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U.S. Department of State

Diplomacy in Action

Global Health Initiative and Non-Communicable Diseases

Lois Quam, U.S. Global Health Initiative Director; Amy Batson, USAID Deputy Assistant Administrator for Global Health; Donald Shriver, CDC Deputy Director for Policy and Communication; and Mamadi Yilla, State Department Office of Global AIDS Coordinator, Senior Public Health Advisor
New York, NY
September 20, 2011

1:30 P.M.


MODERATOR: All right. Well, thank you for joining us on a rainy day. I’m just, for the sake of introductions, going to stand back here and then turn it over to our four experts.

For our briefing today on global health and in the context of the non-communicable diseases meetings going on here at the UN, we thought this would be a good opportunity to talk about this Administration’s approach on global health issues and the importance of the meetings going on here in New York this week.

With us today, we have four speakers: Lois Quam, who’s the Director of the U.S. Global Health Initiative and based at the Department of State; Amy Batson, Deputy Assistant Administrator for Global Health at USAID; Donald Shriber, who is the Deputy Director for Policy and Communication at the Center for Global Health at the Centers for Disease Control and Prevention; and finally, Mamadi Yilla, who is the Senior Public Health Advisor for Sustainability and Integration at the Office of the Global AIDS Coordinator at the Department of State.

Each one will have a brief introduction and overview, then we will turn this over to questions for the rest of the time. Thank you.

MS. QUAM: Thank you very much. I’m Lois Quam from the Department of State.

The United States has a substantial investment in global health because, put simply, it saves lives. And it saves lives in a way that protects Americans and all of the world’s citizens from the challenges of the spread of disease and disruption.

Our investments, as the United States Government, in global health go back decades in the work that USAID has done over nearly 40 years, and then the impressive accomplishments of the Bush Administration in initiating the PEPFAR program and the President’s Malaria Initiative. We’ve been excellent stewards of the United States global health investments in the Obama Administration, taking them to a new level in terms of efficiency and effectiveness.

The launch of the initiative on global health was designed to bring the existing programs that we operate to a different level of achievement by focusing those efforts, working more closely with countries to get to self-sufficiency and higher levels of performance. The initiative on global health was also set up to really, in essence, get us ahead of the game, ahead of the curve, by taking programs and activities that had been disease specific, in integrating working across the whole of the United States Government, to provide more integrated, leveraged global healthcare programs, working with local governments, again for sustainability, self-sufficiency, higher levels of performance and achievement.

We’ve been doing that work over the past two and a half years to great success both in country and at headquarters. And we have focused particularly on the tremendous opportunity to save mothers and children. The President’s Malaria Initiative, for example, saves the lives over 200,000 kids under five each year. We have a very significant focus around saving the lives of mothers in labor and delivery, especially looking at that crucial 24-hour period when two thirds of women die and half of newborns die.

We see an opportunity to move towards, for a first time, creating an AIDS-free generation with the investments that have been made in PEPFAR and the actions and research that has recently come out of the NIH. We work very hard toward those goals. In doing that, we’re always challenging ourselves to find ways to work more efficiently and effectively so that we can spread our resources in a stronger way, and with that challenge our partners, both countries we work with around the world as partners in delivering healthcare services to their citizens and countries who are fellow donors.

So this – our strategy is clear, powerful, and successful. And I’m pleased to be here with my colleagues. And I’m going to first turn it over to Mamadi Yilla from PEPFAR.

MS. YILLA: Thank you very much. And just to build off that, I think that PEPFAR has been an incredibly successful program, has built the necessary infrastructure that we now believe is possible to leverage, particularly to address issues around NCDs and other chronic illnesses. PEPFAR has built an infrastructure around human resources, around laboratories, supply chain, and service delivery. And we think that what it offers under the Global Health Initiative is a platform upon which primary healthcare services that our partner countries need can be leveraged. And look forward to addressing your questions later.

MS. QUAM: Amy.

MS. BATSON: So the President’s Global Health Initiative really is all about results, and that’s how we will be judged. So when we look at building on that progress made, we see we really are positioned now to have an enormous opportunity for results not only in the maternal and neonatal health, as Lois was outlining, but also in child health, and that at this moment in time we have the potential to drive forward our programs such that we could be reducing child mortality by 38, 40 percent. In just focusing on the programs like malaria and achieving our near zero goal that’s been set by the global community, immunization and ensuring that all children have access not only with the older vaccines but in also the new vaccines of rotavirus and pneumococcal vaccines against diarrhea and pneumonia, and of course preventing pediatric AIDS, focusing on those that we now have the technology for and the access for, we can have this incredible impact.

And what the Global Health Initiative has done is created the space for us to work smarter, work with even greater focus on these kind of measurable results, the innovative means of getting there, and building on the platforms that have already been established. So for example, on malaria, with the President’s Malaria Initiative, that’s a platform that’s been very much focused on the community delivery, and how are we accessing the enormous population that are in the rural areas, in their communities that may not be getting access to the hospitals that might be in an urban area.

And what we’re finding is we can get those interventions out there. We can provide those interventions in an integrated way. So it’s not only the malaria, with the spraying and the bed nets, but it’s also the immunization and the neonatal care and having skilled birth attendants able to go further and further out into the community. And that’s where we have the really big impact.

MS. QUAM: Donald.

MR. SHRIBER: Thanks. There are remarkable complementarities, I think, between what we can do in non-communicable diseases and what we’re trying to do in the Global Health Initiative, and I’ll just mention a couple of them.

One is the area of health in all sectors, what we’re referring to as a whole-of-government approach in GHI. And it’s quite striking, listening to speakers from around the world, the extent to which they’re relying on non-health sectors to get health results. So whether you’re talking about the U.S. Government domestically or what we do overseas – and Amy will help speak to this in terms of the multi-sectoral approach that USAID takes – we need engagement from agriculture, from education, from environment, from housing, and from multiple other sectors. And we need to strengthen civil society and health managers so that they can bring together those sectors.

A second area of complementarity, I think, is that there are major lessons to be learned from our work in maternal and child health and in PEPFAR about how we should work on non-communicable diseases. In both infectious and non-infectious diseases, it’s going to take a multifaceted approach, one that relies on behavioral interventions, biomedical interventions, policy, systems, and research. And I would particularly call your attention to policy because it’s getting a lot of attention here in New York for a variety of reasons, one of which is that you can have enormous impact with policy change with relatively small investments.

A third area is prevention. Obviously, again, cases averted – avert very expensive treatment. At CDC, we’re obviously big proponents of public health systems fourth area where we think there’s a lot to be learned from what we’ve done in infectious diseases. And our ability just to quantify where the problems are, where they aren’t, which populations are affected, help us devise very targeted solutions.

And then finally, as Amy mentioned, results are critical to what we do. So we need to monitor what we’re doing. We need to constantly evaluate and we need to improve our programs as we go, and that’s equally true for non-communicable diseases.

And then the last thing I’ll say is just that we have a remarkable reservoir of expertise from both our domestic work and our global work in non-communicable diseases that will be of assistance to us going forward.

MODERATOR: Okay. So we can keep this fairly informal if folks have questions. First, please identify where you’re from and any particular official or if it’s for everyone.

QUESTION: Glenville Ashby, Trinidad and Tobago Guardian. Okay, just general questions in respect to wars in Africa and famine, lack of infrastructural development, and to what extent that impede your initiative. And what concrete steps have you taken or will be taken to circumvent or surmount those areas, which I think are really tremendous and can retard any form of initiative. So I think there’s basically three. That’s wars and natural disasters like in Ethiopia and Somalia right now, and lack of infrastructure.

MS. QUAM: Amy.

MS. BATSON: Yeah. The administrator from USAID was speaking about this quite a bit yesterday, and there was the social summit where there was a lot of focus on the Horn and what could be done. I think that what’s – it really is a crisis, and it is a fact that this is some of the worst famine, I guess, there’s been in decades now.

It is – when we’re in an emergency like this, one has to sort of be immediately responding to the emergency. However, what’s been – what’s – I think what we really learned from it and are taking increasing strides on is what can we do in advance of the emergency to really be putting in place the kind of preventive and warning systems so that we know what’s coming down. And in this case, those warning systems that have been in place now for over a year actually did help us predict that this was coming and did help the U.S. Government be able to take the actions necessary that have prevented millions of people from actually being affected by this – by the tragedy. So we’ve reduced the magnitude and the scope.

But also the kind of actions taken for the crops and the food and the sort of innovations that are taking place right now supporting African researchers on betters seeds that are – that can provide a higher yield. And so that’s actually had a big impact in terms of a three-fold – I guess it’s a tripling of the yield of this certain type of crop, which compared to sort of the yield that you might get here in the U.S. is still not as good as it could be, but it’s still a three-fold increase of where’s it’s been, and so it’s had a big impact.

So that kind of more sustainable investment early on in the process rather than just waiting for the emergency and having the emergency response really becomes sort of the critical issue of good development and helps to prevent the tragedies from before they occur. That comes back to your point of infrastructure. And I think this is where in the health sector, we’re very much focused on building up that sustainable country-owned infrastructure which depends on not only the governments, but it’s the private sector playing its role. It’s the civil society, the faith-based organizations playing their role. It’s really reaching into the communities and ensuring that you have the community understanding, awareness, and support for good health that really is building that kind of infrastructure that enables a country to be better equipped when something strikes.

MS. YILLA: Just to add on to that, you talked about poor infrastructure. I think what GHI offered us is that opportunity to actually leverage other collaborating partners as well. So that if you are building a healthcare center, make sure the road goes to the healthcare center. I think that approach is feeding a lot of the conversations that are happening at a country level right now. I think we are taking our very successful vertical programs and actually interfacing with country governments and saying “How can we support you in a much more sustainable fashion?”

So for example, in a country like Malawi, under the GHI strategy, they’re looking at infrastructure needs across healthcare centers, across the entire country. Those infrastructure needs are to help maternal and child health, not just HIV. They’re figuring out how they can leverage the resources that are available going into refurbishing perhaps a room next door that was supposed to deliver HIV services to perhaps more rooms that would also do something for maternal and child health.

The Global Health Initiative, I think, has been a very welcome development from our partners on the ground because we are able to basically leverage our various streams of resources in a holistic fashion so it makes sense to them and is actually meeting those challenging needs.

MR. SHRIBER: Countries in crisis or those with highly fragmented infrastructures often account disproportionately for death and disability and disease, and I think we have both an ethical obligation and an obligation to protect others in the world, including Americans, working there. And I think it’s a testament to the kind of people who work in the U.S. Government across our agencies that we go into places that are – that have very challenging circumstances.

MODERATOR: Next question.

QUESTION: Hi, I’m Betwa. I write for Down to Earth and India Abroad. Yesterday, when the Secretary General was speaking he came – he spoke very strongly about the responsibility of the food and the beverage industry, and he was quite critical of them saying that historically that they put profits above health and so on. Is there some sort of recommendations that you could give in terms of what the food and beverage industry needs to do, in say, a certain amount of time going forward? And what changes would you like to sort of see, and how can those be enforced?

MR. SHRIBER: Well, without speaking to very specific measures that industry would take, all that we do on chronic diseases, non-communicable diseases, is going to involve a partnership with the private sector. And you only have to walk around New York City and see the changes that have been made here in terms of working with restaurants, on tobacco, on labeling of food products. There’s enormous interest in the corporate community, I think, about being responsible corporate citizens, and there’s going to be a partnership between government and the private sector.

MS. BATSON: And I think one of the spaces we’re quite excited about is with the Global Health Initiative and then there’s a Feed the Future effort, and where those two come together is around nutrition. So there’s a lot of discussion about what is the actual ways that we’re engaging between – engaging the private sector, harnessing their capacity to help ensure that we have sort of highly nutritious foods, that a population is getting that diversity of foods that is necessary for them.

So you have looking at how do you enhance certain sort of basic food products with micronutrients to ensure that they’re getting access to those. You also have some really exciting efforts going on that we can get you more information about that our team on Feed the Future is working on, but about how do you work with private sector with the governments and under the sort of leadership of governments in Africa to create more of a robust food corridor, so that you’re, again, thinking about the future and you’re helping to prevent the kind of risk of future famines. And so using the best and most innovative seed technologies, really driving forward what can be produced in these countries. And through that, you’re not only having an impact on the ability of the population to have healthy food, you’re also engaging private sector in a really positive way in terms of solving some of these problems.

QUESTION: My turn? (Laughter.) I’m Betsy McKay from the Wall Street Journal. I have a slightly different question. I wondered if I could get caught on something with the Global Health Initiative. At one point, there were eight countries that were kind of pilot countries, or learning labs. Is that still going on and, if so, what have you been doing in those countries, what have you learned, is there anything you’ve taken to other countries? I know some of them are in war-torn areas, I think, or at least Ethiopia is.

MS. QUAM: Yes. When we set up the Global Initiative, we started with what we called eight-plus countries.


MS. QUAM: And they led the way in developing the first country strategies. And then we – we’re in the process of completing round two, which were another set of countries, and launching round three. And there’s been a terrific amount of learning in that process. What has been most impressive about it is the learning, I think, that has come from – not from headquarters to country, but between the countries as they’ve talked about how they’ve worked.

And Mamadi, maybe you can speak to it, because Mamadi is now at the OGAC office in Washington, but was in Malawi and has worked with a number of our key countries.

MS. YILLA: And I think the focus, obviously, of the eight countries was around learning, getting those results, and disseminating them to other countries. And one of the approaches that we’ve taken is to – has been to bring countries together, actually countries not just in one region, but bringing people across regions as well, because we recognize that there have been tremendous best practices that U.S. Government teams on the ground have been implementing but not necessarily sharing that information across countries.

So one of the best examples I can cite right now is what happened in Mali, where, as a result of their conversations around the Global Health Initiative and how they were going to work with the Government of Mali, basically did an inventory of programs that they were supporting and across various U.S. Government agencies and also in partnership with the Government of Mali, figured out that about $6 million worth of resources were being used in what might be termed a duplicative manner. And so they were able to figure that out, made out a plan to reinvest those resources in the areas there were gaps in funding. And that honestly would not have happened but for the space that GHI has created for this kind of dialogue to get more efficient planning and implementation to occur.

And so once other countries sort of heard about that, folks wanted to learn how that was happening in Mali. So we went through a process of actually documenting what Mali had done so we could share that as a best practice not just verbally when the team from Mali was with other countries, but also be able to share that in the form of a document.

QUESTION: You said they reinvested their resources in Mali. What did they -- do you know what they reinvested them in?

MS. YILLA: So I think basically what the -- they worked with the Government of Mali on a new health strategy, and certainly within the limits of appropriated resources, but basically looking at areas where there were gaps. And I’ll have to get back to you on what were the specific things they put those resources back into. But we’re very pleased in an environment of tight resources -- very much pleased to be able to find that.

MS. QUAM: One thing we’ve found that’s been very striking is the role that our ambassadors are now playing in global health and bringing together the whole of the U.S. Government team. And what it leads to is a discussion where maybe three years ago it would have been around what are we doing on AIDS, what are we doing on malaria, what are we doing on NCDs. We have that discussion because we have very specific goals. But it’s also how do we work across them and make sure that we’re not duplicating, that we’re leveraging, that we don’t have these tragic circumstances where somebody’s getting state-of-the-art treatment for HIV and then dies of something else where it’s really substandard. So we’ve made a significant amount of headway in these areas and are working very hard to consolidate the gains and move forward.

QUESTION: How far can you extend -- for example, let’s take the PEPFAR platform, right? How far can you extend it? I mean, you’re right; you get someone on lifesaving AIDS drugs, and then a woman dies of breast cancer or whatever. So what was the point of -- but PEPFAR also has a mission of getting more people on AIDS drugs, and you only have a certain amount of money and a certain number of people. And how do you do that? And how far can you extend it? I mean, can you -- can the PEPFAR platform really take on NCDs, for example, treating people -- diagnosing and treating people for cancer or heart disease or --

MS. QUAM: Well, first of all, one of the things we’re most proud of is how we have taken the terrific achievement that the prior Administration made in PEPFAR and taking it to different levels. So the number of people in treatment, the cost per person on treatment, the -- we’ve driven significant cost-effectiveness and efficiency in PEPFAR. So we’re able to, with the same budget, treat many more people. So that’s kind of one key thing.

The second is that the prevention strategy on HIV and AIDS leads you in really important directions. I was just with UNICEF and to talk with them about the significant commitments we’ve made around the prevention of transmission between mothers and children. That brings you into bringing -- testing pregnant women, bringing pregnant women in for services, at which point they can get accesses to other services that may be funded by USAID because they’re maternal and child health services, but brings women in the system. One of the best ways to prevent the spread of the epidemic is to prevent mother-to-child transmissions. So that takes you there at a different level.

Then thirdly, there’s really an opportunity for quite creative partnerships and one was announced last week by Secretary Clinton and President Bush around the link between PEPFAR and cervical cancer, and we think that’s profoundly important. So what PEPFAR has done by creating an infrastructure and capacity then allows for a partnership like that to come into play, which you simply would have never been able to do before.

MODERATOR: We actually have -- we can have more follow-up, but --

PARTICIPANT: Yeah. We have a question in Washington.

MODERATOR: Washington, go ahead.

QUESTION: Thank you very much. Charlene Porter with the State Department’s International News Service.

Ms. Batson, in your opening remarks, you made a point of saying that you thought it was possible to reach a 38 to 40 percent decrease in child mortality. Have I got that right? That’s a pretty big claim. Perhaps you could elaborate a little bit on that. And if the other speakers also might address that particular goal or other goals that they may have in mind for where we go forward with the NCD action as it’s come out of the UN this week. Thank you.

MS. BATSON: So with the investments that the U.S. and many, many other partners have made in health, we actually have both the platforms and the technologies to be able to save millions of lives. We have -- there are -- we have malaria, for example. We’ve seen in those countries where we have -- that have been the focus of the President’s Malaria Initiative -- 25, 27, 30 percent reductions in all-cause mortality in child mortality. So we’ve really seen the impact of these simple interventions when they’re really scaled up and made accessible to all the population.

Similarly on immunization, we have vaccines that are easy to deliver and are extraordinarily effective and that they will protect a child from the risk of these killer diseases of pneumonia, of diarrheal diseases, of measles, of a variety of deaths that will save millions of children. Similarly, we have the, sort of, very simple drugs on preventing maternal-to-child transmission.

So we have these simple, cost-effective technologies, and by focusing on those and really using the platforms that have been developed through PEPFAR, through PMI and the community-based, through our work on maternal and child health across all of these countries, and by working in partnership with governments around the world and partners around the world, if we really take these forward, we have the potential to just have this enormous reduction in child mortality. And just looking at those it could be up to a 38 percent reduction in child mortality in the next sort of over a period of time of somewhere between 5 and 10 years. So it really is an exciting opportunity that we are very well positioned to kind of deliver on and then for the world to take hold of these challenges.

MODERATOR: There was a second question about just where next on NCDs -- that was her second question.

MR. SHRIBER: Two things we need to do with NCD is, one, we need to describe and characterize the problem in every country so we know what groups we need to attack it in and what measures we need to take. And we know how to do that and we’ve proven that with tobacco. And tobacco is a really good example of the second part of the strategy, which is putting in place things that we know work. So that’s aggressive anti-marketing campaigns. It’s making tobacco products less accessible, particularly to youth. It’s helping who want to quit have access to the resources they need to quit. There’s a whole series of steps that, when taken, can profoundly reduce tobacco use and have enormous consequences for reductions in disease.

MODERATOR: Sir, did you have a question?

QUESTION: Yeah, Olaolu Akande is my name. I work for the Guardian of Nigeria. I’m sorry that I came in late. I’m trying to cover several things. I just wanted to explore the Nigerian angle of partnership that the U.S. is doing on the global health, and I want to ask specifically whether this is actually bringing an increase in the kind of resources that the United States is making available to some of these partners, especially in Nigeria.

MS. QUAM: Well, Nigeria has been a very important partner. We have had global health activities in Nigeria for decades. Nigeria’s been important in the work around HIV and AIDS, important in malaria. Nigeria has one of the highest numbers of women who die giving birth of any country in the world, I believe an estimate of 50,000 per year. So we’re very invested in working with Nigeria to make a difference in all these areas. The U.S. Government team working with the ambassador has recently developed a Global Health Initiative country plan for Nigeria, which we’re just in the final stages of reviewing, that will take these efforts to another level.

Mamadi or Amy, would you like to comment on the malaria or HIV work in Nigeria?

MS. BATSON: Yeah. When we look at really achieving this sort of potential for the malaria goal that I was just mentioning, Nigeria is one of the two most important countries, that we cannot achieve this goal without Nigeria. And the importance of Nigeria itself being committed to ensuring the health of its population, ensuring that it is providing the sort of resources, the kind of political commitment, the technical support that exists within Nigeria to make sure that these problems are being addressed, is the most critical component. It’s not only the government. It’s the very rich NGO, faith-based organizations, civil society there.

At the summit last week the -- President Bush’s summit last week on health, it was very interesting. You had Bishop Sunday was there from Nigeria and he has been working with his Muslim counterparts that they’ve had this faith-based effort where they’ve reached out to over 300,000 ministers, priests, imams on malaria, so that it’s really reaching in to the community. And these leaders in the community who are the most trusted members of the community are now going back and raising the awareness of the population and telling their people, “Sleep under bed nets. This is what you need to do to protect your children, make sure that that child is under the bed net.” And it’s having a tremendous impact. And it’s that kind of ownership by the population itself and by the country itself that is the key to success.

QUESTION: So when you said that in terms of funding that the United States is increasing its funding for health issues particularly in Africa, or is it just trying to develop more of the partnership with the government? I’m interested in your take on that.

MS. QUAM: Well, we’ve had a significant investment in global health in Africa. We’ve done that first and foremost because it saves lives. Our investments also protect Americans because it prevents the spread of disease and helps create stronger nations. Where our focus is now is looking at taking the significant investments we have and integrating and leveraging them in new ways, working together in new ways so that we can create the capacity to achieve greater results with the substantial investments that we have in place.

And we see that success happening around Africa and we are challenging ourselves to continue that and challenging Nigeria and other countries we work with to be our partners in developing a self-sufficient, self-sustaining Nigerian health system that we played a role and helped stimulate, but we see it’s very important for Nigeria to – for it to be Nigeria’s health system.

Mamadi, did you want to --

MS. YILLA: And to add to that, I think this is about a shared responsibility. And the Nigerian Government in signing the PEPFAR partnership framework actually made a commitment by 2015 to have taken over a substantial amount of the programs that PEPFAR – the U.S. Government currently supports in Nigeria. And I think just to add to Lois’s point that GHI is focused on results, PEPFAR is a part of GHI, and we look to governments, like the government in Nigeria, to increase their commitment as well to making those targets achievable.

QUESTION: Yes, hello, my name is Terry Mulligan. I’m an emergency physician from the University of Maryland, but I’m an executive editor of the African Journal for Emergency Medicines, a peer-reviewed medical journal, but also a magazine called Emergency Physicians International. And we’ve been involved in setting up emergency medicine and acute care systems in about 25 countries around the world, mostly in Africa, Southeast Asia.

At the University of Maryland, Joe O’Neill is now with our Global Health Initiative, one of the founders of the PEPFAR. My question is about, what do you see the role for the global health initiatives on acute care and emergency medicine systems development as a form of secondary prevention system in addition to all the primary care and primary public health prevention systems that we’ve been talking about?

And I would also just like to ask you to comment on the conspicuous absence in this forum this week on the role of – or the importance of trauma and injury in being one of the number one, two, three, four, or five causes of death in almost every country, particularly low and middle income countries, and how injury and trauma prevention is another form of non-communicable disease?

MS. QUAM: Don.

MR. SHRIBER: The first thing that came to mind when you opened was trauma, and I’ve had the experience many times myself in Africa of being in hospitals where there were trauma cases brought in from preventable traffic crashes. And that dominated the work of hospitals. I remember being in a hospital in Tanzania where they had at least one truck-related crash every single day. And those are often preventable.

And I agree with you that secondary prevention is important, but that primary prevention where, if you put in place simple laws that require people to wear seat belts, to drive slowly, if you improve road infrastructure, which is part of the health and all policies approach, it’s really critical. A I agree with you about secondary prevention, but it’s so much more cost-effective if we can be effective in primary prevention.

I mean, another – a secondary is traumatic brain injury from people who are involved in crashes related to riding motorcycles or motor scooters. And the cost of a helmet right now has been brought to a very, very low point, and all we really need is the behavioral modification and we need policies to require people to wear them.

QUESTION: Do you see a role for the GHI to play in support or establishment of secondary prevention systems? Because although all attention should be paid on primary care and primary prevention, public health, prevention of non-communicable disease burdens, those things aren’t going to start tomorrow, and they’re not going to kick in for years. And in the meantime, we have an overwhelming burden of trauma, heart disease, cancer, stroke, diabetes, and acute presentations of those emergencies that can be effectively handled by secondary prevention systems like acute care systems, ambulance systems, emergency medicine systems that would need to be modified and changed, depending on resources. But we’ve had 15 years or so experience in building these systems in other places and found pretty significant reductions in morbidity and mortality, particularly from trauma. So after the trauma happens there’s a lot of potential to even save further morbidity, mortality.

MR. SHRIBER: There have been enormous U.S. Government investments in health facilities through PEPFAR and other programs. And those have redounded to the benefit not just of HIV patients but people with multiple other conditions, including trauma. And so I think those investments should absolutely not be overlooked. And we have expertise, obviously, in emergency medicine in the United States, which we have and will continue to share with people in developing countries.

MS. BATSON: And as a particular point, I mean emergency obstetric care, and sort of that is a critical piece of a strong system to address maternal health. In and of itself, it’s not enough. You need to have – as you’re sort of saying, you need both to have these kind of referral – a whole system where you have the emergency obstetric care available on a referral basis, but you also need to be reaching the population. Because in many countries, much of the population never, ever gets there because you don’t have the road systems, you don’t have sort of the means of transport, you don’t actually have a population that’s even aware that they could go and get some other kind of level of care.

And so it’s a question of how do you build that whole system, which includes sort of appropriate emergency response but also includes reaching the population with a level of services that can be highly preventive or can address sort of in place some of what they need as we strengthen the overall – or as we work with governments to strengthen the overall system and their ability to access all the care that they need.

QUESTION: I would just like to ask a follow-up of what I was going to ask. How does the limitation in the healthcare infrastructure in countries like Nigeria and Africa, how do that limitation in the healthcare infrastructure or others affect the efforts of the Global Health Initiative here? Does it limit what you want to do? I mean, what’s – does that limit what you’re trying to do? And what is your advice? How do you confront that problem?

MS. QUOM: Well, if you look at the 50,000 women who are estimated to die giving birth in Nigeria each year, we know from our experience that many of those women’s lives would have been saved if they had a skilled person with them who was properly trained and equipped to be able to help her, and that that person had the opportunity, when they needed to, to get the mother to a higher-level facility where she could have an emergency C-section or something else. And there’s a critical 24 hours – there’s a – in the 24 hours of labor and delivery is when we lose about two thirds of mothers and almost half of infants.

So developing the capacity in a healthcare delivery system in Nigeria is crucial for saving mothers, but that very same capacity, of course, can save someone who’s having appendicitis or save someone who’s been in a road accident by creating a network of healthcare professionals and facilities that they can go to.

QUESTION: So why aren’t we creating a PEPFAR for NCDs? I mean, this is a really unusual meeting in the sense that no money is being put up here to address this problem, I mean, unlike AIDS ten years ago, and this is potentially a bigger problem. I mean, look at all the things we’re talking about, and these need to be addressed. So why isn’t the U.S. Government stepping forward with an initial pledge or creation of some sort of, I guess, a PEPFAR or PMI for NCDs in the hope that the rest of the world will follow and step up?

MS. BATSON: I think this is where GHI has really been ahead of its – ahead of the thinking going on, because what GHI is about is how are we building on the PEPFAR we have and the PMI we have in all of the health work that we’re doing to build that more sustainable, more integrated health platform, health system, so that whatever needs to be brought out to the population is actually reaching them, so that you have the trained health workers that can out and educate about nutrition or educate about the things that they need to know, do the triage to kind of recognize symptoms of different – whether they be communicable or non-communicable diseases, and provide basic interventions out there through the communities, where we have these sort of district-level platforms that are able to provide the quality of care, where we’re addressing not like a single disease, but we’re saying here’s the person; they’re coming with a lot of things, they’re coming with communicable diseases, they’re coming with an opportunity where we could prevent them getting a disease if we actually act now, they’re coming with potentially some NCDs that could be – that we could be raising their awareness and training, providing basic education and addressing some of those needs.

And so that’s what the Global Health Initiative is creating. Because at the end of the day, communicable diseases, non-communicable diseases, you need the health worker, you need the supply chain, you need the strong tools, you need the awareness of the communities and their engagement and ownership of these issues. That’s what it takes, and that’s what we’re developing.

MR. SHRIBER: Betsy, one of the most remarkable things that’s happened since this body last met on a health issue, which was in 2001 on HIV, is the emergence of middle income countries that were formerly thought to be lesser developed countries. So in particular, countries with enormous burdens and enormously large populations are now considered middle income countries, and those countries are really uniquely posed, particularly using inexpensive interventions or policy, to serve their own populations. And I think the U.S. Government can work with them in a partnership rather than a donor-donee relationship and make enormous strides.

QUESTION: Will that be happening at this meeting?

MR. SHRIBER: It is happening. Those kinds of exchanges are absolutely happening. You were asking about a massive infusion of funds, but the technical exchanges between our country and the emerging economic powers are absolutely happening.

MODERATOR: And on that note, our folks have to move on to the next event. But thanks very much for coming, and we’ll follow up.

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