy ones. To the donors with the money to fight malaria here or the money to fight this there and the money to find that there, I think it's making demands to say we need the overhaul of our system. Send our doctors back. Help train our nurses. I think that that's the demand which is the unheard one. And that's what we believe is essentially wrong with the global or the international health system that we're -- that we're in currently.

So on the other hand, I want to say that -- having said all of the things that I've said, I'll end on this one. PEPFAR -- after we did the hard work in South Africa of overhauling our health system, PEPFAR has landed on absolutely fertile soil. We understood that we needed to use our resources to build a health platform that could administer what needed to be administered to fight disease in general and deal with NCDs and everything else (in part ?) as well.

The addition of those massive PEPFAR funds has brought us metaphorically to within a meter of the plateau. It's -- the plateau is the point at which HIV stops climbing, and goes straight, and then falls. This is not the right time for a society like the U.S. to be pulling the rug out on the basis where it says, now we want a new regime. Because if we are one meter short of the plateau, hanging on by our nails, and the rug is pulled out, the climb just becomes much steeper.

And to end (up on ?), I was invited to the Gallup Polls-Meridian breakfast a few months ago to assess the approval ratings for U.S. leadership in the world. They measured the last two years of President Bush and the first two years of President Obama. By and large, an average of 40 percent across the world; Africa, last two years of President Bush -- I couldn't believe it -- 68 percent approval rating; first two years of President Obama, 80 (percent) to 90 percent approval rating. And I was asked to explain this phenomenon, and I explained that it's because Africa has seen the impact of a goal. It has seen the impact of PEPFAR. And for less than 1 percent of the overall budget, it's only a foolish U.S. lawmaker who would mess with something that is -- that is really as good as that. What we need is to complement it with investments in health capacity, health systems and governance.

Thanks very much.

HUANG: Well, thank you, Ambassador. Well, we agree that -- probably that PEPFAR is the George W. -- President Bush's -- the -- probably most positive legacy on the international front. And the good news that might take is that the U.S. government has no indication of shifting its current -- the global health commitment, you know, to other issue, (you know ?). So (we ?) will probably stick to PEPFAR -- (inaudible) -- might be bad news for -- (inaudible).

The -- so, well, thank you, Ambassador. Now I become the only impediment between you and lunch. So we'll keep my concluding remarks short. And thank you, Ambassador, again for coming and delivering the remarks and also answering the questions and -- which give us very stimulating, inspiring discussion. And also thank you all for coming, and very much appreciate that. And so let's thank ambassador -- (applause).

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