and now we're up to around -- to an administration that is proposing $9.6 billion for a series of hiv by a program which was started by the president bush which is the president's emergency plan for hiv relief. it's part of an umbrella group of programs called the global health initiative. president obama has said he's going to start changing the way we do business. it's clear we're coming up against some notion of the finite. and the question is how we're going to -- the problems have, you know, even with the funding so the question is going to be, how we're going to deal with, i suppose, problems that we had not began to define is well when president bush, you know, proposed the president's

emergency plan for aids relief so i'm going to start with dr. anthony fauci, who was a part of that group that met in the administration of president george bush to sort of create the president's emergency plan for aids relief. what did we learn from that? we're now up to 33 million people infected with hiv. what are the lessons that have come out of that. and, you know, can we continue, i suppose, treating people? we are now up to 4 million people in africa and around the world being treated even though it's understood that maybe three times as many need treatment? >> well, there's several things that we learned by that experience and biactual implementation of that truly transforming program, and that is that you should not assume the way some people did early on.

that you cannot deliver rather complicated health care implementation to people in the developing world, namely, getting them to get tested and get drugs that you have to take virtually every single day. so it was not only a proof of concept but it was actually something that had been implemented very well. and the numbers are really are extraordinary. the pepfar program is responsible right now for about 2.5 million people who are on therapy close to a million babies that were saved by the blocking of mother to child transmission 10 million people who are under care including aids orphans so it really is one of the truly landmark programs that the united states government has implemented that's the really very good news. the sobering news is that when you deal with such an enormous

problem such as this -- and aids is a classic prototypical example of that but as i'm sure you'll hear from malaria and tuberculos tuberculosis, ugot to treat the people who are infected but if you've got the totality of people in the low and middle income countries, 30 to 40 people of the people who need therapy are getting it. which means that 60 to 70% of those who need it are not. for every one person that we put on therapy, two to three people get newly infected. so if you just do simple math, the number of new infections are outstripping our capability of not only initiating therapy on newly infected people but even sustaining the therapy in the people. it's economically not feasible. we need on try to as best we can.

what we really learned is we've together prevent hiv infection. that you say the thing we need to do. we have well proven modalities of prevention ranging from condom distribution to mother to child transmission. that's the good news. the sobering news to that that 20% of the people who would benefit from those preventive modalities actually have access to them. when you're dealing with a disease like that prevention is a major part of what you need to do. and also you've got to get the countries themselves involved in making these types of things part of their own programs. and i think that's what the global health initiative is trying to do which is what pepfar is a part and maternal health and child health care, et

cetera but it make it countries have a part and other developed countries coming in and continually taking care of them. so a lot -- an amazing amount has been accomplished but there's that has been alluded to some very important lessons that have been learned and i'll stop there because i'm sure we'll have questions about that. >> i'll make it not just about money and we'll come back to this question of whether by changing the approach, you know, strengthening health systems in this countries, whether, in fact, you can do these things more effectively with the resources that you have, the limited resources that you have. but before we go into that, as you noted in the beginning, we started out talking about 300 million or so a decade ago and now we're up to about $25 billion with this administration proposing $48 billion -- which i guess $63 billion with all of

the programs included over the next six years. but then you've got a whole bunch of groups and you've got a whole other folks here involved here bill and melinda gates foundation. the contributor but, you know -- i mean, it contributes to a lot of folks. what we really need is about $40 billion which is the total amount of contributions are right now, but we need probably about twice that amount. you've got lots of people with their hand out or the other and i don't want to say a handout. that's probably not a fair description. what does japan, the united kingdom along with bill and melinda gates -- what is being asked of all of the players and the u.s. is not doing this

alone, let's put it that way. >> well, up with of the things that we all know here from the united states from our own experience is that health cost money. you can have all the good will in the world but unless there's cash to purchase the necessities for cleaning up water supplies and distributing pills and bed neither to prevent malaria invention you can't accomplish very much with just good intentions and albert schweitzer-like zeal the good news between 1998 and 2008 the total pile of cash you out there for what we grandly called globally health increased. it went somewhere in the ballpark depending on whose numbers you're using -- between 4 and $500 million. that's for everything that we call health. from clean water supplies all the way to pills being handed out and training doctors and all sorts of things.

and we are now well into the ballpark of 45 to $50 billion if you include all the range of things that i put in the original number. the biggest driver of that increase without a doubt has been the united states government. and if you actually combine private and public giving from the united states for this whole pot of global health, we are by far the biggest done savior. . -- donor from 68 to 70% of the cash that's out there for what we call global health. so this puts us at a difficult moment in light of the rest of the discussions that you've heard today. general odierno says you cannot succeed in this new vision of iraq or by implication in what he was saying by where we're going in afghanistan if you can't increase the level of the civilian engagement in what

we're dealing with in foreign assistance that means you need a strong u.s. agency for development and a strong u.s. health initiative and, you know, a strong account 150 to put it in budget terms. but we're in a different world now as of the elections and we're in a very different world from the world in which tony fauci played a critical role conceptualization of pepfar and there was anna wakening of christians of a grassroots level across the united states to the need to engage as christians in improving the health and the lot of the lives of people outside the united states. and so you had literally from grassroots churches, a kind of a movement in the united states that supported president bush's very surprising announcement.

i mean, i think tony was one of a handful that knew what he was going to say when he stood up at the state of the union address and announced by the way, i'm going to throw billions of dollars at the hiv/aids epidemic and now where we are when we look at the constant u.s. nudging to combine all of them to match what we give. just to accomplish that we'd have a hell of a pot to fight for global health with. look at where we are now. first of all, we have an enormous wealth gap that has occurred -- that was already in process of occurring before the 2008 financial crisis. just here in the united states in 2005 the bottom 50% of our population earned 12% of the wealth of our country while the top 10% earned 21%.

but according to the 2009 census, that got much worse that the bottom about 3.4% and the top 41.5%. that sort of widening of the gap of wealth and shrinking of the real income of middle classes is not a uniquely american problem. in fact, the most extraordinary gap widening increased for the top 1% of the population over the same time period. and what this has meant our own middle class is shrinking, and is experiencing tremendous pressure and a less altruistic and generous mood at this moment and this is going to make for a real challenge in trying to go forward pushing in congress, pushing on the g20 and various other places for cash dead cade

for global health, to food policy, to water policy to any what i call transnational threats. in addition we are shy americans as -- americans individuals are shy 6.5 trillion for our personal retirements. if it's bad now it's really going to look bad in about 5 to 10 years as the full baby boom generation marches off to retirement or whatever they march off into. and health care is the most rapidly inflating sector, not just in the united states but all over the world in terms of cost. so that in the oecd overall health care costs, since 2000, inflated 7.8% roughly a year. but here's the interesting catch, in single payer economies such as social paychecks in europe it inflated 16% between 2008 and 2010.

so they're feeling the pinch on the home front that is an additional pinch that's going to cohn strain a sense of generosity. we have a currency war going on that essentially involving countries trying to devalue their personal labor forces more than the other guy's labor force in order to attract investors and this doesn't bode well for middle classes everywhere and a liquidity crisis somewhere between 5 and 10% of the 70 trillion deliveries global wealth locked up, not out there at the moment. in general circulation. so when you put all this together, what it means is we're -- we have less cash in circulation. we have a shrinking middle class in most of the wealthy countries. the wealth has really shifted to the top 0% wealthiest in most

large economies in the world. and we're shifting from a g8 world to a g20. and here comes the big catch, most of the big g20 countries are actually still recipients, not donors for global health. china is a major recipient of funds from the global fund by aids tuberculosis and malaria. india is a major recipient country. brazil is still a recipient country. so when the latest g20 summit happened two weeks ago -- if i got my memory right -- >> september the 22nd. >> thank you very much south korea tried push -- south korea tried to push for a real discussion of the donor role of the g20. and the rest of the g20 nations besides the original g8 all said, no, off the agenda. we're talking currency wars here. we're talking trade and market policy. and when you really get locked

down into arguments about how do we deal with global health governance and the intersection between governance and donation to support such things as all those people, 4 million plus that we've successfully gotten on antiretroviral treatment but need to stay on it for the rest of their lives, you cannot stop the pills from flowing. when we look at that big picture at the level of the g20 and the emerging market countries it all ends up being we're not talking in the same conversation as you 'cause we're talking about trade policy, about technology transfer, about who controls pharmaceutical patents and whether or not at the next pandemic we get vaccines or it all stays in the rich world. and so we don't really have a collective conversation where we're talking on the same plane when we say global health except

on the original traditional wealthy nations and they are feeling a lot less generous today than they did four years ago. >> admiral, i know this seems like a good place to segue towards you. i noticed on pbs you had spoken about mr. suarez and you were talking about the generosity of the american people and if they can see their contributions to the global health of developing countries, poorer countries are effective and i think an important point that might get missed by some of the g20 countries is the link between prosperity, productivity and health and about malaria, you're talking about 450 million people, many of them are children. the children die of the illness but the adults -- it doesn't make a very vigorous or healthy work force so i guess the question is, against the

scenario painted by laurie, do you believe, you know, the legacy of president bush will be protected by the -- sort of the new dimensions we see, you know, forming in congress at this point? >> you know, that's good question, brenda because everyone is asking if we have set tremendous expectations in the world today with the success of the programs will and i refer back that -- there is one of the major shifts that have allowed us and the collective multiculture laterals in the country to work is the increase in resources. and what we're facing now, what time it's quite dramatic, and causing a lot of questions, i think we need to remind ourselves that we have been at a place like this before. and so the question is what do we do?

and we don't know yet because the dollars and the economics will become a bit clearer here over the next several months. and at that point we have to look at the realities of what coming appropriates and then look at our national commitments and priorities and make appropriate adjustments. you referenced the generosity of the american people. laurie mentioned that in a number of her comments. i feel that's a trait that we have embedded in our dna as citizens of this great country. and if i can get personal for a second, i have come to that conclusion based on a number of things. i grew up in asia. my parents were missionaries. much of their work had to do with medical missions and in many of the countries today, 50 to 60% of health deliverables is done through ngos, private sector and missions.

along with that investment comes a lot of passion and personal sacrifice. and that's going to continue. that is marginal when you talk about the billions of dollars needed to sustain programs but it still exists. and then there's also the private sector. and the private sector has been extremely committed and involved. let me speak for malaria specifically it's been an inclusive community internationally as well as u.s. where we'd seen the prosports teams, nothing but nets, the soccer leagues motivating. we may not have raised billions of dollars for neither but we certainly have advocated in front of the american people the significance of engaging on a chronic international problem that we call malaria we have had major contributions motivated

and driven by ray chambers, the u.n. malaria envoy who has motivated private citizens as well as foundations to do together and work with governments. and then there's the donations that are being solicited through the booster program and then our own programs. and so as we look to the future and we lack at the commitments that we have communicated to the most endemic countries, and most are in sub-sahara africa, i think the challenge as the budget realities become clearer, then we're going to have to make adjustments because we have made significant progress over the last four years in many of the four countries. and the challenges we have are much different than what the hiv and aids community have. we have pravn effective interventions.

our -- we have proven and effective inventions. of our public/private partnership of which we are very aggressive and significant ppp's and public/private partnership and i call it my prevention, prevention, prevention program because three of the four interventions are about protecting people. as we have seen the incident rate drop as much as 50 and 60% of some countries, and all child mortality dropped by 30% in seven countries basis on two data points, there's a lot to celebrate. so regardless of the amount of money that we get, we're going to have to rally the horses, coral the wagons and do everything we can to sustain the progress we are made with our multilateral partners as well as

the national governments and then work towards sustaining so that when the dollar figure changes, we can continue to scale up sustain build capacity and move forward. >> thank you. >> it's interesting 'cause you said at one point we've been here before. and, in fact, there was a time back when joan f. kennedy was president of the united states and the u.s. people set out to get rid of the malaria, not in the united states. that we had done, the whole world and at that time ddt was brand-new and there were no resistant insects and there were no resistant -- significant resistant parasite population populations and they worked tremendously and we got out there and all over the world the campaign went full bore and countries that had lived with

malaria horrible levels for centuries suddenly went almost malaria-free. jakarta went to a state of no malaria in jakarta and indonesia and so on and then congress said well, we gave you a deadline and you haven't finished it yet so the money is cut off. and boom, malaria soared everywhere and one of the things that soared with it was the chemicals. so the lesson i take from that which i think is really where we need all of you on our side in this -- if i can use that sort of rallying cry is that this surge in global health interest concern and funding is still in an infant stage. the money has poured out but a lot of the programs are just, you know, still making mistakes, finding their way, trying to develop relationships with host governments trying to balance

where does the ngo fit in and the faith-based initiative fit in and we can't pull the plug because we're looking for somewhere else to do with our money >> dr. fauci, we're not just talking about aids, tuberculosis and malaria, i mean, most people in these countries die of the same thing that we die in this done so the question is how do we do it? and there's a way to do it with less resources, i guess? >> you know, all three of us have alluded to it in one way or the other. a couple of years ago in a journal that i'm not so sure people in this room would read regularly called nature medicine. i wrote an article that was a commentary on the success of the programs that we had with malaria and hiv/aids and to some extent tuberculosis and the

point i made in the commentary is what exactly and laurie and tim and what you, brenda have been saying and the catchword is really sustainable health is there. you don't fix health. you have to keep with it because people keep getting sick and diseases continue to emerge. so the answer to your question is, that how we deal with it is true putting more money? you -- putting more money in but it becomes a way that's sustainable, sustainable within the countries that we're dealing with and make health part of the national strategies of the countries that you are working with. i mean, it's no more -- secretary clinton gave a wonderful speech a few weeks ago where she was talking about getting rid of the words aid to and talk about partnerships in development and that's really -- health is part of that it's a fundamental part of that.

and, you know, we were talking about this panel that was here before that was talking about the political events and foreign policy well, you know health is one of the most important components of foreign diplomacy. so i think this is all a big part of the big picture. so the way to do it is to talk an approach that we're not just going to be doing something on the short term or the way congress give us a five-year appropriation and that's it. it can't be that way. it has to be an enormous indefinite commitment and not a commitment of giving but a commitment of building sustainability. >> and i think that's interesting. i referenced president obama's speech to the -- you know, to the development summit in new york in september. and he specifically said we

should not think of development as charity which i think we do. we think of it as something that we give. i think it would help if you -- i mean, i'd be curious to know from you how building health systems -- how do you build health systems in places in places for so long have depended upon assistance and can you make these tradeoffs with countries to get them to do this? >> yes, we can do it but we have to have cooperation from the country we can train people but they have to have an environment in their own country where it is an attraction for them to stay in their country as opposed to training people who then go off to other countries because you've trained them. and we can't fix the economic system in the country or the attitude of a country about how much of their total gross national product they're going to put into health. we've got to partner -- and

that's what really part of the millennium goals are. that's really part of that is to deal with countries who are taking seriously their own contribution to what's going on in their own country. so it's not going to be easy, brenda. it's not easy because some of the countries that have the greatest needs have leadership that don't see it that way. and it's presumptuous for us to think we're going to go in and change the culture in countries but we have to at least try to help train the people. >> admiral zeimer, when i was sort of reviewing what people were talking about, these three pillars of development, defense, diplomacy and development, essentially, i think a lot of people think that in the past we've sort of gotten it wrong and that so much of our resources and so much of the emphasis was on the military. and so the people being -- bringing aid and the people

bringing care were in uniform and it might have colored their impression of what the u.s. is doing and why it's doing. how do you sort of link aid to diplomacy in that sense? >> i would -- i think that's an important point and i would refer back to what the president himself had said in anticipating his policy decision on global development where he addresses the whole idea of sustainment, innovation and incentivizing multisector partners, business. secretary clinton has followed up in saying, you know, we've all heard her 3d speech, defense, diplomacy and development. and it's clear to those of us in the development business that development is a core component of diplomacy, health diplomacy and we can talk about that all evening i think the defense department does understand their role and that your mission and they have been mobilized

successfully over the last number of years to do tremendous work because of their capacity in disaster relief situations, floods, earthquakes, a tsunami. i think there's an awareness, though, by the defense department that what they do is not long-term development. that is an industry and a sophistication that they understand needs to come in parallel to the whole of government approach to effective development. and again, one more thing, underneath the global health initiatives, the principles that we see in addition to focusing on welcome's health, leveraging the interagency process, which includes dod, looking for innovation and lev ramming resources and focusing on what tony said it has to be owned by the country itself so that the donors -- all of the players

look at one basic common plan by which we engage and can leverage what the country requirements are with the other donors i'm optimistic that the playing field is coming together in a clearer way even though the finances may be a little bit fuzzier. >> that's a big irony actually of the moment we're in. as i said this whole global health and development and the linkage between the two and sufficient funding to do something meaningful is a relatively new phenomenon. and we've just hit the point where we had this sort of perfect alignment of an administration -- a leadership in the house and leadership in the senate all agree that there had to be better coherence. that there had to be a strategy to foreign assistance, that it had to be linked in some smart way with defense, some smart way with long-term health and development and now, you know, that leadership on the house side is out we'll have to see what the gop leadership would feel about all of this.

and kerry-lugar never got that far away and what we got away from general odierno's talk which was such an inspiring conversation earlier today was that you're not going to win over support for good governance and for working out differences between tribes, ethnic groups, various groups if the only american presence is a combat presence. he also used the phrase, whole of government the whole of government approach in afghanistan hillary clinton has said over and over again starts with recognizing that an afghani woman has several orders of

magnitude, greater probability of dying in childbirth than in america. and very few women hear ever had to worry -- felt they really had to worry they would die in childbirth but if you were in kabul or out in the rural areas, this would be a very real concern every time you got pregnant well, what does it mean to u.s. interests and u.s. foreign policy if more and more women in afghanistan recognized that because of programs brought by the global health initiative from the united states, fewer of them are dying in childbirth. and more of their newborns are likely to live to their fifth birthday. what does -- what does that kind of engagement mean? and i think that goes to do you build a health system and so on? but it also goes to what are we trying to do as foreign policy? and why do we for so long think that all of these issues you

mean i mean, i've noticed how much of the room has left because this is the soft stuff, right. we already had the hard stuff. >> it's a question i'm going to pitch it to the audience after this. but i'd like to ask each of you to, you know, answer the question why should americans, particularly in the current economic climate -- why should, you know, we continue to -- granted, it's very small percentage of the budget to begin with. so why should americans, you know, let this drop and why should they continue to invest in development? >> well -- >> and global health care and global health. >> there's two reasons probably four but i don't want to go on. the one i used to work on before people got interested in global health and the globality of what we do and that is the pure

humanitarian reason. as human beings we should feel a moral responsibility to help take care of people who are less fortunate and i think as human beings in general and particularly as americans it has been the spirit of america for a very, very long time, ever since the beginning of our nation that's one reason. the other reason is that we live in a global community, and we are all interconnected economically, politically, from a security standpoint. and a health world is a world that will be economically viable and we depend on different countries back and forth. we know that. that's an economic discussion that can go on and on. but also from a security standpoint. i would venture that if afghanistan were not as a poor a country has it has been from the standpoint of health alone, it's one of the most unhealthy countries in the world, i'm not so sure that we would have had al-qaeda being able to go in there and roam free if it was a

strong healthy nation. it goes everything from humanitarian to economic interest to pure security. >> i would go another level and just add to what tony said all of which, of course, i agree with. as long as folks in gaza and the west bank have children contract measles and israel goes decades without a case of active live measles you're not going to have warmth between those two places. if the odds of a palestinian child living to age 10 are lower than the odds of an israeli child living to age 10, you're not going to reconcile the differences between the two places. expand that globally. we had this clarion call a year and a half ago when h1n1 swine flu emerged in u.s. and

explosively in mexico and fortunately it was a relatively benign virus, not anything akin to the 1918 horror of influenza. but everything that we had always warned would happen in a pandemic that would eight tensions between nations and misunderstandings between nations really did happen overwhelming, the very slow and eventually available vaccine concentrated in the wealthy countries. overwhelmingly, the only effective drug tamiflu concentrated in stockpiles in the wealthy countries and overwhelmingly everything in the toolkit that could address the pandemic was far more available in a very rich country than anywhere else in the world. in fact, by the time most of the vaccines supply forever africa reached africa, the epidemic was over.

so what that said to the rest of the world, you know what? why should we partner you on anything? because when the really big one comes, you're going to walk away from us. you're going to hoard everything you're only going to take care of your own. if we can't demonstrate that we think the health and survival of a baby boy in beirut is as valuable as a baby boy in los angeles, we're never going to have an equal conversation. >> health is the right thing to do. and as tony has said and laura, the programs at the u.s. government are invested in are saving a lot of life but now we're seeing it's building capacity and sustainment in addition to health, the united states government is spending -- one of the presidential initiatives is feed the future. so in addition to health, we have nutrition and food to move

towards this whole development commitment and i'll jump back to what tony said earlier the millennium development goals, you hear a lot of chatter on that. but getting back to malaria, we address six which is a reduction in infectious disease and we address the maternal health issue and child survival but healthy kids mean kids in school so we're touching education. in malawi, a mother making less than a dollar a day spends 30% of her disposable income on antimalarial drugs, that's poverty in action. if we can eliminate that from her discretionary income hit that will help her that day and that moment. and so that then drives us to millennium development goal, poverty aliation so while we do excellent work in health where we are saving lives, the united states government can actually show impact and show the data that this is a good return on investment. and it drives us back to the

ultimate goal of poverty alleviation, community development which is what we're all seeking and hope for. if there are questions, we certainly can start here. >> can you hear me? >> yes. >> i'm patricia kraske from the western mass council world affairs. i know it's not a very economic consideration or a militarily important country but for purely humanitarian reasons, shouldn't we be doing more about haiti which is a country in our own hemisphere? i'm very concerned about the

recent outbreak of cholera and the fact that what you read about -- that we had helped initially and then we pulled back and and i want to know from you folks is there any kind of ongoing help in our own hemisphere for countries especially like haiti who have nothing really to offer to us economically, militarily but from a humanitarian point of view? thank you >> haiti, last spring captain mendoza from the u.s. navy and i co-authored a piece saying the national weather service was forecasting 16 major storm events would hit the caribbean with reasonable odds at least one of them would slam haiti didn't we need to immediately as a matter of urgency for the survival of the people of

port-au-prince build some structures that would withstand storm and flood conditions to which people living in tents could flee. build an early warning and radar system which they didn't have for distinct weather detection. build an emergency alarm system with warning and training of the populace so they knew where to one and now hurricane tomas has hit haiti and none of that are in place and people are literally holding pieces of plastic in their heads while the wind and rain are pouring down upon them and we saw similarly with cholera, it's axiomatic as we go into a far more globalized -- which is good news, humanitarian and peacekeeping response in the world. that the humanitarian responders and peacekeepers themselves can become vehicles for microbial hitchhikers from all over the world if you're moving u.n.

soldiers and they're in congo the next week and the next week somewhere else and the red cross workers are the same and the msf are the same, you have the potential for every single one of them to be a disease carrier we know the cholera was introduced from outside it certainly didn't naturally arise spontaneously out of the water of haiti. and it doesn't really matter -- i don't want to blame anybody for that introduction. but i think that our inability to respond very effectively and very rapidly once it did emerge and keep it very localized is disappointing >> i think the initial response and dr. fauci can address with it are dealing with people who are severely injured or, you know, facing major trauma and until -- i mean, that was the initial concern. the question of why we have not been able to rebuild haiti, get around to doing it sooner i think the bulldozer it is didn't get there until october i know

this is not exactly health per se but -- >> no. >> it -- >> it encompasses health it's not really a health it's a commitment problem to our neighbors about of doing something about getting that country to be self-sustainable if you look at some of the health areas from haiti like bill and paul farmer who spent so many years there, it is clear that you can accomplish an extraordinary amount with actually relatively little investment. it isn't as if you're going to than putting billions and billions of dollars in there you could probably do it so the answer to your -- the shorter answer is, we should be doing more. >> because they are in our hemisphere. >> well -- >> and for humanitarian reasons. >> i think humanitarian reasons also. and also because, you know, the whole issue with cholera, you

know, if you look -- again, just very briefly, if you look at the cholera map, the belt of cholera, cholera occurs in regions so to think it's going to stay as laurie said in haiti, once you introduce it into a region and people go back and forth to different countries, you're being presumptuous and naive to think that it's guaranteed it's going to die out there it likely will and i hope it will but it may not. >> in fact, just historically, the greatest cholera outbreaks in the united states were all related to the slave trade and the movements into the caribbean and back up again. and so we constantly had cholera reintroduced into our waters, especially in new york city sometimes with devastating results. >> i appreciate your interest in haiti and just to address the what are we doing right now with the storm and the cholera outbreak, if you go to the usa website owl see that there are

20 mends of a disaster response team that's there right now. and there's a significant aggressive amount of work going on in conjunction with the pan american health organization, cdc and i would invite you to go to the usa went and that will give you at least today's readout. >> thank you. >> next question? i'm sorry, over there i'm sorry. >> my question is on hiv and sub-sahara and africa. i'm chuck from the world affairs council and my question is what funding for the u.s. government and the ngos and other governments are available for hiv and how much take -- and how much funding would it take to a sustainable preventible program for hiv in sub-sahara and africa? >> well, when we put together the original pepfar program, 20 about there of the total amount

was in prevention, 55% in therapy and the rest in care, between 20 and 30% in prevention. what would it take -- and that's just the pepfar program. there are other components of it for prevention. it really would require access to the modalities of provery long that we know know work and that's the point that is so frustrating under the best of circumstances when you have health infrastructures that don't allow any more than 20% of the population who would clearly benefit from a proven prevention modality don't have access to it. and it's the whole issue of what all three or four of us were talking about, about building sustainable health systems. if you don't have a health

system you won't get them in there and let them know what to do to prevent. that's the structural functional answer. but there's also another answer that when you're dealing with a sexually transmitted disease in cultures in which you have flagrant and did you get epfranchisement of women where they don't have the human light to basically protect themselves in a society that really demean it is women that becomes very difficult and we as my friends in africa tell me all the time and a smile to my lips you don't want a white like in africa saying you have to treat your women better. you have to have the leadership in the african countries realize they have to turn around centuries of cultural issues which have not allowed their population, particularly the women to be able to protect themselves.

that's one of the very important stumbling blocks in culturization. >> stigmatization and home phobia in this country and hostility in gays and it has created a resurgence of aids in gay communities. i think this administration is focused zeroed in on certain groups. we have time for two more questions and then we'll to have wrap up. >> i want to shift to another topic as i recall with the h1n1 we did not have enough vaccine even for here and it got into the whole complex of vaccine production and which companies are going to do it and how much lead typically do you have and knowing exactly what virus you're dealing with is and then distribution and i wonder if you would address that part of the problem?

>> well, the problem with not having enough vaccine for influenza is that we have -- the root cause of that really is that we as a nation and the world has not taken seasonal influenza very seriously. we say well, i have the flu and whatever and when you think about a pandemic and you get all nervous but seasonal influenza is a very serious issue it kills at an average of about 36,000 americans a year with 200,000 excess hospitalizations, about a half a million people a year die of influenza but we just take it in stride. the incentive to make a vaccine that in a way that you can quickly ramp it up and got it in a matter of a couple months -- and you'll take it one step further. the incentive to make a universal vaccine that you don't need to change from season to season, that you can give it once every several years and protect not only against drifted

strains but on strains that actually change dramatically as the pandemic strains. we haven't had 7 that incentive on the part of industry or on the part of our leadership to encourage industry of that and the bird flu as laurie said of the relatively mild h1n1 is that it got everybody all exorcised about my goodness are we dealing with antiquated ways of raising vaccine we'll grow it in a cell no, we are molecular techniques to get the virus sequenced and immediately start making it instead of having months delay so what is happening now is that the federal government, to their credit, is now sharing the risk with industry by doing things

like helping with the advance of the advance development production. the have developed a plan to go from egg based to cell based. we're making extraordinary investments to try to develop molecular based flu vaccines and ultimately a pandemic or a universal flu vaccine that essentially covers everything and we're really way behind and i think the jumpstart we're seeing now because we all got frightened by the threat of a pandemic -- everybody looks to 1918, oh, my god we can't have another 1918. so i think it's going to to change but, unfortunately, it took several decades of really mediocre responses to influenza. >> thank you very much. >> yes. >> hi marty long from connecticut. we've had rankings of countries over the last two days and the u.s. is not in the top so i just

wanted to say thank you for putting you get at the top of the list for giving around the world. we did not have one category where we were number one. so thank you very much for that. that's a good feeling. my question is, i think part of that is because, you know, we trick or treat with unicef boxes and we have rallies and we have telethons and we raise a lot of money on the private sector and i think we support our government in doing the same away the world. how do we get the emerging market countries that have huge savings to do the same and they could -- you know, they love to golf in asia, can't they do rallies? i don't think you can do it with the government. i think it has to be a populace, you know, topic that makes the government give more money so that i hope we maintain our number one status but i'd like to see china number two.

>> it's a great question and it goes to what i was talking about in the early part of this discussion. the shift from the g8 to the g20 world. and how do we talk about the priorities of global health and for that matter food and agricultural policy, climate issues all of that in this shifting political landscape? actually interesting what is slamming the successfully emerging countries is the sudden surge in chronic diseases that are typically seen in the wealthy world. and so suddenly they're experiencing an obesity explosion, diabetes associated with it. more and more their populations are living longer to develop cancers, cardiovascular disease and strokes and every one of them has a minister of finance that's sitting down doing the demographics and the long forecast and saying, my good physicals in if we don't do

something, we're going to be bankrupt trying to deal with this end stage disease burden down the road. so what we see now is an increased level of concern in china, in brazil, in mexico, and so on and is spurred about the chronic disease in aging populations it doesn't get to the fact that so many countries, is out africa being a prime example, are experiencing both the same time. a transition to the chronic disease burden while they still have this enormous infectious disease burden that is akin to what we were going through perhaps 150 years ago in the united states. that is where we have a logjam is in a continuing commitment from the global donor population

and the g20 countries generally to that remaining infectious burden to put a data point on something the admiral said, since 2007 the amount of money put into fight malaria globally has increased 166%. that's an astounding figure. and what that means is people in whole parts of the world that absolutely had nothing to do except accept malaria as part of life or death as the indicates may be now actually have tools at hand to save their life if they get infected or prevent infection all together. and those people as brenda said about an hour ago here will eventually die of cardiac arrest or cancer or lord knows what because they don't have any health service for that at all. so i guess you would say the big momentum is to try and sustain

and even increase the commitment to conquer the old disease burdens of infectious disease while at the same time revving up for this demographic explosion that's going to hit most of the countries of the world in the next 20 years that will be aging and chronic disease perfect storm. >> and one would hope that with emerging economies, with growing economies and growing middle class that you would also have an active citizenry which would begin to demand better services. and this administration has said that it's going to link its support even to those second tier our middle incomed countries it's going to link assistance and to democracy and if these efforts are supported by the current congress, is that that will bring about some change. and that's all we have time for.

[applause] >> a very big thank you to our panel on this very critical topic on u.s. foreign policy. thank you very much. i hope we've achieved our goal, our objective of engaging you, our leadership across the country. on the critical issues on foreign policy with the critical players in foreign policy so you could take this back to your local communities and determine what type of programming and educational work you want to do in your communities with this. you would like to thank our speakers over the past several days our donors, chevron, thompson ritaer, stanley foundation, raytheon, northup grummond but most importantly i want to thank you. you've taken your time to engage these very critical issues facing our country. you spend your lives trying to

build or democracy by ensuring that americans have the opportunity to learn more about global issues. thank you for what you do. thank you for coming and we'll see you in the east room for the reception and dinner with larry summers on the global economy. thank you. [applause] >> welcome back to booktv. every weekend beginning at this time here on c-span2. over the next 48 hours we'll bring you programs on nonfiction books, authors and the publishing industry. ...