and it takes a combination. >> i believe it is attainable. from personal experience, yes. >> to see all the winning entries in this year's competition, biz @ the website. -- visit the website. . .

>> thank you very much for coming. we are obviously delighted to be able to welcome to our nation's most important leaders on global health, one a former president of united states and the other the ceo and chairman of one of america's most transformative companies. long after their own places in history were secure, both president bill clinton and bill gates made it their passion to write an impressive new chapter in an effort to solve some of the world's most pressing problems. fighting hiv/aids has long been on the top of that list, and during a polarizing era in american politics it has been the kind of bipartisan success story that defines our democracy at its best. back in 1999 and 2000 i was pleased to work with jesse

helms, bill frist, and many partners from both sides of the aisle to pass comprehensive hiv/aids legislation that laid the foundation. today, thanks to these programs, over 2.4 million people are receiving treatment and nearly 350,000 babies of hiv-positive mothers have been born hiv free. that is a tremendous accomplishment, but it is still not enough. what is more, we have made great strides against malaria. this in turn has cut childhood mortality in some areas by as much as one-third. the global fund, where every american dollar is matched twice over, has prevented millions of deaths. but as long as so many lives remain at risk we obviously cannot rest on past accomplishments. as the administration finalizes

the global health initiative, we need to ask ourselves -- where do we go from here? how do we build on the success we have achieved? the global health initiative has rightly identified several core principles that ought to guide our thinking. first, help systems are more than the sum of their parts. even as we expand our fight against hiv/aids, we have to look beyond any single disease. second, a holistic approach leads us to focus on women and girls, who are the center of each family's health but are too often marginalized by their economies and help systems. this includes taking on maternal mortality, which robs families of half a million young mothers every year. third, because we seek to empower other countries to eventually assumed full responsibility for the care of their citizens we must recognize their priorities and

the importance of building local capacity. these principles informed the strong bipartisan message of the reauthorization bill of 2008. i hope it will provide the underpinnings for strong bipartisan support going forward for advancing global health and strengthening the fight against hiv/aids. last summer, i had occasion to travel in south africa. my wife to reset and i saw firsthand the realities of this struggle. we saw them particularly when we visited a primary school. we saw care givers who devote their lives to helping the region's aids orphans, children left with no choice but to assume adult responsibilities at a tender age and single mothers scratching out subsistence in mud houses, their husbands lost to a horrific disease and many

of them hiv-positive. we saw the crushing economic impact of poor health, which underscores why improving health lays the foundation for better economic development across the board. clearly, our fight is far from over, but we also have more challenges. as our climate changes and mosquitos expand their range, malaria is surging in areas that have hardly seen it before, like the kenya highlands. we must ask ourselves -- are we doing enough to prepare for the challenges climate change may bring on a massive scale? we in congress must answer another crucial question. is this an investment we can afford? in an interconnected world where drug-resistant tuberculosis could be on the next plane landing at dulles, the answer emphatically is that we cannot afford not to invest in these programs. a strong global public health

system is not merely a favor for other countries. it is right morally and strategically and protect our own citizens. in fact, such a remarkably effective bipartisan effort is precisely the kind of program that is worth defending in a budgetary environment where there is pressure to simply/our investments in the world. it is no exaggeration to say that the clinton and gates foundations have revolutionized public-private partnership. the gates foundation has invested billions of dollars for aids prevention, vaccines, and a host of other health challenges. the clinton foundation has done groundbreaking work negotiating down drug prices for life-saving medications and pioneered projects that transcend the artificial boundaries between health and development. our guests today, bill clinton and bill gates, need no further introduction.

i look forward to a lively discussion with two of the great innovative thinkers in america today. we are particularly grateful to both of them for taking time to come here. >> thank you, mr. chairman. i join you in welcoming president clinton and bill gates. we appreciate especially the efforts that both of you have made to change your schedules to be with us today. in numerous locations around the world, the bill and melinda gates foundation and the clinton foundation rival our government as visible representatives of the united states of america. even as these foundations focus on helping individuals they are playing an increasing role in the public sector in lending policy assistance to governments. their actions have influenced public opinion and catalyzed international action. most importantly, they have been vital partners with the united states government in the fight

against hiv/aids, malaria, and tuberculosis. the share in successes our country has achieved in these areas. according to the office of the global aids coordinator, the president's emergency plan for aids relief is directly supporting life-saving anti- viral treatment for more than 2.4 million men, women, and children. they represent more than half of the estimated 4 million individuals in low and middle income countries on treatment. before the program began in 2003, only 50,000 people in all of sub-saharan africa were receiving life-saving anti-retro viral drugs. today, 10 times that many are being treated in south africa alone. the success of prevention programs is harder to measure, but no less critical. vaccine research, development,

and distributions remain at the forefront of prevention efforts for hiv, malaria, tuberculosis, and other diseases that played the developing world. i think the gates foundation for their $10 billion pledged to provide vaccine research and to distribute vaccines to the poorest countries. both of our witnesses have spent a great deal of time thinking critically about how to maximize the funds available for global health. their organizations are deeply attuned to both the strengths and deficiencies of a global help avert, and may have acted independently to implement good ideas. for example, the clinton foundation has devoted efforts to negotiating lower prices for drugs, thereby increasing their availability, especially in africa. among its many endeavors, the gates foundation has worked to promote innovative funding

mechanisms that would encourage research on vaccines applicable to specific circumstances in the developing world, despite the limited potential for profit from such vaccines. i am especially interested to hear the assessment of our witnesses concerning how the global community can more effectively work together to make progress against catastrophic diseases. do you feel that contributions from our friends and our allies are adequate? can global interests including both public and private programs be more efficiently coordinated with one another? currently, do you believe there is a rational division of global health contributions between treatment and prevention? meanwhile, the united states government has to do more to ensure that its own health dollars are being spent effectively. although our program has been a success, we need to seek greater

efficiency with this program and other global health efforts, in particular to improve coordination among agencies working on international health programs. the state department, u.s. aid, the nih, the cdc, and the defense department all have critical capabilities that are being applied to global health. we need to ensure that these agencies are talking to one another, adopting best practices throughout our government, and avoiding duplication in activities. achievable steps to improve performance are insuring co- location of health care agencies and the emphasis where possible and reducing unnecessary overlapping reporting requirements by personnel in the field. conversations with the administration indicate they are aware of these issues ever working on improvements, but i look forward to the results of

these reviews in the near future. as efforts on global health move forward, it is vital they be accompanied by assistance to improve agricultural productivity and food security. the connection between undernourishment and health has long been established. the world food program reports that 25,000 people die each day from malnutrition related causes. prolonged malnutrition in children results in stunting and cognitive difficulties that last a lifetime. health experts advise us that a diverse and secure food supply has major health benefits, including improved cognitive and physical development of children and stronger immune system functions. i am especially appreciative of the creativity and the resources of the gates foundation, as applied to encouraging agricultural research and productivity in the developing world.

when secretary of state clinton testified last month, we noted the strong convergence between her a hunger and food conservative initiative and the global food security act which has been passed by this committee. i believe we have an opportunity in the coming months to achieve something close to a consensus and to pass a global food bill that would have major benefits for international health and stability as well as for united states foreign policy. again, i welcome both of you as good friends of the committee, as distinguished americans, and as witnesses that we have looked forward to hearing. thank you very much. >> thank you very much, senator lugar. thank you for being here. your initiatives have obviously had a profound impact and we are grateful for them and we look forward to your sharing your views on the global health. mr. president, if you would lead

off. >> thank you for inviting me here. i work for this committee. 44 years ago, when i was a junior at georgetown, they worked with me. he now looks 10 years younger than me. i think i last testified before the congress in 1994, while president reagan was in office. i also want to thank you for the chance to be here with bill gates. i think he and melinda and his father and the people at the gates foundation have not only amassed more money for health advances but actually spent the money better and promoted more

innovation and saved more lives than anyone could have imagined. i count it a privilege to work with the gates foundation in many areas. i will mention a couple of them today because i think they reflect how you should consider the global health initiative in the administration. i want to thank both of you for your bipartisan support of large increases in health care investments. the malaria initiative, which began under president bush, was literally an order of magnitude beyond anything our country had been able to do before. in my second term, we were contributing 25% of the total the world was spending on hiv and aids, and my last budget was something like $300 million a year. the biggest thing we did was the millennium debt relief initiative because all of those

savings have to be spent on health care. when you have done here, i think, is very important. i also want to thank you for repeatedly and explicitly recognizing that global health is a foreign policy priority for the united states. if i might just cite one example before we get to the bill, the dates foundation gave us some money that the clinton foundation used to subsidize the price of high-quality malaria medication that would actually deal with the mutations of malaria. we started off testing it in two provinces in tanzania. but we decided to do -- we decided to do the announcement in an all muslim area, a result bill lynch -- a remote village

on a sunday afternoon. 12,000 people showed up. it was in the middle of the iraq war. all these things supposedly made america alienated in this country, were just a few years earlier our embassy had been blown up. 12,000 people showed up and none of them were mad at the united states. they thought we cared whether their children lived or died. i applaud the committee for doing this. let me make just a couple of observations and say something about the bill and make a few very specific recommendations. first, i know what you're going through with the budget. i strongly supported the restoration of pay as you go rules. i understand the dilemma is that

you and the congress will face. most of the time i have spent since i left office i have spent working on global health or matters related to it. i understand its importance. for me, as senator kerry was kind enough to mention -- i have always tried to do more with less because when i started less was the order of the day. i would like to talk a little bit about what we tried to do. you talked about reducing the price of aids medicine. generic medicine was $500 a year. it is now about $120 a year. pediatric medicine is now down to $50 a year. that is the biggest drop. thanks to the gates foundation, the high quality malaria medicine that was about $9 a

dose is now down to 50 cents a dose. by the way, that is harder to do with malaria than with antiviral to make it work. we have lowered the cost of laboratory tests and equipment for tests. we just succeeded in getting our first agreement with a major pharmaceutical company, pfizer, which produces the only drug that we know of that you can take to treat tuberculosis if you also are hiv-positive. it does not make you so sick you cannot function. they give us a discount to buy in volume for people in developing countries. when i asked them why they did this, the new president said, "i realized we had a marketing

strategy designed to saturate 15% of the world. i would like to sell to the other 85%." they have not gotten enough credit for moving beyond their business model, thinking about the future in a different way. this change could help us save 300,000 lives a year. you have a half million people die of tuberculosis every year who are also hiv-positive. what we have tried to do is to lower the cost of commodities -- tests, equipment, machines, and madison -- and medicine -- by going from a high profit business with uncertain payments to a very high volume, low payment, but very certain payment. we have tried to improve the supply chain, to give greater predictability to the process.

i think all of that is relevant to the decision to make on this bill, for reasons i will say in a minute. the second thing we have tried to do is to work on building up health systems. the think i love best about the global health initiative proposal the administration has made is that it is designed to work us all out of jobs. it is designed to break the cycle of aid. it is designed to increase the capacity of local governments. you think about the discussion you're going to have on this bill and the debate we are having over health care in america. it is a classic example of the polarity of problems in the world today. the biggest problem in developed countries is that the interest groups are dug in and therefore change is difficult. the biggest problem in developing countries is they do not have structures that we take for granted. in most cases that we work, all

the stuff we take for granted -- that lights will stay on, the air conditioning will stay on -- people cannot take that for granted. they cannot assume the water is fine. i think the idea of building systems is important. we have worked to train medical personnel in ethiopia and kenya. we put 40,000 health-care workers back into the zambian system. in rwanda, we helped governments to completely rebuild their systems or to build for the first time national systems. the rwandans finally had a hospital in every region for the first time since the genocide. this time they also have a network satellite clinics and community health workers to try to extend the reach of the nation. finally, in ethiopia, where we have 140 people working in the united states government has

spent a lot of money -- when we began, there was a two-tier system. the cities had pretty good health care. 58% of the people lived in villages of 1000 or less, so there were about 60,000 villages and only 700 clinics in the entire country. they adopted a plan to develop 3500 and asked us to help them. they think once we get them built everybody will be within a day's walk to the clinic. this is important. i say that to point out that we have some experience in working here. other parts of our foundation have done work in latin america and on nutrition and providing cataract operations, a problem impacting the workforce in peru. we have done to 50,000 cataract

services in peru. as a global initiative every year we try to raise health care money. we have raised $6.5 million to help improve access and child nutrition. in haiti, paul farmer at the un is going to try to do for haiti what we did in rwanda, build a whole system that the government can run. it is against this background that i want to say the following thing. i strongly support the global health initiative. and it is closely related to food security. i think the two things should be possible, supported hand in hand. i think the bill is well conceived. it focuses on developing systems in the 20 countries. it is the next logical step after what we have been doing.

it focuses on reducing infectious diseases, increasing access to safe drinking water. it is user friendly. they want to have one place to treat everyone. this is a horrible struggle in many countries. there is an enormous emphasis on newborn and child health -- what they call a new business model of public-private partnerships. it has specific goals and scorekeeping system so you know if you are meeting them. i like all this. i hope you will pass this bill. having said that, i would like to make just a couple of observations and a few very specific recommendations. it is a very good bill, i think. and i think it is the next logical step. but it reflects the budget constraints under which congress labor's in the recommendations

for funding. if you have to make a choice, a think they made the right choice. if we do not get these countries to the point where they can stand on their own feet and take care of their own people and work themselves away from total dependency we are not doing right by them. my goal in haiti in this reconstruction is -- before i leave this earth, i want to be able to go to haiti as a tourist, where all they need from me is my money as a tourist. we should be working on this. so i love the concept of this. but i will say this. we have a real problem. bill gates and i started talking about this in january in switzerland. everybody getting aids medicine is living longer, which means they need the medicine longer and more people need it every year. the longer you live, the more likely you are to need second line medicine. even though we have cut the

price of its 50%, it is still pretty high. the volumes are going up more than the cost is coming down for second line medicine. third, if you succeed in building national systems people will show up and appear in the system who are not being treated now, and your conscience is not eating you alive because they are not showing up. but once they start showing up in these clinics they will expect to be treated. we need to think through -- if we're going to approve this budget, we need a different strategy for funding medicine for the next five to 10 years to get on the other side of this divide. the big question is how to get the benefits of the global health initiative. from my point of view, either get more money into the medicines or do more with the existing fund.