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Brazil and Russia's Engagement in Global Health (Transcript)

Speakers: Katherine Bliss, Senior Fellow and Deputy Director, Global Health Policy Center, Center for Strategic and International Studies, and Judyth L. Twigg, Director, Eurasia Health Project, and Senior Associate, Russia and Eurasia Program, Center for Strategic and International Studies
Presider: Yanzhong Huang, Senior Fellow for Global Health, Council on Foreign Relations
January 10, 2012
Council on Foreign Relations

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YANZHONG HUANG: And welcome to the Council on Foreign Relations. It is a great pleasure to see old friends and many new faces.

I am Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. And this is the second meeting of the New Emerging Powers in Global Health Governance roundtable series. That actually build off of our first meeting on South Africa's role in global health governance that was held on November 4th in Washington with Ambassador Rasool.

It's been more than a decade since Goldman Sachs' Jim O'Neill coined this term "BRIC," which later become BRICS, including Brazil, Russia, India, China and South Africa. And as the economy of these states grows stronger than ever before, we would expect that they seek to have their impact felt and their voices heard in global governance. And as governments increasingly address health issues as an important foreign policy issue, we would also further anticipate these emerging powers to bring to the table a new set of increasingly influential players with their own values, worldviews, histories and strategic considerations.

And this, of course, raises a series of questions such as how deep are the engagement of these countries in global health governance, in which areas their engagement would make a difference, where the addition of these new players leads to a clash or convergence with existing major powers in the management of global health issues.

So today we are fortunate to have two leading experts who will discuss Brazil's -- Katherine -- and Russia's -- Judy -- engagement and outlook with regards to global health governance. You should have both of them -- their full bios in the included handout, but I want to just mention that Katherine -- Katherine Bliss is the director of the CSIS Project on Global Water Policy and a deputy director and senior fellow with the CSIS Global Health Policy Center. She's also a senior fellow with the CSIS Americas program. She was the international affairs fellow with the council when, I believe, she was a member of the State Department policy planning staff. And she is the author or co-editor of books, reviews and articles on global health, including the most recent report, entitled "Key Players in Global Health: How Brazil, Russia, India, China and South Africa are Influencing the Game."

And Judy Twigg is a professor at the -- well, actually, I probably -- I should have made that -- Douglas Wilder -- (chuckles) -- School of Government and Public Affairs at Virginia Commonwealth University, VCU. People have told me that if you don't remember this acronym, just remember this is a very cute university. (Laughter.) She's also a senior associate with the Russia and Eurasia program at the Center for Strategic and International Studies, where she directs the Eurasia Health Project. Her work focuses on issues of health, demographic change and health systems reform in Russia. And Judy is the faculty liaison for VCU's ongoing partnerships with Moscow State University and St. Petersburg State University in Russia.

So after both Katherine and Judy's remarks, we will open up the floor to questions and discussions. And also, just to let you know, this meeting is on the record, so you can feel free to use and quote today's discussion. And please remember to turn off your cellphones. My distinguished colleague Laurie has a policy that whoever found -- (chuckles) -- failing to turn off their cellphones will be fined for $50, which will go to a charity fund. I forgot which charity fund exactly. (Laughter.)

We'll begin with brief remarks from Katherine and -- about the Brazil's role, followed by remarks from Judy on Russia.

So Katherine.

KATHERINE BLISS: Thank you. Do I need to activate this or --

HUANG: I don't think so. Yeah, it's on.

BLISS: Yeah, OK.

Well, thank you very much. It's a pleasure to be here. And thank you for inviting me up to New York today.

I thought I would start out by providing a bit of an -- kind of an overview of the overall trajectory of Brazil's engagement on global health and then move into a bit of discussion of the philosophy behind Brazil's increasing engagement, where and on what issues Brazil has been most active, and take a bit of a look toward the future, you know, what is going to be the likely trajectory looking ahead.

So if you look back over the course of the 20th century, I mean, Brazil has actually been very much engaged on a variety of issues related to regional cooperation, research and regional support. If you look to the early 20th century, research on yellow fever in cooperation with the Rockefeller Foundation characterized some of Brazil's early work. Brazil was very much engaged in regional treaties and arrangements on port sanitation, quarantine and migrant health. It was an early member of the Pan American Sanitary Bureau, which became the Pan American Health Organization, joined the WHO in 1948. And one of the first WHO directors was Dr. M.G. Candau, from 1953 to 1973. So you know, very much in the -- in the setup of the international system on health, Brazil was a very active member.

In the 1950s Brazil set up a national commission for technical assistance. That was largely to coordinate support to Brazil from international partners on health and other issues. But by the 1960s Brazil had also begun to provide, in limited quantities, technical support to other developing country partners.

Now, more recently Brazil has become significantly more engaged in providing what it calls technical cooperation to other countries around the world. In 1987 Brazil set up the Brazilian Cooperation Agency, the ABC, to emphasize cooperation, not assistance. Brazil also emphasizes being a funder and not a donor of activities, and it emphasizes horizontal and not vertical relations when it comes to health.

Now, just to put, you know, some of this cooperation in perspective, the ABC reports having done about 150 health projects over the past -- over the past five to -- five to 10 years. I mean, most of them have been, you know, fairly recently. But you know, it's very hard to actually get numbers in terms of the amount of dollars that are being spent. In 2010 the ABC reported that about 16 percent of its budget went to health projects, which came out to about 5 million (dollars). In 2007 the Ministry of Health, which is also very much engaged in international work, reported about $27 million for international projects. Brazil has donated about $200,000 to the Global Fund for AIDS, TB and Malaria.

So the dollar amounts are not anywhere near what we might see, you know, coming from some of the more kind of traditional funders or traditional donors. But there's very much an emphasis on cooperation, horizontal relationships and on what Brazil likes to call south-south cooperation and support.

Now, why has Brazil expanded its work on global health in recent years? I think we can look to three, maybe four kind of major factors. One is the constitution of 1988. And Article 96 of that constitution states very clearly that health is a human right and that it's the duty of the state to provide it. Now, this article and this ideal was inspired in large part from the sanitarista movement in the 1960s and '70s, which was part of a larger pro-democracy movement against military dictatorship in Brazil and which engaged doctors and health workers and others in pro-democracy activities, but also in a(n) emphasis on the importance of health within the larger domestic scene.

After the passage of the constitution of 1988, this led to the creation of the universal health system, the SUS, in the 1990s, which led to the expansion of care -- public access to care in Brazil from about 20 million people ideally to the full population of 190 (million).

Now, Brazil's government sees this constitutional provision that health is a -- is a human right as having international implications as well. They see it as a duty of the state to share Brazil's experience on providing domestic -- access to domestic health care as a -- they see it as a responsibility of theirs to share that experience with other countries that are also partners on the development trajectory.

I think we can look at two other issues as well. One is that engagement on global health fits into a broader vision that Brazil has articulated about its engagement with the international system and the world. And for this, we can look to the articulation -- the vision of Brazil 2022, which, you know, in some ways states, you know, that Brazil kind of sees it important to challenge what have been, in many cases, the kind of traditional or longtime-held privileges that it sees of some of the countries of the "global north." And they want to create greater space and a greater voice for leadership of the southern countries and for their influence.

One other thing that I think we can look at is that Brazil also sees health as an engine of industrial development. Sometimes you see Brazilian officials talking about the health-industrial complex and, you know, the possibilities for pharmaceutical industry and other health-related industries as promoting economic development for Brazil domestically, but also internationally.

Now, where and on what issues has Brazil concentrated its efforts on global health? Well, first I think we can look regionally and bilaterally within Latin America and the Caribbean. Brazil has been very engaged in the last few years through UNASUR, which is the Union of South American Republics. And this -- UNASUR, I think, was started in 2008 as a broader project to promote political and economic integration throughout the region, basically bringing MERCOSUR and the CAN -- the Community of Andean Nations -- together, and economic and political integration, you know, looking toward a broader regional focus.

I think in 2009 UNASUR set up a health council and then more recently has set up the South American Institute for Governance on Health. That's based in Rio, and former Minister Jose Temporao, the former minister of health, is taking the lead on the ISAGS. And this has, you know, basically two points. One is to strengthen communication among ministries of health within the South American region, and also to strengthen health systems and national institutes of health in the area.

Now, a second group that Brazil has been very engaged with is the community of Portuguese-speaking nations and, through the Declaration of Estoril in 2009, articulated, with other countries, an emphasis on working on public health. This has been largely concentrated in Mozambique where Brazil has supported work on an antiretroviral pharmaceutical production plant that could be capable of serving the needs of southern Africa, but they've also worked very much on malaria in Sao Tome and Principe, in Angola, Guinea-Bissau, East Timor and other countries through the CPLP.

Now, principal themes on which Brazil has been engaged include HIV/AIDS, national institutes of health, schools for training of health technicians, kind of the affiliated professions, and also malaria. I mean, we can also look to disaster assistance and human milk banks as well as some of the areas where Brazil has been most engaged.

On HIV/AIDS, a lot of the international work builds on Brazil's own successful domestic AIDS program and the 1996 decision to make provision of antiretroviral therapies available to all Brazilians who were in need of those free of charge. This program was recognized by the Bill and Melinda Gates Foundation in 2003 and also hailed as a model by UNAIDS and other agencies. And so it has really resulted in Brazil's government and national AIDS program in particular being consulted by other countries and other international organizations for guidance and support.

In addition, just a couple of other points. Brazil has worked very hard to share its experience on developing the SUS and the -- and the challenges that have gone along with that over the past 20 or so years with South Africa, Peru and Ecuador in particular, and has also become much more engaged through the WHO and the BRICS countries, which I'll talk about now.

Now, in the WHO, you know, as I mentioned, Dr. Candau was the second director-general at the WHO from 1953 to 1973, and clearly, you know, exercised a great deal of influence over that 20-year period. More recently Dr. Paulo Buss, who was the former head of Fiocruz in Brazil and is now the head of the Center for Research and International Relations on Health (sic) within Fiocruz just completed a term as the vice chair on the executive board. So until the end of 2011 Brazil was in a -- in a very influential place in terms of the executive board itself.

In 2003 Brazil's leadership on the Framework Convention on Tobacco Control was widely recognized as playing a leading role, both as, you know, diplomats and speakers within the negotiations, in terms of getting that passed.

In 2009 the World Health Assembly saw considerable discussion and debate around the H1N1 outbreak and vaccine and, you know, the development of products related to that. And Brazil spoke for, you know, many in the -- in the group there in terms of trying to assure that developing countries would be prioritized in terms of access to any products made available.

Within the World Trade Organization, Brazil has also played a leading role in advocating for TRIPS flexibilities with respects to pharmaceutical products and emphasizes its philosophy of patents -- I mean patients, not patents, excuse me.

Within the G-20, Brazil has participated in the Development Working Group discussions, a number of years ago, for the Muskoka meeting, promoted language on NCDs, which did not -- which I guess did not -- did not make it into the declaration, but had, you know, seen the G-20 as a possible venue for that kind of discussion. It has more recently supported the discussion coming out of the November meeting on social protections and health.

And then, you know, finally, I guess I would just say with respect to the 2006-2007 discussions around health and foreign policy, Brazil was a key player in the development of that process and particularly the Oslo Ministerial Declaration, again about health in all policies, and joined with France, Norway, Senegal, Thailand, South Africa and Indonesia -- I think that's about the right group; I'm probably missing someone -- but in articulating the sense that health should be integrated into all foreign policy discussion.

And then finally, on the BRICS: You know, Brazil has joined with the BRICS in meetings before the major gatherings like the G-20 to coordinate positions and outlook and to try to articulate a strategic vision for what the BRICS want to see come out of some of those discussions. They also attended the July ministerial hosted in Beijing on health involving ministers of health and signed on to a declaration about coordinating among the BRICS to promote universal access to health care.

Despite this rhetoric, though, it's hard to know how much the BRICS are really going to become, you know, a formalized alliance capable of organizing this kind of cooperation and program activity. The BRICS have a lot of rhetoric in common, but I think, you know, there are a lot of differences as well on trade on commercial issues and others. So I think it'll be interesting to see how things develop. And I think in the short term, or at least in the medium term, it's going to be more likely that Brazil works bilaterally with some of the different BRICS, and also through the IBSA alliance with India and South Africa, to promote work on health kind of in a more common framework.

Looking ahead to the future, I would say that, you know, Brazil's vision internationally is a strong but changed international system with southern countries playing a more influential role. And so I think it sees its continued work on global health as part of -- and its work on strengthening health systems as part of process to strengthen and promote that vision of south-south and horizontal kinds of cooperation.

Having said that, you know, I think we're also seeing more trilateral cooperation come out as well. And this is something that, you know, can involve, you know, three countries. It can be, you know, a country from the north and two countries from the south or three countries from the south -- any number of different options. Brazil has worked with the United States in Mozambique. It's worked with Cuba in Haiti on disaster relief and, you know, I think, you know, increasingly sees trilateral cooperation as a way to pool resources, to, you know, build on already strong existing bilateral relationships to, you know, potentially, you know, strengthen the contributions to the development of health systems, aware nevertheless that there are significant challenges logistically and otherwise with the trilateral cooperation framework.

You know, in the longer term I think Brazil will need to deal with some domestic constraints, legal and just, you know, with the domestic health situation itself, as it seeks to increase its role in global health. Just, you know, looking at the ABC, you know, for the most part, those projects -- those health projects have had to rely on personnel from the Ministry of Health. They've had to rely on other kinds of experts, because the ABC itself doesn't, you know, like USAID, have a professional cadre of development professionals who are, you know, ready to go out and carry out development work. I think that's changing, and I think there are effort to develop educational programs and training for that, but for the moment that is a constraint.

You know, at the same time, there's not federal legislation in place like, you know, our Foreign Assistance Act or something, that allows for a widespread or kind of overarching funding for global health activities. And so many of them have had to be funded agency by agency or project by project, which can limit the sustainability, perhaps, in the long term.

And then, you know, more recently, the SUS itself, the universal health system, has been a bit in crisis. There have been a lot of complaints about lack of access, about quality of care. There have been a number of lawsuits in some of the different states around the SUS itself. And you know, as Brazil's middle class continues to grow, there may be, you know, increasing discontent or frustrations that may, you know, lead to a greater focus on domestic health issues.

But, you know, I would say, even with the recent economic issues, President Dilma Rousseff still enjoys very good popularity ratings and people seem to be very supportive of the trajectory, you know, at least in these -- in kind of a general sense.

So it'll be interesting to see how some of this plays out -- (inaudible). Thank you.

HUANG: Thank you, Katherine.

Judy.

JUDYTH TWIGG: Thank you, Yanzhong, very much for the invitation to be here.

The last time I spoke here at the Council on Foreign Relations was about 11 years ago, when I was working with the Carnegie Corporation of New York on a big project examining the future of Russia. And the major question that dominated that evening's discussions was, who cares about Russia? Why should we care about Russia? And the best answer anyone that evening could come up with was because Russia had lots of nuclear weapons. (Laughter.) So interesting to see how things can change over the course of a -- of a decade.

Russia has been dipping its toes in the water of global health leadership and international development assistance for health for about a decade. And this year, 2012, appears to be the year in which Russia is going to finally reconfigure and solidify its institutional domestic architecture for global health assistance, perhaps as a prelude to a more serious presence as a global health leader and as a partner on the landscape of international development assistance.

Prior to the Soviet collapse -- the Soviet Union obviously was an active contributor of foreign assistance, about $26 billion worth just in 1986 alone -- those efforts obviously ground to a halt, as the Soviet Union collapsed and during the turbulent 1990s, but they picked up again as Russia began to realize the benefits of its oil and natural gas wealth.

Russia's total international development assistance -- not just for health, but overall -- grew from about $50 million a year in 2002, 2003, to about $100 million in 2004, to about $500 million last year. And that's a little bit below the 2009 total. There was about $700 million in 2009, but those were advertised as one-time-only deals because of the global financial crisis. And in fact, the Russian government has said that it has a goal of holding steady at about $500 million a year in total international development assistance for the foreseeable future. Russia's level of development assistance has accelerated more rapidly than any other G-8 country over the last decade, but in absolute dollars, its contribution is still lower than that of any other G-8 country.

What are Russia's motivations for getting involved in development assistance in general and development assistance in health and for becoming a global health leader? Well, one prerequisite obviously is that now they have the money to spend on it, whereas they didn't eight or 10 years ago. And getting those resources has obviously led to a psychological component where Russia is very anxious, obviously, to reassert itself as a leader on the global -- on the global stage. So Russia doesn't want to be seen certainly as a recipient of aid anymore, and Russia doesn't even want to be seen as an emerging donor. Russia wants to be seen as a donor, period, on a par with any of the other advanced industrial societies.

When you look at the priorities that Russia has laid out for health assistance, certainly those priorities are in keeping with Russia's own domestic health challenges, which are considerable. They focused on infectious disease; tuberculosis; HIV/AIDS; more recently, polio, as we'll talk about in a few minutes; and also, over the last year or so, much more on noncommunicable disease and injury, which is really the bulk of what's plaguing the Russian health landscape at home.

Russia's also perceived by what it sees as health threats from migrant populations from neighboring countries. There's an enormous amount in the Russian press about the threat of tuberculosis and HIV/AIDS from Central Asian migrants, bringing those pathogens into the country, although I should note as a footnote that, in fact, when you go out and do the empirical research, it appears to be the case that the flow of infection is exactly in the opposite direction that migrants actually come into Russia disease-free, they contract tuberculosis and HIV when they're working and -- in Russia, and then they take it back home with them when they go home.

This perceived threat from migrant communities is -- was certainly exacerbated by the outbreak of polio in Tajikistan in the spring of 2010 where there were a couple hundred cases of polio that then migrated their way into southern Russia and that's what led to a U.S.-Russian agreement on collaboration for a global eradication of polio at the beginning of last year.

In terms of mechanisms and priorities for health assistance, for exercising global leadership in health, the focus until now in Russia has been -- almost exclusively been on providing financing to multilateral institutions. There have been very few bilateral projects, very few project-type arrangements, and virtually all of that limited number of bilateral assistance projects have been in emergency relief or disaster assistance.

So, really, the key catalyst or the key turning point so far in Russia's global health leadership has been Russia's presidency of the G-8 in 2006. There Russia put health as a priority on the G-8 agenda for the first time -- the other two Russian priorities there were education and energy security -- and that G-8 presidency was a real moment of emergence as a leader for Russia on the international stage in general, and certainly Russia used the fight against infectious disease and the globalization of that fight against infectious disease as one element of this leadership strategy. And this was good timing, right? You know, avian flu was a very clear and present danger at the time. SARS was still fresh in everyone's memories, and so this was not a difficult strategy to put forward.

So, during that G-8 presidency in 2006, there was lots of focus on building global surveillance networks, also a focus on collaborative scientific research and development, which was one of the areas where Russia felt as though it could actually make a significant contribution.

Since then, Russia has hosted a flurry of international meetings on infectious disease and on noncommunicable disease and injury, and I won't go through a laundry list of them. Probably the most significant one was in April of 2011, where Moscow hosted the U.N. high-level meeting on noncommunicable diseases where Prime Minister Putin and Margaret Chan shared the stage together for some very important remarks.

And there are opportunities coming up in the next couple of years for something of a repeat performance of that 2006 G-8 presidency. Russia will host the G-20 in 2013, although as Katherine said earlier, it doesn't seem as though health and noncommunicable disease is what some have tried to get onto the G-20 agenda -- it doesn't seem as though the G-20 at least at the time -- for the time being is too enthusiastic about putting those issues on the agenda except for maybe a mention of NCDs as important for global labor force development.

So probably most importantly will be Russia's next turn at hosting the G-8 in 2014 and possibly Russia's hosting of the BRICS (ph) meeting in 2014, although again, I'd echo Katherine's point that, so far, those BRICS (ph) meetings in general and certainly the discussions of health at the BRICS (ph) meetings have been a fair amount of talk, but nothing really concrete emerging from those.

In terms of the domestic institutional architecture for health assistance, there's a patchwork of Russian government agencies that have responsibility for development assistance in general and for health assistance in particular. The Ministries of Foreign Affairs and Finance have been butting heads for the lead role. The Ministry of Emergency Situations has been very important because, as I said earlier, disaster assistance, emergency relief has been a very important part of Russia's efforts here and, to a somewhat lesser extent, the Ministry of Health have been active. There's been no significant -- some, but not significant activity from a laundry list of other ministries inside Russia.

And the strategy governing development assistance and health leadership from Russia for the last several years has been a concept paper that was signed by Prime Minister Putin in the summer of 2007 and that was really a concept note rather than a strategy. Frankly, it was prepared for a presentation at that 2006 G-8 meeting, more than anything else. It prioritizes poverty reduction, achieving of the Millennium Development Goals, the importance of coordinating Russian aid with other bilateral and multilateral donors. It again prioritizes health, education, energy security as the three sector areas of note.

Most importantly here, though, I think, are two things about this concept. One is that there was no action plan set out to implement this concept. So it has been an ideas document, but there's been nothing to really move it forward in the five years since it was developed.

And that having been said, I -- it's kind of unusual to hear someone say this when talking about Russia -- but this is one area where Russia actually seems to be doing things fairly carefully and right. Russia recognized, in that concept paper, and has recognized fairly explicitly since then, that it does not have the institutional capacity; it doesn't have the human resource capacity to just jump in to international development assistance and start doing a whole bunch of USAID-type projects.

And so Russia has been very carefully looking for help from all the right places. They've partnered with the World Bank in a bunch of projects, including some World Bank trust fund trilateral arrangements, just like Brazil, to learn how to finance international health projects. They've gone to the United Nations Development Program, to UNDP, to figure out how to conceptualize international development projects. And they've gone to USAID to figure out, among other things, how to build a human resource capacity to do these kinds of projects.

So they've been working with all three of these agencies on building capacity of a variety of different types for overseas development assistance for the last three or four years. And it's impressive that they recognize that there's a lot they don't know, and they've recognized all the right places to go to build the capacity to be able to do it.

That having been said, there's still no legal basis for a development assistance budget mechanism in Russia. Russia's the only G-8 country without an official budget category for foreign aid or an agency for foreign aid. Now, for a couple of years everybody's been talking about the development of a Russian equivalent of USAID, and that has met with all kinds of bureaucratic opposition for a variety of reasons. One is that a new agency would actually devote too much of its budget to its own support rather than actually implementing programs.

One is that the relevant expertise is actually located in the functional ministries rather than in some separate agency, so the argument there, for example, is that the health ministry can do health assistance much better than some Russian aid agency could do it; and doubts that a new agency would have the kind of bureaucratic clout that it would take to herd all of the cats, to herd all of these other ministries that have had partial responsibility for this whole enterprise over the last couple of years.

That fight appears to be close to over, though. At the end of August 2011, the Russian government a announced that RUSAID, the Russian aid agency, would launch at the beginning of 2012, and so even as we speak that agency is being launched with a staff of about 50 specialists.

So Russia's very much in a period of conceptual and institutional transition. It's still a recipient of foreign aid. USAID -- (the bank ?) still have offices in Russia, and yet Russia is clearly moving toward a restoration of its Soviet-era position as a major and reliable leader and donor on international health. And they're very deliberately building the institutional framework to realize this -- this vision.

I just got my three-minute warning, so I'm going to scan through here pretty quickly.

Overall public knowledge of international assistance in Russia is pretty limited. The World Bank did a survey in the middle of 2011 of about 1,500 Russian citizens across the country and found that there really is not much public interest in or support for foreign aid, foreign health assistance coming out of Russia. Russians are much more focused on developments in their own country than they are on helping others. They say that if we did try to do this, it would just be unstable and corrupt. They say that Russia's not rich enough to be taking are of others, that we should be taking care of our own priorities here at home. And perhaps most crucially, most Russian citizens seem to think that aid to other nations wouldn't necessarily result in those nations becoming more friendly toward Russia and Russia's foreign policy and security interests.

So one of the most interesting things about this survey was that the results were pretty stable across income categories, across age categories, across class -- social class categories, which means that if we think about the kinds of political turbulence that are taking place in Russia right now, and if we think about a new, you know, younger, relatively affluent and sort of middle-class, more progressive generation of opinion leaders beginning to shape Russia's decision-making landscape, it's not at all clear that those folks are more amenable to the idea of Russia stepping on the stage than the current leadership is.

So the bottom line here is that what can Russia offer as a health leader? What can Russia offer as a donor of international development assistance either through multilateral or bilateral channels? Well, at $500 million a year, you know, it's more than Brazil, but that's still a fairly modest sum compared to what the big donors are giving. And so just with the money, there's not much potential to make a substantial difference on a global scale. In fact, most Russians would argue that there's a risk of (some dilution ?) of Russia's contributions if they continue going the way they're going.

Russia's health technologies are either outdated or they're not particularly applicable in spheres outside the former Soviet Union. Russia's human resources are constrained. Russian physicians, as a rule, speak little or no English. They themselves lack medical education that is up to international standards, in most cases. There's no dedicated training program for Russian specialists who want to go become aid workers, and so it's difficult to find the cadres of specialists. Frankly, those 50 people who are supposed to staff this new agency, I don't know where they're coming from, because there really aren't 50 people who know how to do this in Russia.

Russia's own track record on health, as Laurie (sp) has taught us, is hardly worth emulating. You know, Russia right now, for example, has life expectancy that's five years below that of Tajikistan. And so not much to -- not much to model there.

So what are the realistic approaches that Russia might pursue here? Well, Russia does have strategic interests in, obviously, its neighbor countries. There are health challenges, particularly in Central Asia, that do have quick, readily observable potential results that could be achieved with a relatively limited budget. The Central Asian countries have health and demographic profiles that in many cases are quite similar to Russia's. There's potential for mutual benefit in tackling some of their common epidemiological challenges that threaten to trickle into Russia -- TB, HIV, malaria, water-borne diseases.

The entire region retains the shared legacy of the Soviet system, shared legacy of pharmaceutical preferences. Health workers in Central Asia retain a respectful attitude towards Russian physicians. In fact, many of them are still trained in Russian medical schools, or were trained in Soviet medical schools. They all still speak Russian.

And perhaps most importantly, there are some fairly easily defined public health challenges in Central Asia that could have a relatively quick fix and a relatively non-costly fix. In other words, if you're trying to build capacity in Russia, if you're trying to build public support within Russia for this enterprise, go into Central Asia and spend a relatively small amount of money on iodine deficiency, water-borne diseases, nosocomial outbreaks of HIV. You know, some fairly low-cost direct projects that could result in immediate payoff.

And so I and most of the colleagues with whom I speak in Russia who think about this think that the best bet as Russia emerges into this new, possibly bilateral oriented era of global health assistance is that Central Asia is the best bet, and that's what we're likely to see in the near future.

HUANG: Thank you, Judy. I found, actually, the remarks of both very informative and inspiring.

I was reading just a couple of days ago an opinion piece by Fareed Zakaria on the emerging powers. He seems to be very pessimistic, saying, to quote: If 2011 demonstrated anything, it was the inability of these countries -- meaning BRICs -- to have much influence beyond their borders. They continue to grow their economies but they all face internal and external challenges that make them less interested and less capable of exercising power on an international or even regional scale.

So it seems that their engagement in global health governance is actually inelastic through the internal and external challenges they face. So that gives us hope that they will continue to be active in engaging global health governance despite, well, in the case of Russia, the 2012 presidential election and then the rise of the new political -- (inaudible), and in the case of Brazil, the contracting economy; I just read that the economy for the fourth quarter last year contracted by 0.7 percent, and also the crisis of SARS. So that is encouraging.

But I just have some -- actually two quick questions, one to Katherine and one to Judy. Katherine, could you elaborate a little bit the role of civil society or the private sector for Brazil engaging global health?

And for Judy, you mentioned that Russia has few bilateral projects in its involvement in global health. Could you explain to us why is that the case? Yes, go ahead.

BLISS: Sure. So on -- yeah, on the role of civil society, I mean, I think, you know, you can look back to the Santa Theresas?? in the late '60s and '70s as, you know, a very strong mobilization of physicians and health workers and others who, you know, were engaged in a much broader societal process of promoting democracy and -- and to the military dictatorship. I think, you know, that group played a strong rule on influencing the outcome of -- and particularly Article 196 of the constitution of 1988.

You know, since then I think, you know, we've seen, particularly around HIV/AIDS even, you know, and in the SUS, support for civil society participation. You know, the World Bank loans that Brazil received in the 1990s around HIV/AIDS supported some work around civil society participation.

Government funding also supported the work of NGOs, and has increasingly supported the role of NGOs in providing care and support. In many cases, with the SUS itself, one of the interesting things, you know, about some of the, you know, kind of unhappiness currently around the SUS is that there are explicitly set up, you know, kind of civil society -- they're not tribunals, but they're organizations at the local and provincial level that allow for discussion and, you know, promotion of recommendations and conclusions.

And so I think, you know, there has been a significant participation by civil society. But, you know, by the same token, you know, the extent to which the general population is aware of Brazil's international work and whether they support that or not is hard to -- hard to assess.

TWIGG: In 25 words or less, the reason that Russia has focused on multilateral efforts is that it's a whole lot easier to just write a check, and therefore trumpet your participation in global health efforts that way, than it is to build the capacity to do bilateral projects, which, you know, obviously takes quite a long time.

So that's why I think that with the creation of this new Russian aid agency we're likely to see the development of some bilateral projects over the next -- over the next few years. And so Russia has, as I indicated earlier, really stepped onto the stage through contributing to the Global Fund, to a variety of U.N., WHO initiatives. It's been through the provision of funds that it's been able to, you know, flex its muscles in an introductory way as a global health leader.

If I could also address your -- the question you posed to Katherine about the private sector and civil society, because they're important in terms, I think, of the human resource questions that I raised earlier, over the last few years, the private sector in Russia, as it operates in other countries, particularly in Central Asia and the Caucasus, has become very aware that there's a social responsibility sort of expectation. And so increasingly, as they do business in these countries, and especially in Central Asia, they have started some health-related assistance projects.

But they've done that very much separate from government, and there's virtually no communication between the two about what's going on. And I think this is fundamentally because the private sector doesn't trust government here. There's an idea that the government will just try to hijack whatever the private business is doing, and that basically becomes another tax, where the government tries to take those efforts and use them to further foreign policy and security goals for the government.

Now, obviously, there's plenty of distrust between the government and NGOs within Russia, but it is the case that all of these international agencies that have been in Russia over the last 10 years -- you know, the Global Fund, the World Bank, USAID -- I mean, those are the international institutions that have trained the human resource capacity in Russia right now that knows how to do health and knows how to do global health. Those are the incredibly talented people -- and it's not a huge cadre of them, but it's, you know, some very substantial and talented young people there who could very much be the backbone of Russia's global health leadership going into the future.

But what's happening right now is that that landscape of international organizations is pulling back from Russia. You know, DFID's gone; the World Bank and USAID are trying to figure out how to reconceptualize their approach toward Russia. And so most of those people who have been so well trained and become so knowledgeable and so skilled are moving into the private sector now. They're moving into the pharmaceutical companies, into the medical equipment companies. And so there's a danger over the next, I think, year or two that we're going to lose all those folks to the private sector, and so if the Russian government really ramps up something useful in the -- in the bilateral assistance area, it's not going to have those folks to call on.

HUANG: That is very interesting, because I presumed that -- because I didn't ask you the question because I presumed that the role of the civil society or the private sector is negligent (sic). But that is very interesting information.

So we're going to open the floor up to questions. Please identify yourself and your affiliation before responding. Please also -- I already saw some flipping -- (inaudible) -- card to indicate that you have a question. And we also allow (one finger rule ?), and if you have any quick follow-up remarks, please do so.

So we're going to start with Laurie (sp).

QUESTIONER: I think I'm the Helen Thomas of the Global Health program. (Laughter.)

Thank you so much, both of you, for joining us. We're really blessed to have your intelligence and insight here at the council to help us on this subject.

And I wanted to ask you both, with slight nuance differences, the same question. No country is engaged in any kind of overseas development in health program without some self-interest involved. We have ours, France has theirs, et cetera. In -- it's interesting that for Brazil the two key self-interest issues would be the UNASUR versus PAHO, boulevardista (ph) versus everybody else; and Brazil kind of having this super -- supra position, straddling the divisions, in a way, within Latin America. And in the case of Russia, it's the rest of the Russian-speaking world, and trying to continue to say: You know, since Ivan the Terrible, we've been numero uno, and that ain't gonna change.

But in terms of global health, I think if you were to look at the two and their brand at this moment, how the rest of the world sees them, in the case of Brazil, it would be, you know, extraordinary domestic achievements, especially around HIV, that bear being replicated around the world, a very positive role in assisting in that kind of replication; but primary -- primary role on the global stage has been around patents, World Trade Organization issues, and in some case obstructive. So there -- that's sort of the Brazil rap at the moment.

And I think the Russia rap would be Russia has yet to make its transition domestically from being Soviet in its own health outlook, and therefore it's -- it contradicts every single recommendation made on the global stage about how to handle TB, how to handle HIV, where to set your priorities for nosocomial transmission and antibiotic resistance. And the last thing the world wants is for Russia to export how it deals with drug addiction, how it deals with alcoholism, how it deals with the risks of those for TB and HIV. So, sort of the global-brand view of Russia would be: Stay away. (Laughter.) Don't come in this space.

So I wonder how both of you would respond.

HUANG: Katherine?

BLISS: Yeah, so on, you know, the Brazil question, I mean, I think their, you know, view of -- you know, and desire to strengthen the place of the (global south ?) within the international arena, you know, is -- you know, kind of creates a consistency across the different issues that you've mentioned. I mean, you know, UNASUR as a, you know, regional association that doesn't include the United States and Canada, you know, has the potential for, you know, creating a -- you know, I mean, -- you know what they say -- I mean, they talk, you know, to some extent, about creating a regional epidemiological shield, you know, they talk just kind of on a health security side. But also, you know, an association among those countries -- you know, an alignment of interests around health and other, you know, aspects of political and economic integration.

You know, on the WTO and TRIPS issues, you know, I think this -- you know, their emphasis on this idea of health in all policies, and in particular the, you know, economic issues, should not somehow trump health issues, has, you know, been played fairly consistently, you know, within their own domestic deliberations, you know, around FCTC and the pressures on the part of the domestic tobacco industry to kind of back away from support for that, you know; and then, you know, has led to their, you know, really pushing in the Losartan case around the hypertension medication, and the generic from India that was caught up in, you know, discussion in Rotterdam.

So I think, you know, again, that position still fits into this broader vision of kind of a resurgent or a strengthened southern voice and southern participation in international arenas. So I see it as fairly consistent. But, you know, certainly, those are kind of some of the hot issues that they have been very much associated with.

HUANG: Judy?

TWIGG: Yeah. (Laughs, laughter.) And I -- and I see the global community, you know, kind of saying it's OK if you just keep writing those checks, but -- you know, and this points to the bigger picture, I think, right? You know, you've got, you know, the international institutions, like the Global Fund, which are having some serious financial troubles. You've got the major donors -- or traditional donors, which, you know, are in a period of fiscal austerity that doesn't look like it's going to end any time soon.

And so, you've got these potential new donors -- China, obviously, first and foremost among them, but Russia and Brazil I think as important, also. And I think everyone's looking at, you know, the BRICs, the emerging new donors, and saying: Oh, it's all right if you all want to contribute a whole lot of money to make up for the shortfalls from the traditional sources; but good God, what are we going to do if you all start insisting that you have ideas about, you know, how to shape the overall architecture, how to actually do things? Because with the exception of Brazil, I think it doesn't look like there's much, in terms of models to follow, worth following coming out of the domestic landscapes of any of these players.

But that having been said, let me just throw one idea out, out on the table. And that is looking for those really smart, capable exceptions to the rule in the Russian system. A lot of what I know about the Russian system I learned from you, but you know, the Soviet system mitigated against innovation. It militated against creativity. It mitigated against the use of technology that was available to the rest of the industrialized world. And that meant that there were a whole lot not just of Russian doctors but Russian practitioners in any field who, if they wanted to accomplish anything that was reasonably efficient or sophisticated, had to get really good at being like MacGyver in that old TV show where they did amazing things with paper clips and rubber bands. You know, they were forced to take low-tech approaches and turn them into solutions that worked at the end of the day.

And in an era in this country where we're looking for cost-effective solutions to problems, maybe there's something within that approach by those really creative people, you know, still working under the incentive structure of that old Russian system where we might be able to find something useful from those approaches.

HUANG: Thank you, Judy.

OK, Dan.

QUESTIONER: Next, a question on Brazil. Brazil --

MS. : Identify yourself -- (inaudible).

QUESTIONER: I will, yeah. Dan Altman with Dalberg.

Brazil has to make choices, like every other country, in universal health for its own people or when it does global health initiatives, doesn't have unlimited resources, even thought it's getting wealthier.

In terms of the things that Brazil thinks are most important for basic services, what are they? What is the motivation for those choices? And how have the choices that Brazil has made for its domestic services been reflected in its global health initiatives?

HUANG: Yes, Katherine, that's your question.

BLISS: OK. I mean, I think, you know, Brazil's HIV/AIDS program has been, you know, the cornerstone of its international work. And you know, Brazil made the decision, you know, after -- you know, essentially after the Vancouver international AIDS conference, where, you know, a lot of the information about the efficiency of antiretroviral drugs, you know, was made available -- I mean, it was that year, you know, essentially they said, OK, you know, we know we're looking at a projected HIV case burden of -- I don't remember the numbers now, but a significant -- a significant burden over the next, you know, 10 to 20 years. And you know, they saw the provision of antiretroviral therapies domestically as a key way to address that.

And that was, you know, contrary to some of the advice and, you know, information that was, you know, provided by the bank and others, you know, around prevention and some of the other kinds -- some of the other kinds of -- I mean, it wasn't -- it wasn't contrary, but a lot of people said, you know, you're not going to be able to afford this or you're not going to be able to pay for this.

You know, I think in part -- I mean, this goes back to, you know, the answer that I just gave around civil society -- there was, you know, a lot of pressure within Brazilian civil society, you know, support for that initiative and, I think, you know, also an awareness that there were, you know, NGOs within the country, you know, kind of beyond the health system and some -- beyond the formal public system itself, that were also capable of being incorporated into that model of providing that treatment.

So I think, you know, Brazil's experience in trying to -- domestic experience in providing those medications and the challenges that it faced have, you know, inspired it to share that with -- you know, with other countries.

I mean, right now, I mean, the work -- the current work in Mozambique -- I'm not sure of the dollar amounts. And for some reason $8 million is sticking in my mind, but 16 (million dollars) as well, so I'm not sure. I don't want to tell you, you know, how much that is. But that's based, you know, largely on support for, you know, the construction of a pharmaceutical plant in Mozambique, but again, to allow that country, you know, or that government and, you know, fulfill, you know, market demand in other parts of Southern Africa, again, to make these kinds of treatments available.

QUESTIONER: Could I ask you just to go beyond HIV because it affects a small part of the Brazilian population? You know, there are so many other choices to make. Do you focus on maternal mortality? Do you focus on tobacco prevention? Are there are any priorities that Brazil has set domestically that are being reflected in its international work, besides HIV? Because, as I said, it's kind of a small --

BLISS: Oh, sure. I'm -- yeah, I mean, you know, just universal access to care in general, whether that's, you know, access to primary care facilities -- you know, I think -- I think primary care facilities is probably, you know, where you could start. But you know, Brazil has been consulted, you know, very much by South Africa as they've been, you know, looking to expand their health system coverage; also by Peru and Ecuador, in a sense.

I mean -- but you know, I think Brazil, in addition to, you know, sharing some of the lessons it's learned in -- you know, in trying to reach all corners of its population and -- it's faced significant challenges around that as well and, you know, in particular as you get up into higher levels of care, you know, that's not available to some of the more remote populations and some of the more vulnerable populations.

And so, you know, when you talk to public health officials, you know, they say that they, you know, try to be very open in terms of the challenges that they face in reaching, you know, that extensive population, but they are very proud of the fact that, you know, they say that they reach 199 million people, you know, with at least some form of access through -- (inaudible). So --

HUANG: Just for information, yesterday we had actually a round table devoted to universal health coverage in Washington that William Hsiao of Harvard and David de Ferranti of Brookings talked about this issue, universal health coverage, and actually used Brazil as one of the examples, you know, that you have extended health coverage, but it's very hard to say it's really a successful case.

So, Henry?

QUESTIONER: I have another question for Brazil that relates, I think, to Dan's. The Brazil Ministry of Health just came out with a(n) actually superb plan for NCDs. And they outlined a plan, and they -- and they announced in this that the -- that noncommunicable diseases -- particularly heart disease, diabetes -- is the number-one problem in Brazil and around the world.

And I'm wondering when they would translate this plan, which is yet to be fully implemented in Brazil but is certainly, in a sense, ready to be taken abroad. And it could be, you know, a stunning contribution, and it would tie directly into what their priorities seemingly are going to be in the 21st century. And I'm wondering if there -- is there any move in Brazil to look at that as concepts to be exported?

BLISS: I mean, I think, you know, you can look at it -- you know, a couple of different events that have just passed and, you know, that are on the horizon. You know, certainly, you know, as I mentioned, I mean, in the run-up to the Canada-hosted G-20 a couple of years ago, Brazilian officials did try to get NCDs on the international agenda, you know, both in terms of their, you know, economic impact and their challenge, you know, financially but also as a -- as a social issue. They were not successful in that -- in that area.

You know, if you look back a little further, I mean, there's support for the Framework Convention on Tobacco Control. It certainly fits into that as well. I mean, that goes back to 2003. But you know, I think this is something that they've been engaged with -- you know, recognizing the domestic issues -- for a while.

You know, in terms of, you know, how they might work to mobilize that strategy, you know, one way, you know, could be through the UNASUR and the ISAGS, the regional institute for governance on health and their work through -- you know, in support of setting up national institutes of health to strengthen regional disease surveillance and communication on those issues. You know, I would expect them to be supportive within the regional health assemblies and the World Health Assembly on resolutions, you know, as --

QUESTIONER: Well, given that none of the major funders touch this, I mean, it is an -- it is an opportunity for huge leadership for a country that wants to step out front and have -- and really do something. And the plan that they have outlined is really, you know, phenomenally clear and detailed and, you know, data-driven. It just seems like a wonderful opportunity for them to use that.

BLISS: Yeah. And they have been, you know, in recent years -- I mean, in -- not just on tobacco but also on alcohol and other issues -- I mean, they've been very willing to confront domestic industries and, you know, just say, you know, this is not -- you know, we're not going to subject, you know, our public health policies to trade imperatives.

So yeah, I'd be interested to see more --

HUANG: (We have ?) --

QUESTIONER: One finger? One finger?

HUANG: OK. (Chuckles.)

QUESTIONER: Real quick, is there any thought in Brazil about -- since they probably have the highest rate of universal access to HIV treatment of any developing country -- probably any country, period, on the planet -- now that we're in this huge debate, does treatment equal prevention?

Is Brazil prepared to talk about what's happened with the incidence of new infection with prolonged access to treatment and whether or not, as a public health model, it actually is achieving that goal of, with adequate treatment, having prevention of new infection?

BLISS: I honestly don't know the answer to that. I would imagine that the -- you know, as they're compiling the data, they would, you know, be willing to share that. But I honestly don't have an answer for that right now. So --

HUANG: Monica (sp), you have any quick --

QUESTIONER: Yeah, just to -- (off-mic exchange) -- just to complement what Katherine was saying in terms -- and what you were asking in terms of the priorities, we've -- and what you said at the beginning that in Brazil -- and I'm talking about Brazil, that it's basically enshrined in the constitution the whole -- the whole issue about health as a human right. And equity is certainly, you know, if I start from broad, an overriding theme. And when you translate that -- this is in these terms of access, access to medicine, access to service -- and that has been a theme that Brazil has certainly been a champion. And I represent the Pan American Health Organization, and we certainly have welcome to have a country like Brazil championing a lot of the issues in terms of access to medicines and the whole issue of vaccines, of technologies.

And this is some -- this is a theme that they continue to push. Certainly their SUS has problems, but if you -- if you think of putting in practice a program of that caliber in -- I mean, in that country -- (chuckles) -- I mean, I don't think any country would not have problems. But -- and they're also trying to push all of their -- I mean, their programs because in a way, it's a little bit of a protection because the SUS is constantly being attacked from within, from within their own country. And so it's -- that's one of the reasons, too, that they like to share the -- this experience, and they're constantly to -- in that quest.

But also I would say that in terms of the NCDs, what you were saying in terms of what to export -- and again, they're trying to tie all these issues of access, and they're trying to, for example, have a lot of programs in terms of primary health care and with NCDs. And so you see a country that is bringing all these issues, health -- (inaudible) -- they have -- they had the meeting of determinants. They have now the Rio plus 20. So they all are trying these things, and they -- and we -- I mean, the other countries are -- of course are looking for the leadership of Brazil, but Brazil is also, you know, engaging the other countries in -- you know, in having -- in sort of a concert of integration in -- as a way of advancing the issues in the region. So I just wanted to add that.

HUANG: Thank you, Monica (sp).

Richard.

QUESTIONER: Thank you. Richard Huber, and in this context, I'm a retired chairman of Aetna. And directed at you, Katherine, when we had a large -- the largest health insurer in Brazil. And we found that the technology, particularly as far as electronic health care, was by far the most advanced of any place where we operated. We operated health care insurance businesses in a dozen or so countries, and the 100 percent electronic system in Brazil was by far the most advanced -- including the U.S., I might add -- of any place where we operated.

And we used that technology, and we tried to export it to other countries with some success -- obviously none in the U.S., where we still do everything with paper and pens and quills. (Laughter.) But have you seen that -- I saw it very much from the -- from the very narrow point of view of a -- you know, a dirty capitalist pig trying to make a buck. (Laughter.) And we did use it quite extensively. Have you seen that used as a model or exported in more the public sector?

BLISS: Not specifically. But you know, certainly in their broader effort to, you know, promote -- to strengthen health systems through these institutes, through the, you know, schools for health technicians and other allied professions, you know, I would -- I would see that, you know, knowledge management and information management as being a key part of that.

You know, again, you know, I think it's important to, you know, extract lessons from the public sector and the private sector in Brazil. I mean, the public sector covers only about 80 percent, and then, you know, many of those who can afford, you know, more, the 20 percent, will, you know, go ahead and pay for that additional amount. And so you know, I would expect that lessons from both of those experiences would be informative in strengthening, you know, this work with other countries. But I can't say that I've seen specifically about the digital recordkeeping, but it makes sense that lessons from that would inform some of the efforts internationally.

QUESTIONER: Thanks.

HUANG: James, you have -- you should have a question on Russia, right? (Laughter.)

QUESTIONER: Thank you. And thank you to the council for its hospitality and the invitation. I'm James Tunkey with a company called I-OnAsia. And I've been observing -- I think it's really quite a nice comment, Judy, that you opened with about where we were a decade ago -- that most of the donors that have been focused on lab safety and lab security seem to be declaring mission accomplished and moving on to other countries, expanding scope. But I'm just curious what your take is from Russia. It seems as -- you know, lab safety is incredibly important. There's been, you know, quite a lot of work to try to build up lab safety and lab security. And what was -- what's Russia's take from that whole exercise? Did they come out of it with their national pride? Did they come out of it with expertise? Is that something that can be used?

And I guess as a -- as a follow-up, perhaps to Katherine, and it's a bit of a reach, but this whole idea of accepting foreign aid to try to achieve some local initiative seems to be something that Brazil has rejected. It seems as if Brazil really is quite reluctant to take any kind of foreign aid except as it comes through the International Red Cross. And so my question is just, there seems to be a lot, especially if you look at the context of health and its relationship with water security and the poor quality of water and water access in Brazil, that there's a lot that could be done if there was more engagement in sort of nondirect health matters. And I'm just wondering if you have any thoughts or comments on, you know, what the likelihood, you know, given the contentious sort of trade relationships that Laurie highlighted earlier, whether there's any other areas of engagement within Brazil that, you know, might be sought after. Thank you so much.

TWIGG: Well, I'm certainly not an expert on lab safety and lab security, so I won't venture into that specific area. I can tell you that in general, in terms of technical expertise that's been transferred, and in particular in terms of technical expertise that involves the use of equipment that's been transferred, there's a whole lot of equipment that's been donated that's still sitting in stairwells and on shelves because no one's been trained in how to use it properly, or if they have been trained in how to use it, they haven't also been given the consumables that they need to keep it going over time. I know there are some European medical device manufacturers who are pulling out of the Russian market for reputational reasons because they export their products, staff aren't trained to use them properly, accidents happen, bad outcomes happen as a consequence of that, and they don't want their own business reputations to suffer as a result of people being badly trained to use equipment that should have been functioning quite fine, thank you.

The whole issue of pride and security and the politics of that are very complicated, obviously. Russia, as I said, you know, doesn't want to be seen as a recipient country anymore, and yet beneath that veneer, they realize that even though they've got lots of money now, they still have a lot to learn about how to spend that money effectively. And I mean that in the biggest, broadest sense: how to spend that money effectively in virtually every way that you can conceive of that -- of that term.

The highest-level decision-makers and leaders in Moscow would never in a million years admit that. But there are lots of people at the regional level, there are lots of people working in the lower levels of government, even in Moscow, who not only understand that they have a lot to learn, but they genuinely want to do their jobs well. And so they are much more receptive than the people at the top hierarchy would be toward receiving some kind of assistance even though now we are politically compelled to frame that in terms of -- in terms of partnership.

And so there's a certain amount of finesse that needs to go into this, and I'll -- can I have 30 seconds off the record to tell a story?

HUANG: Yeah, sure.

(Note: Off-the-record portion not transcribed.)

HUANG: They have that tradition of making -- (chuckles) -- this kind of thing.

TWIGG: Absolutely.

HUANG: Katherine.

BLISS: So, you know, one thing I probably should have mentioned is that Brazil is one of the few, if not the only, place where, you know, there is a USAID mission that still does some work on health and a country where the U.S. cooperates externally with Brazil on health. There's also a CDC presence, you know, in Brazil. So the U.S. is not out of Brazil on health, but, you know, I think that, you know, because of the work that, you know, Brazil has been doing internationally, I mean, that presence has been significantly reduced, for a number of good reasons.

But I think that's -- you know, this is why in some ways the potential for trilateral cooperation is very important, because as I said earlier, you know, Brazil works with a host of different trilateral partners -- you know, Canada, Japan, France, Cuba and others -- working in third countries but has also worked with the United States in El Salvador, in Mozambique, in Sao Tome and Principe, among others. And, you know, I think those have been important even if they haven't always been, you know, the most fruitful experiences, because they've allowed both countries to build on their shared experience of having worked together bilaterally, you know, for such a long time, and, you know, that shared history.

You know, I think based on what I understand from the experience in El Salvador, there was, you know, some difficulty just on the part of agreement within the different U.S. agencies working on health that ultimately led to kind of some delays in trying to work on a national institute of health in Brazil, and in Mozambique, you know, again with some bureaucratic funding issues, you know, kind of delayed some of the work from the U.S. side, which was, I think, to partner. You know, so if Brazil is supporting the ARV plans in Mozambique, the U.S. through CDC has been supporting behavior -- you know, education and behavior change around HIV. So, you know, seeking to do complementary work that builds on, you know, the strength of programs, you know, existing strength of programs.

So I think, you know, the trilateral cooperation -- while it presents a lot of challenges, you know, that I don't want to go into, necessarily, around, you know, work permits and visas and all that kind of thing -- you know, also has some potential.

On the water issue, you know, I think it's a good area for potential cooperation between the U.S. and Brazil because both are federal systems that, you know, manage water at the state level and, you know, present -- I mean, that just presents a whole number of challenges because of, you know, the riparian boundaries and that kind of thing. So I think, you know, there has been exchange of information and cooperation, you know, at some levels.

And I think at the regional level there's been support from the U.S. for transboundary work, you know, within the Amazon Basin and, you know, prospectively, you know, that should continue, both in terms of research and in terms of broader support and potential, you know, kind of trilateral or quadrilateral or, you know, whatever kind of cooperation you want to talk about.

HUANG: Thank you.

Alan?

QUESTIONER: Yes, thank you. Alan Batkin. Back to Brazil. Sorry.

Could you talk a little bit about the internal government process -- political process in getting the country to agree that HIV-positive people were entitled to free antiretrovirals for life? In this country and other countries, a decision like that would debating for 10 years, and the right wing and left wing would be arguing. Was it just a given in Brazil? Was there a political process? How did they decide to take the resources to devote to this away from other diseases? Was there a religious faction opposed to it?

BLISS: These are all very good questions, and I'm not sure I have a lot of depth to answer this, but I will certainly try.

You know, I think that there was leadership from the top in terms of the commitment to, you know, take the information, you know, coming out of the '96 scientific meetings around HIV/AIDS and, you know, to look at Brazil's existing epidemic and the very negative projections that were coming out at that point and, you know, to say, well, this is certainly one area where we may be able to make a difference.

There was certainly civil society pressure and encouragement to address the HIV/AIDS epidemic, you know, in all of its aspects, you know, from prevention to treatment and long-term support. I mean, at that point, you know, there wasn't, you know, really a vision for long-term support, you know, until the advent of these therapies.

You know, in terms of how the, you know, internal decisions within, you know, kind of the SUS bureaucracy in terms of how to allocate that kind of funding for the HIV work as opposed to others, you know, I couldn't say a whole lot about that. The fact that there was World Bank money available to, you know, offset some of the expenditures, you know, on some of the HIV/AIDS work, you know, around prevention and that kind of thing certainly freed up monies for the purchase of antiretrovirals. You know, Brazil was also, you know, able ultimately to negotiate preferable prices for those on the international market.

But, you know, in terms of the, you know, role of, you know, opposition, I don't know a whole lot about that. I know more, you know, just about the general support on the part of civil society groups that had been organized, you know, in kind of a pro-health or pro-HIV, you know, action kind of way. But I would suspect that there was opposition from other sectors, but I don't have that information right now.

LAURIE GARRETT (Senior Fellow for Global Health, CFR): I might be able to add just a little bit to that. One big piece of the Brazilian experience was that HIV was primarily a gay men's phenomenon there as was here in the '80s and early '90s. And in the past-junta environment, the post-military environment in Brazil, there was a lot of euphoria of liberation in many key communities, one of them being the gay men's community and the overlap with transsexuals, transvestites and so on. And that filtered all the way up into the government.

And so at that moment when I would go to AIDS meetings in the late '80s, international meetings and all way up to the Vancouver meeting itself, all of Brazil's delegation, both civil society and government, came from basically the gay community of Brazil, with one key exception, and that was those that were dealing with HIV-positive prisoners, which was a huge phenomenon in Brazil. And they tended to be both gay and straight.

And so I think that it -- you had a unique situation in Brazil of this sort of euphoria of the post-militarist society, the euphoria of the rise of a sort of gay liberation mood. And then, yikes, look, here comes this terrible disease. And it came together in a way in that country that has not happened anywhere else.

HUANG: Well, actually, just a follow-up of Alan's question -- this is to Judy. What's the internal -- in terms of the internal policymaking process with regard to global health, which government agency is the dominant agency in, for example, determining development-related assistance? Is it the Ministry of Foreign Affairs, the Ministry of Health or any other agency?

TWIGG: They're still battling it out, but it's primarily been the Ministry of Foreign Affairs and the Ministry of Finance who have competed for primacy. The Ministry of Finance obviously controls the dollars. But now that they're moving into this RUSAID structure, they're wondering how that's going to work because it's the Ministry of Foreign Affairs, obviously, that has the actual presence on the ground in other countries. And so it's still very much a work in progress, still very much a situation where there's plenty of bureaucratic infighting going on.

HUANG: OK, Leith.

QUESTIONER: Thank you. Leith Greenslade. I think it says GAVI Alliance in the document, but I actually just stepped off the board, so I'm not with GAVI Alliance. We've been talking about global health, but we haven't talked much about the Millennium Development Goals. And with four years left to go, I'm wondering what the state of internal debate is in Russia and Brazil on those goals in terms of what contribution the country is making or needs to make to help meet them. And not just the public sector, but is there an internal debate in the two countries with the private sector in terms of how we can contribute to meeting some of those goals, and particularly in maternal and child health, which is where the world, as you know, is really lagging?

TWIGG: I'll go because it's a short answer. (Laughter.) Until the last six months to a year there was virtually no conversation about the MDGs in Russia. Things just weren't phrased on those terms, although I think, in the last year or so, the Russian leadership who's engaged in these issues has perceived that they'd better start using that vocabulary, at least if they want to be perceived as a leader in global health. And so just last fall there were two major regional meetings on the MDGs, one on HIV/AIDS and the other on maternal and child health, in Moscow. And so I think that was the beginning of a process where at least for the next four years, we're going to see Russia very much more engaged in MDG-focused conversation.

Russia's infant mortality rates, if you believe the official statistics, have gone down dramatically since the collapse of the Soviet Union. This is one area where Russia can claim some success in its own country that they can argue is exportable to others. Now, there are lots of problems with the statistics that I won't go into unless you're interested, but at least if you look up what's on the books, Russia can claim that they've done it well in their own country. And so they feel much more comfortable in that issue area, I think, engaging than they do in some other issue areas.

BLISS: In terms of Brazil, you know, I think you can look at the domestic experience and then what they've been, you know, saying and doing internationally. I mean, domestically, you know, there's been a focus on reduction of hunger within Brazil, particularly under Lula. There was the Bolsa Familia and, you know, conditional cash transfers that sought both to reduce hunger and to enhance access to primary care.

By the same token, you know, while Brazil has certainly made, you know, achievements around HIV/AIDS, you know, and some of the -- some of the others, I mean, maternal mortality is still a factor in Brazil. The -- trying to think of the numbers -- (inaudible) -- but I think in -- and I -- and I don't know the year -- it's within the last five years -- but Brazil still ranks 86th out of however many nations -- a hundred, you know, eighty or so that were surveyed, you know, in terms of, you know, improvements in maternal mortalities. So there's still certainly an area for improvement there.

At the summit last -- September before last the Brazilian minister for social development and the fight against hunger stated that Brazil has provided, I think, 1.2 (billion dollars), $1.3 billion, you know, around the MDGs internationally. Now, what I've -- that was -- that was a statement that was made. I don't know what agencies that came from, what specific kinds of programs, you know, that went to, and that kind of thing. But you know, that suggests that it's motivating some of their work across a broad range of categories.

HUANG: Quick question to Judy. Does Russia still send medical teams abroad like China or Cuba does?

TWIGG: They virtually stopped doing that during the -- during the 1990s, although it's interesting, I've heard from several of my Russian colleagues that at the time that the Soviet Union collapsed, there were a fair number of Soviet doctors who were stationed in Soviet satellite countries around the world. And many of those folks just stayed. You know, they had nowhere really to go back to.

HUANG: Privatized? (Chuckles.)

TWIGG: And so there are these pockets of, you know, Russian-speaking, Soviet-trained physicians in former Soviet client countries around the world. But they're not, obviously, working under any kind of Russian government auspices.

One of the things that's happening particularly with USAID now is that USAID is funding projects in sub-Saharan Africa -- a limited number of countries; I think Mozambique is one; Ethiopia is one; Tanzania is one -- that is putting Russian laboratory specialists in place in these African countries. And there's been some success with development of a new and more effective rabies vaccine in Ethiopia, for example. So it's a process that ended for about a decade and now seems gradually to be starting to ramp up again.

HUANG: Fascinating. Laura.

QUESTIONER: Thanks. I'm Laura Herman, with FSG. My question is for Judy. Sort of reflecting back on the world's perception of Russia and emerging to influence potentially in a bilateral way, I'm wondering about the dialogue in Europe. How are some of the big health donors from the European countries either seeking to influence Russia or responding to some of these changes?

TWIGG: Well, DFID has pulled out of Russia, you know, partly for financial reasons and partly out of -- out of a stated recognition that Russia is no longer appropriately a recipient country. The Germans, a few others are still there providing technical assistance but, you know, much like the United States and the Bank and others are doing, are searching for a productive way to recast the relationship in a way that makes sense when you have a rich country that still needs that technical assistance but might not be willing to admit that it needs that technical assistance.

A lot of what the Europeans are doing is also wrapped up with business interests. In Europe, obviously, they are much more tightly tied as trading partners, certainly with pharma and medical equipment, than the American companies are.

HUANG: Very interesting. Well, thank you.

Actually, maybe I have a last set of questions, just to wrap up this discussion. It seems that from your -- these discussions that even though both Russia and Brazil are considered the emerging economies or grouped into this BRICS, their ways, patterns of engaging in global health seems to be quite different. Maybe each of you could summarize, just maybe two or three sentences, what are these major differences in your opinion?

BLISS: OK. Well, I'll try. Let's see. They may not be sentences -- but you know, funders, not donors; cooperation, not assistance; horizontal south-south cooperation; and, you know, a role -- a strengthened role for the "global south" and a strengthened voice for the "global south" in the international community. (I think ?) those are probably some -- (inaudible).

HUANG: Judy?

TWIGG: In terms of contrast to Brazil, you know, Russia very much wants to act with dollars as much as or more than it acts with policy, really not willing to engage in policy that in any way would against its own -- its own fairly narrowly-defined interests. And unlike Brazil, which I think has a fairly clear sense of its identity in this -- in this whole endeavor, I think Russia is still searching for its identity in global health.

HUANG: Well, maybe it's -- well, actually, this is consistent with its total foreign policy orientation. It's still searching for its identity. (Chuckles.)

TWIGG: Exactly.

HUANG: That's the problem.

Well, I think we are almost there. And thank you all for coming for this absolutely fascinating discussion. And thanks also for our two speakers for their very inspiring remarks. And we'd also like to thank Robina Foundation for their generous support to make this round-table series possible. And thank -- I'd also like to thank Zoe (ph), research associate of the global health program, and Basil (ph), who's the intern of the -- (our ?) program, for their help.

And thank you all for coming also. (Applause.)

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