ina glorious weekend here d.c. with no traces of the swamp. it is easy to be hopeful on a day like today. a study of 15 years, a paper and dr. by tom dashiell

bill frist. for those of you were a new our mission is to seek to combine the best ideas to promote health, security, and opportunity for all. viable policy solutions to the power of analysis, negotiation and advocacy. we will be talking about have far -- pepfar. this is the second time we've looked at pepfar. we released our report looking at the effects on health and u.s. national security ensures. we are returning for two hopeful reasons. us first is that it reminds united states does not have to choose between pursuing its own interests and helping others in the world.

earn -- learn that it continues to be associated with opinion ofs, public the united states and measures of governance and countries that receive those investments, helping promote u.s. interests. reports on the effect of diplomatic engagement. included a new analysis explores the role in the response of the 2014 ebola outbreak. it tells us america does well when it does good in the world. secondly, this is important to the bpce, the importance and

continued ability of washington to find bipartisan agreement. for those of you counting we are due for another reauthorization and we are hoping that it will be just as strongly bipartisan. if you miss them on your way and we have copies of the report and a summary at a table by the .ront door, and online this event is being streamed by c-span. we invite you to interact with us on twitter about today's events. i invite you to turn your video.on to a brief thank you.

>> 15 years ago the hiv age tend to make certain to wipe out a generation in africa. in the face of preventable death and suffering my administration believed we had a moral duty to act, and we did. we launched the president's emergency plan for aids relief. a work of mercy to help the people of africa. over 15 years, thanks to the generosity of the american people millions who would have died are living full lives of promise. we are on the verge of an aids free generation of the people of africa still need help. the american people deserve credit for this tremendous

success and should keep going until the job is done. >> thank you to the george w. bush foundation for that video. i'm the chief medical advisor at the public policy center. have two excellent panels today. the first will feature senator .ashiell the two authors of the report being released today.

both panels will be taking questions. please raise your hand if you have a question. we will have microphones and get those to you. it is my honor to invite senators dashiell and frist to the stage. tohael is a senior advisor advocacy organization that works poverty.treme michael is a columnist for the washington post and served as the assistant to the president for policy and strategic planning. thank you to all of you. >> it is an honor to be with you all.

one reason the program is exceptional is because of its bipartisan nature. it spans the gap between social conservative and liberal global health advocates. it spans the gap between administrations. pepfar has been a haven on the bitter politics. it represents how government can work. they turned the idea into a reality and remain tireless advocates. it is good to be with you. pepfar isn said that one of the most successful global efforts in terms of scale and impact. some people in the audience may not know about the pre-pepfar

period. can you tell us what it was like living with hiv in the hardest hit areas? you for allmplement of your work and leadership. you were one of the inspirations, one of the true organizers. for those who may not know the history michael had a lot to do with the fact it was as successful as it was. on my left was incredible. it was a pleasure to work with him on that extraordinary effort. i would say people started to 1960'shiv-aids in the but by the year 2000, around the time the bush administration took office, over 25 million people had lost their lives. there were countries in africa living inof those these countries had been

affected, infected. it was becoming more and more widespread. there was an enormous social structure -- social stigma attached. people were reluctant to become engaged. there was a lot of confusion about what was right, what was wrong. ust led to an and norman degree of confusion about how we approach the issue. howfinal thing would be expensive the cost of medicine was. , with marginally effective treatment initially. that compares to six dollars. it was a dire after the turn-of-the-century.

>> you would see grandparents and grandchildren, an entire generation gone. talk about what you saw. >> it is exactly right. it is one that best from it ties happening. it was a halloween out of .ociety somewhere, during that time, through the 1990's into 2000, unc grandmothers and little babies. you would see no middle-age. adolescent girls, men because of this halloween out.

they would create 11 orphans. looking at when there was only 500 cases in the united states, nobody talked about the virus at all. we did not know it existed. it does not seem like it was a very long time ago today. in the next year, 2000 people died. within three or four years, 3 million people died in the world. from a handful to 3 million. over that time africa was especially hit. 1990's, this virus which

-- a cageyfined little virus. it was halloween out society. it was hitting the military, the civil servants, politicians, people who would keep civil society safe. 2000's,s, up until the it was the reality we had to face. >> it affected families. there were no village elders left. really extraordinary. time thehad at the lazarus effect. described that? >> i will jump in. it was so real. weeksd spend two or three

in the united states senate going in and doing medical mission work. early on, it was the voluntary counseling and testing. there were just no tests for it. , whiche antiretroviral was the miracle drug, was causing $8,000 of treatment. 3 million people dying every year. 20 million people affected. people said it was impossible. had political movements. we had our industry. we had our pharmaceutical companies come forward. the cost started coming down.

in the 1980's and 1990's, 38 years of age. sudden, in terms of the story, back to 62 years of age. >> what did you see in the aftermath? isthe most exciting thing people are getting their lives back. on a personal level people were .ecoming more optimistic you saw economic growth and prosperity restored. one of the greatest impediments to employment is illness. when you see the widespread impact hiv and aids had across the spectrum, you saw a

resulting decimation of the economy. then from that a decimation of the civility of governance itself. great deal of uncertainty about how stable these governments were going to remain given the tremendous volatility in turmoil that existed as a result of all of this uncertainty and, i would also add, psychological pain. there was a stigma that was so pervasive. that affected society in a profound way. as soon as we actually could see results, hope and optimism began to be restored. that had a catalytic effect on the economy, on stability, and the capacity to restore some degree of normalcy.

>> that hopelessness, it sets a time and place, post 9/11. even the 1990's. bin laden left in the mid-1990's. part of the hopelessness when you are a 12-year-old or 13-year-old, you see no hope. you have no hope of caused. you have death and destruction, and chaos. your father has died. your mother has died. somebody gives you that little .lement of hope, of life that is probably one of the best antidotes of the time. if you were given hope of a future, to put a roof over your head, center dot her

to school, that is a powerful antidote to whether it is terrorism or peace. >> by the way, it was interesting how treatment encouraged testing. people said i know it is not a death sentence now. i'm going to get tested because there is hope. that was necessary. treatment really was important. point, a get to a focus of the report, the economic gains in these countries. this has not gotten as much attention in terms of gdp per ,apita growth, and productivity how does supporting countries with access result in approved

development? first of all, the fact that you have such pervasive and widespread illness affects the capacity for employment itself. unemployment is going to go up dramatically. the reverse is true. when you address that illness and make people healthy unemployment goes down, people are beginning to develop a capacity for work again. that has profound economic consequences. that there is a direct connection between healthy and having a healthy and strong economy. beyond that you have to create greater capacity. that can be built through improvements in infrastructure. that, to address

not only the challenges of the illness, but the concept of making a healthier society. whatwas a big part of began to see, clear connection between the strength of the program and the strength of the economy. there are many other countries. ofhave seen an appreciation what this can do. it has macroeconomic effects that are still appreciating 15 years after the fact. >> four of the top five folks in the region have been major

investors. >> that is a good corollary. , we got to the point where tom and i were leading in the senate, and the evolution of this bill which passed an eight strong bipartisan way, coming in. it was months. to president, unbeknownst 99% of the people, he -- even his own secretary of health, made that statement. in six months the whole bill was passed. , we didn't concentrate

on the socioeconomic gdp growth, which this does. 4% fall in gdp because of this virus. an ad can reverse that hope and optimism, and employment it can be explosive. the other thing, the impact on trade. not just health and productivity in the community or region but in the country. you mentioned our biggest importantre most partners coming forward where we invested the most over time. because you obvious have better employment in the community. you have young people who are less interested in causing trouble because they look to a hopeful future.

-- tin roofsoofs over a house and girls going back to school. u.s. flying in and putting americans on the ground. these were partnering's, taking local people, sharing information, using their ideas, building an infrastructure throughout the whole country. one, there would be three or four little kids. they would say my parents named me america because of this thing they have done. that kind of impact. partnering, and it is resources going in, one of the things are global partners

a degree oftary transparency. a degree of the ideals that are exactly to what the government will have. using health as this tool and instrument, this transparency meant more and more trade over time. has been described as a display of american values. in countriessitive where it is invest -- invested heavily. >> if i can start by saying i

think first of all, just the impression people have about the u.s. as a compassionate and a generous country, a country that has a capacity to work with people. one of the values, while i give inat credit to our diplomats all countries, they deserve our praise and gratitude for all that they do. what a singlend embassy can do. it is in the communities themselves. it carries to the core the grassroots of these communities. the real values america represents at its best. in these communities, in the churches and the local community centers, in the clinic's, that representation, that physical understanding of the generosity,

compassion of the american people is evident. that makes a big difference. a kidis a great story of who said he saluted every day when he went by the clinic, he would think the united -- theren american flag. he would think the united states for their commitment to him and his health. i think the other thing that would really contribute is the so much local talent is being used. it isn't americans coming in with nothing but people from washington or new york, these are local people helping their families, helping their communities by giving -- by being given the resources. by being given the know-how, the technological capacity to help. so, the local talent is a big factor as well. michael: why is it important that the worldviews america favorably for security? quite sets a great question and we didn't go into it, back in

those days in 2003, that state of the union message in our discussions on the floor, it's not why we went into it. it really was a public health, society andh of that was the thrust of it. there was a moral imperative. it didn't matter where you were born, the united states, ethiopia, sudan or south africa. struck down by a disease, you should be lifted up. you should never live in fear. in the 21st century should live in fear of a virus striking you because of a lack of attention. but the impact, ultimately, has been just that. we have a socioeconomic impact, and impact on traded self. our ambassadors, one of the great things we did in the report that we take credit for, but that we heard, that our team did, was to talk to the ambassadors. and we will talk about it in the

next panel, but then you hear this great brett -- breadth of this power that tom talked about. it's red to the community and every little tiny village and every little tiny group of three or four little houses that people feel the caring and the compassion. it happened to be america that led, but it really was a global effort. we did the global fund, which the u.s. let on as well. but then there were 30 or 40 other countries that participated in that. it was the caring and the compassion of humanity that people felt. forg medicine or health diplomacy, strategic diplomacy, is a real thing. ini mentioned in my lifetime africa, i always said that medicine is a currency for peace. our military might is ultimate.

the military might for the world is just absolutely protective of our freedoms, protective of our democracy, but i think what we increasingly realized, because of the success of this government led but broad bipartisan people supported, in america and outside america, is that caring and compassion and health can be a true currency for peace and understanding. you have got your military might protecting and all, but on the ground you have some sort of aid coming in to save the life of your child for $1.50. it comes from people that you don't know. that breeds faith in humanity and yes, the source of most of it or half of it comes from america. using medicine, you don't go to war with someone who has just saved the life of your child. you don't do it. it all fits together, the caring and compassion as strength, just like we use the military as

strength. given that this was so effective, what are some of the other public health threats that strengthen diplomacy? sen. frist: bill can prop -- sen. daschle: bill can probably talk about it much more than i, but we have probably seen the impact that this extraordinary effort is made with our ability to cope with ebola couple of years ago. i think that -- we applied a lot of our lessons learned to what we were challenged by with ebola. seeave also been able to --e to be and have see hepatitis b and hepatitis c efforts were especially addressed by this effort. even heart disease. billere i defer to especially, but even with cervical cancer problems that we are now witnessing, because of the early efforts to detect and

then treat hiv and aids, we are able to detect more capably those who might be also afflicted with cervical cancer. there is just an enormous array of other illnesses that we can address because we have been able to set up the infrastructure, because we have been able to take the lessons learned over the last 15 years and apply them to other institutions as well. people sometimes are you that we need to spend more money on other health systems. there was increased professionalism there. an unbelievable story. that is why this 15 year retrospective with new information and analysis is so important to tom and me. we came in because we had this kg virus, constantly changing. you can't hook a molecule onto it and kill it.

it still cannot be cured today. the goal has got to be to contain it. for what we are doing, that's why this continued money is necessary. fundresidential emergency for aids, that was one little virus, $60 billion spent, more than anybody in history. the global fund, the side fund of the exact same time, president bush played a big role in that, but it was the largest single gift to the global fund. that expanded to the malaria and the tuberculosis. other infectious diseases at the time, hiv was killing 3 million per year. malaria, one million per year. that'scut age-related down to 50% of what it is. but what happened? you just set it, when you come in and you have an anti-retroviral, or knife era a drug costs one

dollar to save a baby, you have to have a system of compliance. you don't take it one time and go away. the whole testing of it was revolutionized in tests because it cost $300 and was reduced to about two dollars, you have to set up an infrastructure. 11 million orphans, a mother with hiv would give birth to a baby with hiv and you put a dollar in there and it didn't happen and someone had to identify the mom, set up the infrastructure, go with the community and while you are there you have other issues of maternal and child health. it might be breast-feeding, it might be early detection of other diseases. suddenly this huge infrastructure gets ill on the single virus expanding to other -- other diseases set broadly. ultimately that saves countless other lives. if we save maybe 20 million lives, so far in this

investment, that's conservative. probably five times to six times that have been saved because of this broad infrastructure that had to be set with the diagnosis, delivery and treatment of that initial parity. sen. daschle: it's amazing to go to these hospitals in want of it used to be overwhelmed by aids case -- aids cases and can now be cancer. billw an appropriations that there was strong bipartisan support for with other critical health efforts. let me read you a quote from our former colleague, lindsey graham , who is chair of the senate, the state and foreign operations appropriations subcommittee. of the 2019 bill he said that this will make america safer by supporting critical diplomatic efforts around the world, providing security assistance for our allies, directing stabilization assistance for areas in conflict, and

supporting life-saving health and humanitarian assistance to people in dire need. now is not the time for retreat. this ill signals to the world that america is not acting away from its role as leader of the free world. an era of america first, why does that leadership remain important? i would say that it remains more important than ever, in part because the world is in such chaos. you've got 25 failed countries. you got an enormous challenge on virtually every consonant. i think that american leadership , especially in this context has never been more, more critical. said it's attis singly, once, that if you cut back on funding for programs like this, i'm going to have to buy more ammunition. that's aces synced way of saying that there is a direct correlation between the stability that he can create through good health and good economic growth and support at

the local level. ultimately what we have to look at from our national security perspective, regardless of the continent, small investment, big result. we have seen that, now for 15 years. mostcould arguably be the important investment we could make to overall stability worldwide. especially in the parts of the world where we don't have a very strong military or diplomatic presence today. michael: you opened with that. sen. frist: this has been bipartisan since day one. in our early years it was very partisan. as tom mentioned, it was hugely stigmatized and it was a condition that was pushed off to the side. i remember jesse helms writing a piece for "the new york times" basically saying that this is something we don't need to be dealing with initially and then about four months later after the american people spoke, after

democrats spoke, after the faith-based community came on board and said that 3 million people dying of a single virus every year, 11 billion orphans out there, we have got to act. two, bono, he was at a concert and he did play a huge role in saying that america is great -- he can be critical of america, too, but that this is the single greatest thing this country has ever done. that image from the outside. in perspective, we are talking about, if this is the budget we are talking about everything we just talked about in this much. all global health is about one quarter of 1% of the nation's budget. one quarter of 1%. we talked about gdp, reputation, national security, america first. in our document if you read it you will see the principles of america first outlined, maybe the next panel will get into it. we meet every one of those

principles. different language, but we meet every one of those principles of coming forward. down toissue does boil this, which we point out in the report. if it's only one quarter of 1% it goes to all global health. not just hiv-aids, but all global health and it really is a currency for peace and it really is a national security issue and an issue of individual well-being for people can provide for their children and give them hope the first time in 20 and 30 years. now that our administration comes back and says let's cut the global fund by 30% question mark why is it that the administration says cut it by 12%? luckily the congress has come back and essentially given flat level funding for the last four years. the environment is about flat, we have come back every time, but now is not the time to step act. now is not the time to have an

administration credit global health -- cut global health when ofhave this 15 year history positive, constructive, broad, yes global benefits of being able to cut the deaths related to hiv-aids in half in 15 years. it's time for a few questions. we only ask that you ask your questions in the form of a question. [laughter] is there microphone coming? >> high. first ofall -- hi, all, thank you for being here. my name is olivia landau of the senate foreign relations committee. i wonder how you dealt with south african former president [indiscernible] and hivon to a rv denial is him -- denialism. at the time we had

recipient countries with high where the thought was that antiretrovirals don't work. hiv-aids is not caused by a sayle virus, didn't really what it was. it was called wasting disease at the time. was in the what it 90's. what we did at the time -- this is a pretty interesting part of the story. he wrote aear now, lot with the president to articulate this, but what the president did before was set our head scientist in the united states of america for infectious disease, before even the announcement, he sent him to africa and said basically -- what is the science? he came back again, this was before the state of the union and said --

mr. president, this can be done. the naysayers out there are wrong. it was caused by a virus and if we mobilize american industry and make it a public-private it wasship, at the time about $15 billion over five years put into it -- i can promise you, based on science, i can pledge to you based on science that we can diminish the cost and reduce the burden of this disease and cut it in half. it came back to science, plowing straight ahead. remember there were recipient countries saying america, the west, stay out of our business, antiretrovirals don't work. we relied on science and the best of the industry. >> i do remember. >> i was just going to say, to complete that thought, it was the results. he became convinced, once he saw the results, the results were happening all around him. bill's point, once you had the science and you had the results, it was hard to deny how you

could do the same in your own country. sen. frist: what the you remember about those times? sen. daschle: i remember sitting at a lunch next to a south african health official who told me that aids could be cured with garlic. you had this element. but beneath that, there were a lot of really good health people in south africa that knew what was going on. you had some leadership problems, but you had a real health yurok received that would hold these views. sen. frist: and you had countries like uganda. those of you might remember, uganda came forward, the first lady went on television at the exact same time and said that our country, and that was before we had really good counseling and testing for hiv, but it plummeted there, you had countries with that voice and uganda was probably on the forefront at that time with the

president and the first lady out front. let's get another question. this side, maybe? the urban institute >> i work at the urban institute. i was interested in the political issues around family planning and condoms from perhaps religious groups and others. how you dealt with that. sen. frist: i don't know how to answer historically, but what it was at the time was this. , notew people were dying just dying, but suffering around the world. we had to give a voice to the reality of what that was. time,swer at the remember, we didn't know much

about antiretrovirals. we knew that they cost $100,000. what we and our scientists in the industry told us was that if we came together we could get the price down. at the end of it everybody could rally behind, but therapy, with five people walking in with hiv every day, there's no way to be able to get enough therapy to all of them with the number of people that were dying. the only real answer was the prevention end of it. even to this day. right now we have cut it way down, but we know that abstinence works, right? that's kind of obvious. number two would be that we know that birth control, condoms, protection works. so what we did, you had democrats, republicans, evangelical, a lot of the faith-based community came on board even though some of them were very much against condoms, an element of birth control. based on what the government said from a policy standpoint, we didn't get that involved with

that. certain parts basically had to be watered down just a bit to get the coalition that was there and we basically brought in the and saided community that if you want the abcs, you push that forward and support that legislation. -- notwant some kind of abcs, but you could say you are for or against condoms as part of it, but we left it broad enough -- at that point in time people in realize that we were distributing more condoms than any country in the world already at that point in time. that is how it was handled in the people came on board if they didn't believe in antiretrovirals therapies. the people that didn't believe for the condoms, just faith and the abstinence part of it, just the belief in the abstinence part of it, that's how the coalition was developed. michael: let's get one more question, maybe in the back.

is sabrina and i am with malaria no more. my name is sabrina and i am with malaria no more. what do you think of the reemergence of polio in venezuela and an upturn in the malaria cases in the americas? sen. frist: i will jump in quick. has toson this funding be -- this isn't a thing that is cured and goes away. we have too issues and you brought up one that we should have mentioned really earlier, and that is, it's one of the big ones, we have to continue to invest or this will come back. foro not have a cure hiv-aids. malaria is a little bit different. malaria mainly kills children. just so that people will know, it was very much part of the global fund, malaria no more. the thing that you brought up is the resistance to current therapies today.

malaria, the regular syscon hiv, you have this emergence of resistance and you could begin in antiretrovirals drug and all of a sudden malaria evolves and it no longer works. we have to have that continued research coming in. the other big issue that we talk about in the report is this resurgence of young people in africa today. as that resurgence of young need toomes, they receive that education because culturally if you are not receiving that education in some way, those same sort of behaviors come with that virus and it would come right back. i would just add that a couple of times now we mention the importance of the infrastructure we created. it's so vital as we go forward and take the lessons learned. there is a new concept that is oftentimes referred to as data diplomacy. using data for the purposes of

applying what we now know -- the infrastructure that we now have, to address the challenges that we now face. i don't think that anyone can fully appreciate the magnitude of that contribution. it's hard to document it a macro economic, but it's there, it's a real. data diplomacy and transparency, the tools that we brought to this challenge are very applicable over the next 15 years. we have to apply them just as effectively as we have done in the past. michael: we have to conclude there. but i want to thank the senators in americaeadership and in compassion. please, join me in thanking them. [applause] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] [captions copyright national cable satellite corp. 2018]

? allow me to echo --? allow me to echo -- >> allow me to echo that in helping us to guide us through the description of the infrastructure and how it works, and really a touching and impact story of the change that it has wrought on the continent and how it has changed the lives of millions. to talk a little bit more about the pepfar does today and impact it can continue to have, i would like to call up our second panel. please welcome to the stage ambassador deborah burks and the global representative for u.s. health diplomacy, general charles wald, former deputy commander of united states european command, and ambassador mark's a relative, former ambassador to zambia and

secretary of state at the bureau of migration. the moderator today is dr. charles homes, who in addition to consulting on this report is the director for global health and policy and the exhibit -- the visiting professor at georgetown inversely. prior to joining georgetown, charles served for four years as the ceo of detective -- of research in zambia and served as the chief medical officer in deputy u.s. aids coordinator at pepfar. charles? ? given the range of diplomatic and public health, as well as security concerns and issues that we have talked about already, we really couldn't ask for a better panel here today. bios, but i will

introduce, of course, ambassador burks, general wald, and ambassador [indiscernible] honor ofd the great working with the ambassadors in various settings over the years. this is really a special occasion. i would like to start with you, general wald. as reference earlier, prior to that werecieties hardest hit, particularly sub-saharan africa, had sharp declines in life and that life expectancy and faltering economies. the new report finds that pepfar has been successful and other agents have been successful in impacting health, socioeconomic development and also reducing state fragility. because of these effects, we have heard about parallels between he pepfar program and

the marshall plan. given your background with the european central command, can you remind us of some of the objectives of the marshall plan and the advantages that that had in rebuilding europe? as well as the united states? and do you see parallels with the pepfar program? i do.ald: yeah, i was asked to prepare for this question, so i look it up a little bit, but for those that don't remember the marshall plan, at the time it was something like $13 billion post-world war ii, which today sounds like not a lot of money, but at the time was quite a bit. read, or there is some are vision is some revisionist history now that says the marshall plan was implemented by the u.s. government to give us a better global market and increase the market of the united states. which is kind of cynical,

meaning that there was not a benevolence there. that it was mainly for self-improvement of our economy. and i suppose there is some of that. but i think there was also the reality that europe, i mean, if you think back on it, thinking about it in today's context, why would we -- president trump is getting ready to go to the nato summit this week. i just talked to jim jones this morning. he's going over there, too. this abovenet a more supportive worsen in the world than jim jones on nato. you have to say to yourself, why are we involved in europe and, later, we will talk more about africa. but what is in our interest there other than, maybe, historical relationships from generational relationships, whatever the case may be. it's in our interest to have a group of nations around the world that are stable the he can depend on to help solve some of our security problems. we are going to hear from too

really significant people here as far as our diplomacy and government goes, but there is a military aspect that was alluded earlier. senators my feeling as a military person is always been that the best thing you can do is a military person is avoid conflict, avoid involvement. prevention is number one. i think most military people would say idealistically that if you could do away with the military, it would be a good thing. i would rather not the in combat. the marshall plan had a couple of things going. one, there was a certain amount benevolence and sincere concern for our european friends. i mean, i don't think any of us could imagine world war ii and the devastation, so there was a certain amount of just kindness involved. two, there was a serious test

george marshall had some of the smartest thinking in our nation and the military and he was smart enough to know that the tools of security and national security are multifaceted. like mike mullen said one time, our former chairman, the number one national security issue for the united states of america is our economy, which is ironic for a military guy to say that. without an economy, you can forget about national security. i think that the third part was that he saw the future and it's thatof repetitious security in europe is not necessarily guaranteed and we will need a partnership there of people that could actually purchase their own military capability, train with us, and be there as a partner. if you look at hiv-aids, which we are going to talk about now, i felt the same way when i was

in european command. at that time, european command, for those that don't know or don't care, we had africa and of it,n command, most and our responsibilities were about 92 countries, 50 somewhere in africa. we spent a lot of time there and it was kind of a nascent. -- nascent area. withwe consider extremism potential terrorists being grown there now, at the time it was an area that wasn't well-known. not a lot for ambassadors, but that was great for us that they were there, they did great work. there wasn't any real strategy involved in africa. the strategy that evolved was basically driven by the fact that china was investing white a bit in africa and was kind of replacing us in influence. but the hiv portion of it became a huge issue for us from the

standpoint of kind of rebuilding capacity in africa and the more capacity our friends, wherever they are, have to take care of their own problems, the better it is for us. that's the marshall plan in comparison. thank you. as you know, and as we talked about in the first panel, africa is experiencing rapid growth in the younger populations. such that by 2030 is estimated of the people living in sub-saharan africa will be under the age of 20. in a study referenced in the new report, the cia, as it was called, a youth bulge, it was a destabilizing force. general, we are going to stick with you and then move on to the ambassador. why is the glue -- growing youth population, a positive on one hand, but a concern from a security perspective? what are some of the ways that

you see pepfar and other health and well development programs being important for that population? i set it to mike earlier, which i've never had a chance to talk about this before, but one of the sad parts about president george w. bush's administration is that he should this.aken big credit for he's not the kind of person that would, but when we first started in 2003, it was fairly nascent, not a lot of people had been there, to africa. there was a growing instability already, as was alluded to by senator frist. had been inden sudan. there was a lot of activity in north africa. we had europeans that were kidnapped in north africa, about 40 of them. that became a big issue.

the group that kidnapped them became al qaeda. we had issues in mali and timbuktu, as a matter of fact. we had issues in libya, obviously, going back. much of it had to do with the reality of social media, the arab spring. .ut also, the youth knowledge probably most of it was because there was communication amongst young people that started for them to be -- there was a realization of what was kind of -- the kind of government they had and the society they were growing up in. there was a disenfranchisement of young people becoming pretty apparent. we had a fantastic intelligence officer, a guy named rick, who became the head of army intelligence, that coined the word, i think he did, disenfranchisement of the youth in africa. his concern was that unless

something is done, this youth it in as he referred to the report, is going to be looking for things to do. first of all, they don't feel supported by the government, number one. number two, they really don't have any relief for what their life is all about. they are looking for some kind , someolvement, somehow kind of relationship. the whole issue about paying attention to the young folks in africa was -- again, it was primarily a security issue for us. number two is -- the youthful transmission of hiv a process andreally a growing issue the mobility of the society there was growing. us,ecame really apparent to i think, that the hiv-aids program was meant to be a big deal for us and, again, i took senator hagel, who became the

secretary of defense later, to along withral times, others, who realized that the amount of money being put into the program was going to pay big dividends. we will talk about it a little later, but the impact on the fact that our interest in european command was for having africans take care of their own security and stability was not in our best interest to have to do that. we would like to help them, but the hiv-aids program may have turned around much of what's happening in africa today. that probably would have been 10 times worse if we hadn't had the pepfar program, no doubt about it. burks,mes: ambassador you have made the collection and more effective use of data one of the hallmarks of pepfar. one of the major issues that has come out of this data, as general wald referenced, the youth bulge, but also the

adolescent girls and young women who are now accounting for 74% of the new infections in sub-saharan africa in that age group. given the rapid growth of this population in africa, it has been suggested that these high rates of infection in that age group could actually lead to a 'sversal of some of pepfar hard-fought wins in gains over the years. in are these rates so high adolescent girls in the region? doing to prevent them from hiv infection and realizing that prevention is not just a health issue, but has multiple societal determinants? amb. burkes: well, that's a lot of questions, the thank you. -- but thank you. we were very excited about data and the use of data, because it lets us see down to the communities. when you heard about that discussion about where pepfar

was grounded in translation of science to action, we had to be able to see everything. --not just an average everything. not just an average. i call it the tyranny of averages. saying that this is how you serve everyone. when you start looking geographically and start doing tose surveys that were down the community, that is when we found everyone that we were missing. you can understand how this happened. because when pepfar started it really was an emergency to save lives. and to save parents. so, a lot of our treatment went to the very sick and we forgot, it sometimes, that you have a disease for eight to 10 years before you are sick at all. but it is finally destroying your immune system. when you think about it that way, you have to realize you had a lot of 15 to 20-year-old that were probably infected then, but were not visible to the health care delivery system and what

these surveys are allowed us to do was to see everyone. so, it's not that the -- they call them incident rates and then the absolute number of new infections. the incident rate, as described in the prior panel, was actually dropping in all of the different age groups. when you have twice as many 15 to 24-year-olds than you did at the beginning of the epidemic, you see that you have to have those incident rates just to tread water. we really noticed, then, that young woman -- women, and this really was a study done by [indiscernible] , it really showed us five years ago the risk to young women. we followed a lot of infections, but we didn't really understand the risk. there was a sense that it was crossgenerational regarding institutions and sexual activity. it was men,und that six years to seven years older, youngeren, and

adolescents, that were 16, with a 22-year-old. people always say to me that that is so shocking and i'm like -- weren't you in high school? didn't you want to date the college kid who has a car and some disposable income? this is universal everywhere. we started really listening to young women about what was putting that at risk. that is when we lost -- launched , recognizing the young women are in a community with multiple faceted risk and we couldn't just approach it in one direction. so, we had to bring together, just like pepfar has always led in bringing people together, bipartisan and inter-agency, we had to bring the ministry of education with the ministry of finance and the ministry of gender to work together in a new way. to really look at every aspect of a young girl's life and address the issues they are faced with. i think that one of the biggest

issues we have uncovered through the violence against children surveys is that one third of one sexual experiences rate. that is when you use the diplomacy of data. using that objective evidence you can take that to the ministries and work together to address an issue that tosses the lives of young women. i think you have seen our recent report. 40%ave seen a 20% to --line in new objections infections. that is what will drive cost is communities. but like all data, it also points out where you are failing . i think that part of this bipartisan support, and the report that just came out, for us to understand where we are doing great and where we need to do better, with the young women we can clearly see that we probably don't have programs that are optimized for young

women in highly urban areas. if you look at johannesburg, and nairobi, we had a 10 to -- 10% new5% decline in a infections where in the other areas we had a 16% decline. what the data is useful for is to point out where you are doing well, but also where you are not doing well, and fix it. that is how we want to use data, to understand where we are doing well, but also our need to fix things. people say to it -- to me all the time, when will pepfar stop changing over time? never until the epidemic is controlled. strips, constantly evolving and changing, affecting ofple at different walks life, so you constantly have to be looking and changing to keep up with it. dr. holmes: so in the same way that you worked to use data and

make it more available, you have also opened up the country operational process, the annual process for pepfar, making it more transparent. you have also involved partner governments and civil society. as we heard on a -- on a previous panel, that kind of transparency is really one of the hallmarks of strategic health diplomacy. what prompted your move for that greater transparency and the involvements of both governments and civil society? what are some of the benefits and challenges you have experienced from that? from the previous panel, you heard where pepfar was grounded. i want to thank the people in the audience that wrote comprehensive reports on how pepfar to be better. still do that, we read them all the time. one of those reports, several of those report said that you talk about transparency, but you are

not transparent. you write these things in secret rooms and the you tell everybody that this is what you are going is notnd the data available. we felt we had to be more transparent. that made everybody nervous. .gov,f you go to pepfar every site works and has the data on the website and everyone can see it. the communities we are serving can see it, governments can see it, civil society can see it. part of what we do in the planning process is to bring together the communities who are affected and impacted by hiv, with a government who is providing services, bringing that together so that we are both listening to each other. i think that that is the big difference, listening to each other we have been able to

double the number of people on treatment in a flat budget in the last four years just by listening to how we could do things better. ofhave quadrupled the number -- infection impact by increasing the number on a flat budget. how do you do that? listen to the communities telling you that you're doing it this way and you would be more effective if you did it that way. these communities and governments are doing this when there is really no funding often going directly to them. people are altruistically telling us and helping us to be better without paying us -- paying them to help us be better. i think that is still the spirit of pepfar and it buoys are spirit all the time, listening to people talk about and help, i see many of you in the audience that helped us on the dreams program. you wanted that program to have thect, you talked about

young women around the world and that's what we still see in this program every day. in her spirit and wisdom to us every day, it makes us that are. that is so powerful. keep writing your reports and helping us get better. we are in this until we get control of this epidemic. you heard that there wasn't a cure, there isn't a cure for malaria and tb. there is not a vaccine. those are being developed and work on right now by scientific institutions around the world and they need to be continued to fund it to do that, but in the meantime there should be no excuse to not move forward as fast and as effectively as we can. a second, we for went act to that -- we went back to that point about data, probably 100% of you know the issue and are already in support .f more pepfar

you understand the problems with hiv-aids, the security part and all of that. but the narrative has to be better. all, people like yourself or the people in this audience understand totally what you are saying. at lunch with the european parliamentarian back in africa, we talk about the benefits of stability operations, including putting money into what some people call soft power and the benefit security wise. constituencyy doesn't understand why we are in this case, europe and the united states, why the senator would tell me that my people in rapid city don't understand why we are spending money on africa when they have a pothole out on 16th street or something.

the problem is, you have got to start developing. i asked the general accounting office at the time, what do you estimate the amount of money that we saved by actually investing in prevention of soft power? they came back with a number that for every dollar that you spent on prevention, which i money assider pepfar prevention of instability issues, you save $10 in response. words, you spend $10 in military spending for every dollar on prevention. we should have more of those stories because that's exactly what's happening to us. don't care about humankind or other people -- by the way, if you travel over there, you get a feel for what you should actually help, the suffering is unbelievable. but if you are a purist could care less about anything but the united states, those are the

kinds of numbers we need to have out there. we need to have that narrative developed. said --hat the lasseter the ambassador said, but the average american in north the coder could care less. dr. holmes: building on the idea , you and others have referenced ways that pepfar has helped you to open doors in the cases of difficult relationships with governments and built a kind of trust that enable you to pursue your foreign policy security objectives. can you give us an idea of where you have used that? >> amazingly, in zambia, it was a game changer for achieving

broader strategic objectives. not just health objectives. a government there didn't want to meet with us. we had the opportunity to announce the framework. because of its size it had real weight and we announced $125 million in that opened up doors for us in the government. we said -- you know, we have more money that we can bring to the table. it was end of the year money that we can bring to the table. but we want you to match it. it took three meetings with the president and the president said finally that we will. he didn't know that we were going to spend the money anyway, but it gave us the leverage and it really helped. but there were other areas that mattered. a big thing that we cared about democraticly was elections. the elections there had had a stormy and difficult history. sometimes good, sometimes not so good. it turned out that the most

important allies of the united states, in pressing for clean elections in the electoral commission, actually counting the ballots, were the three mother churches. we had great lines to them because they were all partners in pepfar, which meant we knew all the leadership and they trusted us. instead of us having to say that the electoral commission had to be independent, we had these churches each sunday saying that we want an independent electoral commission and we want the ballots to be counted. as you know, the opposition actually one and the president, incumbent, conceded and there was a peaceful transition in africa on a democratic asus. we have been working to have a defense relationship with zambia and we had lots of trouble because of the history of the united states in southern africa. the breezy and -- previous president of zambia said that africa -- that america would

never label on the ground there. that meant that china was active . that meant that zambia was not [no audio] on basis, saving the lives of the soldiers. not just the soldiers, but their soldier's families, too. over a few years that really broke things open for us. i remember taking the minister guardense of zambia to to -- stuttgart. zambia after that, offered to host our biggest endeavor inside of africa. that happened in just three years. you wouldn't think it, but pepfar was at the heart of that strategic change in diverse

areas. it's remarkable. you have spoken before about the role that pepfar has played in efforts as diplomacy a masseter. can you help us to better understand the ways that you can public diplomacy? related to that, one thinks about the improved public perception of the united states that we heard about earlier. do you think that some of these public diplomacy efforts helped to drive that influence of pepfar? amb. storella: public diplomacy involves having a good product to sell and it involves reaching the audience to sell it to. is a good pepfar piece of that. after being in zambia for a while, one of the things that i saw was the political leaders were important and tribal leaders were really important. we didn't have that much access to tribal leaders.

one that there was referred to was voluntary male circumcision. this was a way of really improving our ability to prevent the hiv virus. how can we convince zambia, who are not used to medical male circumcision, this was a good idea. the answer was to reach out to tribal chiefs. they were eager to have the opportunity to partner with us. we would go to their difference -- the district and highlight their leadership. that wasn't all, though. one thing that really helped us was we needed young people. young people were where the infections were, they were the future, as the general discussed. one of the things we did when we

, these were young tv personalities, pop icons, artist. they would go with us. attract huge numbers of young people and more than and they are fascinating to teenagers in places like zambia, but they found the artist and the musicians much more interesting. it meant that young people knew that the united states was doing good things for zambia, hearing and i just from us but from popular culture icons. we could go much longer with this wonderful panel, but i want to open it up to the audience for any questions they might have.

? dana, global health partnership consulting -- >> dana, global health partnership consulting. thank you very much. withe mentioned partnering the corporate sector or the private sector and i'm wondering if that is being done to help further everything. thank you. thank you. we have been very intentional about the public-private partnerships and have tried to utilize their intellect in new ways. so, with dreams and with circumcision, with issues where we are not having the impact where we need to have it, we put out a call saying can you help us. our most recent one was dreams. we did it for circumcision with the bush institute, but with dreams, the bill and melinda gates foundation, the nike

this is whate said we can offer to you because that was extraordinary. johnson and johnson knew how to do market segmentation to reach, again, public health people, we talk in a special language that is boring to young people. johnson and johnson knew how we had to speak to 15-year-olds versus 19-year-olds versus 24-year-olds and really helped us bring what they do for marketing to our public health program. in exchange, johnson & johnson brand, wellpepfar recognized the generation of the american people had immediate access to other markets. reals a bidirectional movement and i think it is the core reason why. we were putting out -- we are putting out a call right now to work with us on our biggest challenge right now, finding well men.

men who are not sick. if we want to contact --, hiv and the dual infection, we cannot wait until men present with low counts. well men don't want to come to the clinic at all. what kind of information does it take to get a 25-year-old to come to the clinic to be tested and go on treatment if they need it, or get the prevention information that they need to remain negative? the public-private partnerships that we have now are large and are having a huge impact. this really is a very bidirectional movement that we have had over the last couple of years.

>> hello. in the recent development since the last reauthorization of pepfar, how important do you think rep prophylaxis will be preventing things globally? that's a great question. our job is to constantly apply the new science. the new science that has come out with how effective it can be among high-risk young able, among key populations, just like [indiscernible] this is the next venue. we are working with ministries of health and youth to really work this message into the work that we do. because again, just like young men, young people don't want to come to the clinic. they don't see themselves as ill . remember, for the first eight years, you would be overage.

you would think you would not need prevention. these are the issues we are working on with government communities and how to bring that message forward. it clearly has a huge impact. so does the sexual debut and preventing rape. we are pushing on all of those elements. if you know us, you know we are unrelenting in pushing all the different elements to make sure that we have a maximum impact and prevent as many new infections as we can. because the new infections are moving into this group that will be 50% of the population. i think we are also working with governments and the defense forces to really understand how important keeping girls and boys in high school are. that is where we can get messages through to young people. so, we are really working in a much and continuously horizontal says,hich as general wald we don't talk about that.

we don't talk about the billions we have invested into the health system, into institutions for young people's health and welfare. i think we have to do a better job of converting that message into the strategic message that it is important to americans in iowa. gen. wald: let me just pile on. excuse me. there is a group in the united states call the u.s. global leadership coalition, maybe some of uf heard of there are 180 53 and four-star -- 185 three-star and its-star generals, and advocacy for foreign aid because foreign aid is always the last priority for a lot of people because of the folks at home. no offense, senators. is,the fact of the matter

we give about 25% of our budget to foreign aid. it's actually about 1%. a quarter of it is what chris dodd talked about. to congressdvocate as well. there is a staffer here. you probably got the message. i hope you do. from a religious standpoint, he is pretty supportive of the foreign aid program. he is one of the last people most people would guess would do that. lindsey graham is way on top of this. it goes back to what the ambassador said. people don't necessarily think of foreign policy or foreign inairs, but the saying

africa was the chinese gives the africans what they want and the americans tell them what to do. we are losing the battle there. it's a long-term issue we need to look out there. it's a whole humanitarian issue and we have to get the story out. >> early on, we talked about the marshall plan, which saved the continent of europe. president bush's autobiography, he refers to pep far as his marshall plan. there were parts of the continent that were hollowing out. what i would say is that when they hollow out, they don't go .ilent

there are opportunities for the united states. and there are opportunities for radicalization. and there are opportunities to flee, which means migrants showing up all over the world. the united states should help save a continent. that's a strategic investment for the strategic interests of the american people going forward. wille that strategic view be appreciated, especially by congress as they think about appropriations. >> thank you for that. >> the myriad of id. -- of elements that have been identified make it clear that robust support must continue. with some of the emerging challenges we have heard about, particularly with preventing hiv, increases will be needed in the coming years, i would imagine. with that, i would like to thank

very much our distinguished panel. thank you. [applause] >> that was a terrific discussion. thank you. i hope everyone has a chance on your way out to pick up a copy of the bbc report released today on pep far strategic health and diplomacy. we welcome your comments in the months and weeks ahead. if you don't get a chance to read the report in its entirety, take a look at page 15. they say a picture speaks a thousand words. if you look at page 15, figures six, you will see how all of this is connected. a program that benefits health and diplomacy,

there are secondary effects on national security interest's. i would like to conclude today's program with a few important thank you's. i would like to thank senators daschle and chris for their tremendous leadership on this project. thank you. [applause] also like to thank the senators staff as well as our consultants. scientist a political and director of the global health policy and governance lawiative at the georgetown o'neill institute. i would like to thank all of our panelists and moderators today. central to ensuring support for global health initiatives and soft power in american foreign-policy. i would like to thank all of our partners and funders and the bill and melinda gates

foundation, thank you. and thank you, everyone, for spending the morning with us. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] [captions copyright national cable satellite corp. 2018] announcer: we continue bringing you live coverage. we head to the congressional internet conference academy discussing a recent supreme court decision on internet sales tax. it started a few minutes ago. some background on the case is being given now. >> what are the immediate implications and consequences of onlinecision on retailers, municipal governments, shopping centers