whenever possible, we try to work with the government. we developed a good relationship. i have to give him credit. i argued that he should allow funds to be used to buy the least expensive generic drug and we reached an agreement which he honored. if the medicines that we sell in 70 countries that serve 2 million of the 4 million people getting treatment -- if they pass fda scrutiny, u.s. money could be used. we worked through all that. my goal is not to go someplace where my being there causes problems for america's foreign policy. . .

>> it doesn't matter who is the president now. the interest of the united states and the challenges we face are sufficiently different from other countries that nobody is going to be popular in all these decisions. but i think we have to recognize is, we don't want to politicize our work, but we wanted to be reinforcing of the best of america. this is not complicated. when people think you care whether their kids live or die, they like you pretty well. they cut you a lot of slack. you can disagree with them on a lot of things. this is not complicated.

i believe that we don't want to overly politicize what we do. the best thing we can do for america is to do a good job of these things that we do and avoid causing some real conflict with current american policy by going somewhere are doing something with someone that would trigger that conflict. >> mr. gates? >> president clinton mentioned his personal situation. my personal experience is that if you are rich enough, there will be some resentment, no matter what. [laughter] the u.s. is the richest country in the world, so if you look at our popularity, it reflects many different things. in countries where the u.s. is most admired are the countries in africa, where this aid is

visible and it is making a huge difference. in the middle east, other factors come into play. it is disappointing but those polls showed as far as attitudes towards the united states. in terms of the scale of spending, i want to make sure it is clear that ritual governments spend dramatically more than all foundations, including my foundation. our foundation as a whole would be about 5% of the overall spending. the u.s. government is substantially bigger, and it is amazing how the other rich countries, with very few exceptions, even in these tough times have maintained their global health spending. there is the incredible countries like sweden and denmark and the netherlands that have stayed super strong, 1% of

gdp, and countries like germany and the u.k. that have continue to increase their numbers. it is really that in total that has made this possible. i do think this work as a substantial impact on help the country is viewed. a willingness to take our science and our innovation and had been a fit the poorest people in the world -- have id benefit the poorest people in the world. >> mr. president, it is good to see you again. you have both presented a compelling case why the u.s. must continue to lead income global health. i have seen firsthand, as many americans have, the tremendous goodwill generated by our leadership in global health. i have also seen americans of all ages and many from wisconsin who have been involved in health work abroad.

in 1999, when you were still president, one of the most moving trips to africa was with your e united nations ambassador, richard holbrooke. i saw the devastating and destabilizing impact of hiv aids then. holbrooke said to me then that aids was not just a health issue but a diplomatic and a security issue. this is true today, not only for hiv aids, but malaria, tb, child and maternal health and more. our global health assistance plays an important role but only in saving lives but also in advancing our overarching national-security goals. i believe you both spoke about building strong help them restructure earlier. many doctors and nurses in the developing world emigrate to europe or north america for better pay and better working conditions. the so-called brain drain continues to put a strain on

health systems in many developing areas, especially africa. i would like to get both of your views on how the u.s. can help governments address this problem, or at least ensure we are not contributing to it. what is the role of private foundations in this regard? >> thank you, senator. i worry about this a lot. i would like to say first of all, i don't think you can eliminate it completely, because people will make personal judgments about where they want to live and what they want to do. i do think the system's matter to the outcome. one of the most important things this global health initiative can do is to intensify the ability of countries to recruit, train, and retain health care workers, and deliver models that are affordable in the long run for those countries. i think there are plenty of able

people that will do it. what can we do? we can find more in country education training programs. weekend -- we can figure out how to help countries over rough spots. as i said in zambia, the whole health care system was breaking down. i think it is in the documents we sent, but we helped them to rehire 4000 people -- 40,000 people. we set up a training program for nurses in ethiopia, one in kenya, where we build that with the partners in help, in rwanda and malawi, we were involved in going down a training committee workers. let me give you an example of pre-earthquake heydey versus africa. in many cases the per-capita

income is about the same. most african universities, a lot of them collapsed at the end of colonialism because they were supported entirely by the colonial government. the haitian private universities, a lot of them were supported by the church or religious organizations. before this earthquake, we had quite a large number of really gifted young haitians that were able to get a college education in haiti. a young american who went there to teach was so moved by this that he stayed and organized an ngo to raise money to send patients to school in haiti. he had about 75 graduates before all this happen. not a single one of them had left the country to work. 68 were already working in haiti. others were overseas doing graduate studies. i think we need to seriously look at how we educate and train

people. i am thinking about this in haiti, because we have to figure out what to do with these kids to schools were destroyed for the next year or so. it may be that we should offer scholarships to foreign students which become grants that they work off if they go home, just like rural medical service programs. when i was a governor in the 1970's, it helped us so much in our effort -- and are desperate infrastructure problem. if you stay in america, of course you can do it, but you have to pay your loan back. you can convert your loan into a scholarship if you go home. i think we really need to think about how you take the life experiences of people and make it work for them. there is nothing you can do about the fact that you are going to be able to make more

money here than in rural ethiopia, for the foreseeable future. but if you make it easier for people to stay and operate at a high level of efficiency, i think more will stay. you will be amazed how much this global health initiative will help just by building the infrastructure. people do not like to fail at what they do. they do not like to feel they are in an environment where their efforts will be fruitless. that is the concept behind ghi. if people think they can succeed, they are more likely to stay at home, even for less money. >> mr. gates, let me ask you about the malaria issue. i would like your thoughts on the future in the fight against malaria. >> just add to that previous thing, the people who leave the country are actually responsible for the best thing

that happens in african countries, which is remittances. remittances are five times all foreign aid. when somebody leaks, it is not a bad thing, because they are going to be sending -- when someone leaves, it is not a bad thing. they will be sending money back. in terms of malaria, these are exciting days. that is the rollout of bed nets and indoor screens. the numbers in many areas are quite impressive. there's some areas where the bed net format does not work as well, so we need to deliver a candle or sticktight format to get the insecticide their. there are new tools coming. there's a vaccine in a phase 3 trial. president clinton mentioned the idea that getting the very powerful medicines out by subsidizing their price will have a huge effect, because the

older, cheaper medicines, there is widespread resistance to those. only by getting these better drugs out will we be able to reduce the number of deaths. there has really been a lot of engagement, great people coming in into this field. the malaria no more group. i think you will continue to see a number of the red -- a huge reduction of the number of childhood deaths. there are a number of countries where malaria's hold on the country is tenuous enough that it is within the possibility to substantially shrink the malaria map. >> mr. gates is being a little too modest to.

we had 12 dozen people show up because we were given the medicine that worked -- 12,000 people that showed up because of the gates foundation funding it. this madison was selling between $8 and " $10 a dose -- this medicine was telling between $8.10 dollars a dose. we are not at the volume levels now, given the cost of the component parts, to have the market take it. without the gates subsidy, we could not do it. now we are in 11 countries in africa, doing this, thanks to the gates foundation. huge numbers of people will live. other people are still taking this old madison. it is like taking aspirin for a headache. pretty soon you are sick again, and people died. this is one dilemma you are going to face here with this

whole global fund issue and the present malaria initiative issue. we can get these malaria drugs down in price, but to do it, we have to figure out how to get enough of the compound and how to get the volumes up so that you can get the prices down, the way we did before. we would not know any of that if it were not for the gates foundation. these 11 countries in africa are were doing it. that is the dilemma you face. >> in both the issue of hiv aids and malaria, on behalf of all my colleagues, this has been an area at time when people look despair of bipartisanship. bipartisanship has been superb on both these issues for years, and americans should know that is happening here in this body. >> the center menendez.

>> mr. president, thank you for your incredible continuing service to this country and for the world, for what you are doing with the foundation. mr. gates, thank you for making a difference as an individual, using your resources to be willing to make a difference in a really powerful, positive way. i am fortunate to chair the subcommittee on all our foreign assistance abroad. i would like to take your experiences and try to extend out some of those experiences on how we may do better. mr. president, as the united nations special envoy to haiti, you have a tremendous amount of convening power as well as tremendous reach across multilateral efforts in haiti. i know that work is only going to get harder, even though we have had a tremendous response. it will only get harder in the days ahead. it seems in some respects that

haiti is an example of not just a technical challenge but a leadership challenge as well. i am wondering as we look at haiti and our response is there, are we doing enough, whether it be haiti or overall long-term thinking about how we do foreign assistance, and hal in that context are we looking at how we develop leadership at the end of the day to help us, whether it be global health initiatives are health initiatives? we can externally provide resources and make a difference, but at the end of the day, the question is, how at the same time do we create indigenous leadership to move us in the right direction? mr. gates, if you could comment on that as well. you have a unique ability through the foundation to make long-term commitments in which

individuals and countries can ultimately depend upon. that is somewhat transformer to, versus what we do here in the congress on an annual basis. i wonder if you have any thoughts in that regard. i would love to hear from both of you. >> i think it is very important, president preval is here and is meeting with the president today. the secretary of state and i had dinner with him and his wife last night. the haitians have got to settle on one of the few options for a model of how this reconstruction process is going to play out. i believe the one that indonesia adopted after the tsunami is a good model, or something like that at will give the world

coffee is that there will be great transparency in the process, and that it will be moving in the right direction. secondly, haiti is a bigger job proportionally than ache was. it has some advantages. there's a real commitment to the modernization process from the haitian government. i think that our goal should be empowerment. in that sense, our model should probably be rwanda. the rwandan government hopes to receive no foreign assistance by 2020. to give you an idea, this is one thing you can tell our constituents. in 1998, four years after the rwanda genocide, the per-capita income was still only $268 a year, less than a dollar a day. 10 years later, $1,150 a year.

there is no other country in the world that quadrupled its per capita income, even from a low base, which shows that this can be done. the haitians had adopted before the earthquake of very ambitious long-term development plan to make the country more self- sufficient. it covered education, economic development, health, the whole range of issues. it required them to modernize their government and open it up and opened the port and airport system. they are sticking with the plan, and putting it the response to the earthquake into that plan to amend it. i believe that we have a real shot to support a successful enterprise there, because they think the same thing you do. they think they have to retain

talent and be held accountable. they want to not need us except as friends. that is what we are trying to do. the key is in the structure and personnel, but i believe, based on the conversations we have had, they are going to make good decisions on that. >> there is always the challenge of which country to help, the ones that are in greatest need, or the ones that have the best government, so that the money will be most effective. right now, in ethiopia, in the help area they have very effective leadership. the ghi proposal talks about some of the ambitious goals they have set. the u.s. money will allow them to succeed with that program. there are some things like vaccinations they can be done

even in the worst areas. the vaccination rates in somalia are higher than in many other countries. he began, do grass-roots work, vaccination were. some other things like getting the mothers to a clinic to treat conditions that might come up, that is very difficult if you do not have reasonable governments and roads. these programs have to be tailored. vaccination's should be done everywhere. training health care workers and trying to get a big improvement there, you want to pick places where you have strong governance. ghi has this government -- has this idea of taking countries -- you want the ability to pick parts of the country. it is too important to the global help picture not to have it be involved in some way.

nigeria is a challenge. health statistics are tough there, so you want to work, and yet the government coordination has not been very good. you have constant trade offs. nigeria, polio is the last place in africa where it still is. >> one thing you said relates to what senator lugar asked about, the impact on foreign policy. before the current coalition government took office in zimbabwe, we were providing pediatric aids medicine and some other anti retroviruals.

two-thirds of the kids in the world who get this mess and get it from the contracts we negotiate. -- who get this madison. the state department made the right decision. even though there are all these controversies, there is a humanitarian case to be made. south africa is wallowing in an aids problem that has been aggravated by people pouring across the border from zimbabwe. i think that goes back to what bill said. there is an inherent conflict sometimes between how good the government is and how much the need is. there is no one rule, but you cannot walk away from the humanitarian crisis, and it often turns out that is the best policy. >> thank you very much for everything you have done to help internationally on help, and thank you for being here.

i think your presence here today helps in the challenge that senator kerrey pointed out about getting the type of support, but also the type of focus and priority to this issue in this congress. i want to underscore the point that you made about capacity. it is sometimes very difficult to get support to build up the internal capacity of the country. we have elise your time with disease specific programs. the strategy was to use those programs to get the type of activity in that country to build its capacity so it could take care of its own needs. i applaud you for using it up funds to deal with the direct disease but also to build the structure in the country. president clinton, you said one thing that really got my attention and i want you to expand on this, about not

tolerating corruption. the countries in which you both have been actively involved, there is a lot of country -- there is a lot of corruption, but evidently have been successful in getting the funds for help to the people and not being diverted to fund the greed of certain corrupt officials. is there a lesson you can help us with as we tailor foreign assistance? we look at ways of changing our foreign-aid focus to make sure there is transparency, to make sure there is oversight and accountability, so we do not find that the international assistance is going to find corrupt regimes? >> i don't think i have ever had a conversation with bill about this, but i am not in the position i was then when i was president. when i was president, the

question is, is this government corrupt, and to what extent? now i just do not want the help care systems to be corrupt. they cannot take the money and medicine and i bring in their -- this is a good way into building good and honest governments in countries. you can argue that corruption in health care programs kills people. the only country i ever pulled out of, and i do not want to cause any embarrassment here, insisted on paying $880 for my age drug. i had a very good personal relationship with the leader of the country. i said because this is a little world, and three days from now, they will know in africa. if somebody in africa does what you did, then six people will die for every like i say. -- for every life i save.

i do believe that the health care issue is a good way in, but also, if you do it, you may or may not want the state department to do this, or the new global health initiative. i can go into a place and it is enough for me if we run the health program honestly. i try to build capacity. i am very careful of the words i use. most of this money, we never touch. it goes directly to the government and they buy the medicine. we just cut the deal. i do not want them to need me. i want them to build their capacity. there is one country where i buy the medicine because the president is a friend of mine. he said there was a lot of corruption and the previous government, and i have to get rid of a lot of people and i cannot start with the health

ministry. will you buy the medicine for a year or two? the point is, he recognized -- they recognize that we have to operate honestly. my advice to you is, first decide, will you only go into places that are 100% clean, or will it be enough that nobody messes with american money and there is integrity in the health system. i would argue to you that there is less corruption wary improve capacity. this is worth a lot to save these lives and build the capacity. people are so proud to be doing something in honest government, that you will perhaps create a different culture in these countries if you do it. if you want to say this, you have to be prepared to walk away. i only had to do it one time. i did it, and i hated it, but it was the right thing to do. >> mr. gates, have you confronted corruption in the countries in which your

operating? >> things like vaccines are bed nets are not that attractive for the political elite to stockpile. if you contract the grant to purchase the commodity and the commodities being delivered, then you can make sure the money is not being diverted. it gets more difficult as you get into personnel systems. that is the difficulty with education, and even health systems, to make sure that the work is actually being done, that the jobs are not just being given to the politically favored as opposed to the people who have the skill sets. that is not always executed very well. we see programs like in ethiopia where that is being done well. in india, the results are mixed. the north,