[Senate Hearing 111-627]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-627
 
          BUILDING ON SUCCESS: NEW DIRECTIONS IN GLOBAL HEALTH

=======================================================================



                                HEARING

                               BEFORE THE



                     COMMITTEE ON FOREIGN RELATIONS
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 10, 2010

                               __________

       Printed for the use of the Committee on Foreign Relations


  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                               index.html




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                COMMITTEE ON FOREIGN RELATIONS         

             JOHN F. KERRY, Massachusetts, Chairman        
CHRISTOPHER J. DODD, Connecticut     RICHARD G. LUGAR, Indiana
RUSSELL D. FEINGOLD, Wisconsin       BOB CORKER, Tennessee
BARBARA BOXER, California            JOHNNY ISAKSON, Georgia
ROBERT MENENDEZ, New Jersey          JAMES E. RISCH, Idaho
BENJAMIN L. CARDIN, Maryland         JIM DeMINT, South Carolina
ROBERT P. CASEY, Jr., Pennsylvania   JOHN BARRASSO, Wyoming
JIM WEBB, Virginia                   ROGER F. WICKER, Mississippi
JEANNE SHAHEEN, New Hampshire        JAMES M. INHOFE, Oklahoma
EDWARD E. KAUFMAN, Delaware
KIRSTEN E. GILLIBRAND, New York
                  David McKean, Staff Director        
        Kenneth A. Myers, Jr., Republican Staff Director        

                              (ii)        



                            C O N T E N T S

                              ----------                              
                                                                   Page

Clinton, Hon. William Jefferson, chairman, William J. Clinton 
  Foundation, New York, NY.......................................     5
Gates, William H., cochair, Bill and Melinda Gates Foundation, 
  Seattle, WA....................................................    10
    Prepared statement...........................................    12
Kerry, Hon. John F., U.S. Senator from Massachusetts, opening 
  statement......................................................     1
Lugar, Hon. Richard G., U.S. Senator from Indiana, opening 
  statement......................................................     3

                                 (iii)




          BUILDING ON SUCCESS NEW DIRECTIONS IN GLOBAL HEALTH

                              ----------                              


                       WEDNESDAY, MARCH 10, 2010

                                       U.S. Senate,
                            Committee on Foreign Relations,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:39 a.m., in 
room SH-216, Hart Senate Office Building, Hon. John Kerry 
(chairman of the committee) presiding.
    Present: Senators Kerry, Feingold, Boxer, Menendez, Cardin, 
Casey, Shaheen, Lugar, Corker, Risch, and Barrasso.

            OPENING STATEMENT OF HON. JOHN F. KERRY,
                U.S. SENATOR FROM MASSACHUSETTS

    The Chairman. Thank you very much. This hearing will come 
to order. Thank you all very much for coming. Today we are 
obviously delighted to be able to welcome two of our Nation's 
most important leaders on global health, one a former President 
of the 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 at the top of that 
list, and during a polarizing era in America's politics it's 
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 for PEPFAR. Today, thanks to these programs, over 
2.4 million people are receiving life-saving 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's more, we've made great strides against malaria. This 
in turn has cut childhood mortality in some areas by as much as 
one-third. And the Global Fund, where every American dollar is 
matched twice over, has helped to prevent millions of deaths 
across 140 countries.
    But as long as so many lives remain at risk, we can't 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 that we've 
achieved?
    The Global Health Initiative has rightly identified several 
core principles that ought to guide our thinking. First, health 
systems are more than the sum of their parts. Even as we expand 
our fight against HIV-AIDS, we have to look beyond the vertical 
silo of 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 health 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 assume full responsibility for the care of their own 
citizens, we must recognize their priorities and the importance 
of building local capacity.
    These principles informed the strong bipartisan message of 
the Lantos-Hyde PEPFAR reauthorization bill of 2008, and I hope 
they 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 and my 
wife, Teresa, and I saw firsthand the most courageous and yet 
frustrating realities of this struggle. We saw them 
particularly when we visited the Umgeni Primary School near 
Durban. We saw caregivers 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 against HIV-AIDS is far from over, but 
we also have new challenges. Already, as our climate changes 
and mosquitoes expand their range, malaria is surging in areas 
that have hardly ever seen it before, like the Kenyan 
highlands. We must ask ourselves, are we doing enough to 
prepare for the health challenges that climate change may bring 
on a massive scale?
    We in Congress must answer another crucial question: Is 
this an investment that 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 
can't afford not to invest in these programs. A strong global 
public health system is not merely a favor we do for other 
countries, it is the right thing to do morally and 
strategically, and it protects 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 slash our investments in the 
world.
    It is no exaggeration to say that the Clinton and Gates 
foundations have revolutionized the public-private partnership. 
The Bill and Melinda Gates Foundation has invested billions of 
dollars in support of HIV-AIDS treatment and prevention, 
vaccines, and a host of other health challenges. The Clinton 
Foundation has done groundbreaking work negotiating down drug 
prices globally 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, but I look forward to a lively discussion 
with two of the great innovative thinkers in America today, and 
we are particularly grateful to both of them for taking time to 
come here.
    Senator Lugar.

          OPENING STATEMENT OF HON. RICHARD G. LUGAR,
                   U.S. SENATOR FROM INDIANA

    Senator Lugar. Thank you very much, Mr. Chairman. I join 
you in welcoming our esteemed panelists. We especially 
appreciate the efforts they have made to change their schedules 
to be with us today.
    In numerous locations around the world, the Bill and 
Melinda Gates Foundation and the William J. 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 and rendering policy assistance to governments. Their 
actions have set global precedents that have influenced public 
opinion and catalyzed international action.
    Most notably, these foundations have been vital partners 
with the U.S. Government in the fight against HIV-AIDS, 
malaria, and tuberculosis, and they share in the successes that 
our country has achieved in this area. According to the Office 
of Global AIDS Coordinator, the President's Emergency Plan for 
AIDS Relief is directly supporting life-saving antiretroviral 
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 antiretroviral 
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 
distribution remain at the forefront of our prevention efforts 
for HIV, malaria, tuberculosis, and many other preventable 
diseases that plague the developing world. I commend the Gates 
Foundation for its $10 billion pledge to provide funding for 
vaccine research and to distribute vaccines to the poorest 
countries.
    Both of our witnesses today 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 the global health 
effort, and they have acted independently to implement good 
ideas. For example, the Clinton Foundation has devoted intense 
efforts to negotiating lower prices for HIV-AIDS drugs, thereby 
increasing their availability, especially in Africa. Among its 
many endeavors, the Gates Foundation has worked hard 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 assessments 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 efforts, including both 
public and private programs, be more efficiently coordinated 
with one another? Currently, do you believe that there is a 
rational division of global health contributions between 
treatment and prevention?
    Meanwhile, the U.S. Government must do more to ensure that 
its own global health dollars are being spent effectively. 
Although PEPFAR has been an unqualified success, we need to 
continue to seek greater efficiencies in this program and other 
global health efforts. In particular, we should improve 
coordination among agencies working on international health 
programs. The State Department, USAID, NIH, CDC, and the 
Defense Department all have critical expertise and 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.
    Two achievable steps that could improve performance are 
ensuring colocation of health care agencies in embassies 
wherever possible and reducing unnecessary overlapping 
reporting requirements by U.S. personnel in the field. 
Conversations with the administration indicate they are aware 
of these issues and are working on improvements. I look forward 
to the results of these reviews in the near future.
    As efforts on global health move forward, it is vital that 
they be accompanied by effective assistance to improve 
agricultural productivity and food security. The connection 
between undernourishment and health has long been established. 
The World Food Programme 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 function.
    I am especially appreciative of the creativity and the 
resources that the Gates Foundation has applied to encouraging 
agricultural research and productivity in the developing world.
    When Secretary of State Clinton testified before us last 
month, we noted the strong convergence between her Global 
Hunger and Food Security Initiative and the Lugar-Casey 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 U.S. foreign policy.
    Again, I welcome both of you as good friends of the 
committee and look forward to hearing your statements.
    Thank you very much.
    The Chairman. Thank you very much, Senator Lugar.
    President Clinton, Mr. Gates, thank you very much again for 
being here. Your initiatives have had a profound impact and we 
are grateful for them, and we look forward to your sharing your 
views about where we head on global health. Mr. President, if 
you would lead off, and then Mr. Gates.

STATEMENT OF HON. WILLIAM JEFFERSON CLINTON, CHAIRMAN, WILLIAM 
              J. CLINTON FOUNDATION, NEW YORK, NY

    President Clinton. First of all, I thank you very much----
    The Chairman. Can you press the button on there.
    President Clinton. There you go.
    The Chairman. Thanks.
    President Clinton. Chairman Kerry, Senator Lugar, members 
of the committee, thank you for inviting me here. I worked for 
this committee 44 years ago when I was a junior at Georgetown, 
and Bertie Bowman, who walked me in here, worked with me, too. 
He now looks 10 years younger than me.
    I think I last testified before the Congress in 1988 on 
welfare reform when President Reagan was in office. So I thank 
you for giving me the chance to come back.
    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 with the Gates Foundation have not only provided more 
money for health advances, but have 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'll mention a couple of 
them today because I think they reflect how you should consider 
the Global Health Initiative proposed by the administration.
    I want to thank both of you for your bipartisan support of 
large increases in health care investments. The PEPFAR and the 
President's Malaria Initiative, which began under President 
Bush, were literally of an order of magnitude beyond anything 
that our country had been able to do before. In my second term 
we were contributing 25 percent of the total the world was 
spending on HIV and AIDS, but my last budget was something like 
$300 million a year. The biggest thing we did was the 
Millennium debt relief initiative because all those savings had 
to be spent on health care of education or development. So what 
you have done here I think is very important.
    I also want to thank you for repeatedly recognizing that 
global health is a foreign policy priority for the United 
States. I might just cite one example before we get to the 
bill. The Gates Foundation gave some money to the Clinton 
Foundation, to subsidize the price of high-quality malaria 
medication that would actually deal with dug-resistant malaria.
    We decided to test it in two provinces in Tanzania, and we 
decided to do the announcement in an all-Muslim area, in a 
remote village of 2,000 people on a Sunday afternoon. Twelve 
thousand people showed up in the middle of the Iraq war that 
alienated America from Muslims throughout the world. We were in 
a country where just a few years earlier our Embassy had been 
blown up. Twelve thousand people showed up, and none of them 
were mad at the United States because they thought we cared 
whether their children lived or died.
    I applaud the committee for doing this. Now, let me make 
just a couple of observations about the bill, and make a few 
specific recommendations. First, I know what you're going 
through with the budget constraints, and the restoration of the 
pay-as-you-go rules, which I strongly supported. I understand, 
therefore, the dilemmas that you and the Congress will face in 
funding this initiative.
    Since I left office I've spent a lot of time working on 
global health and matters related to it. As Senator Kerry was 
kind enough to mention, and Senator Lugar--I've always tried to 
do more with less, because when I started less was the order of 
the day.
    You talked about reducing the price of AIDS medicines. 
Generic medicine that was $500 a year is now about $120 a year. 
Pediatric AIDS medicine that was $600 a year is now down to $50 
a year. That's the biggest drop.
    Thanks to the Gates Foundation, high-quality malaria 
medicine that was about $8 or $9 a dose is now down to 50 to 60 
cents a dose. That's harder to do with malaria than with ARVs. 
So far, we still need a subsidy.
    We have lowered the cost of laboratory tests and equipment, 
and 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's the only drug that doesn't make 
you so sick you can't function. Pfizer gave us a 60-percent 
discount to buy in volume for people in developing countries. 
When I asked the Pfizer chairman why he did this, he said, ``I 
realized we had a marketing strategy designed to saturate 15 
percent of the world. I would like to sell to the other 85 
percent.'' So far, they have not gotten enough credit for doing 
this, for thinking about the future in a different way.
    But this one change could help us save 200,000 to 300,000 
lives a year, of about a half million people who die every year 
of tuberculosis who also are HIV-positive.
    Basically, we have been able to lower the cost of 
commodities--tests, equipment, machines, and the medicine--by 
going from what was a low-volume, high-profit margin, uncertain 
payment business to a very high-volume, low-profit margin, but 
absolutely certain payment business. We've tried to work with 
the manufacturers to improve the manufacturing process, to 
improve the supply chain, to give greater predictability to the 
process. I think all of that is relevant to the decisions you 
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 thing I love best about the Global 
Health Initiative proposal is that it is designed to work us 
all out of jobs. It is designed to break the cycle of aid, by 
increasing the capacity of local governments to care for their 
own people.
    Think about the discussion you're going to have on this 
bill and the debate we're having over health care in America. 
It's a classic example of the polarity of problems in the world 
today. The biggest problem in developed countries is that the 
interest groups are rigidly dug in and therefore change is 
difficult. The biggest problem in developing countries is they 
don't have the structures that we take for granted. In most of 
the places that we work, all the stuff we're taking for granted 
today--that the lights will stay on, the air conditioning will 
stay on, the microphone will work--people can't take any of 
that for granted.
    So I think that 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 Malawi, Lesotho, and Rwanda, we helped the 
governments to completely rebuild their systems or to build 
them for the first time. The Rwandans last year finally had a 
hospital in every region of Rwanda for the first time since the 
genocide, but this time they also have a network of satellite 
clinics and community health workers to try to extend the reach 
of health care to all citizens.
    Finally, in Ethiopia--where we have about 140 people 
working and the United States Government also has spent a lot 
of money--when we began there was a two-tier system in 
Ethiopia. The cities had pretty good health care. But 58 
percent of the country's 80 million people, approximately 60 
million people, lived in villages of a thousand or less. So 
there are about 60,000 villages, and just a few years ago there 
were only 700 clinics in the entire country.
    So they adopted a plan to grow to 3,500 clinics and asked 
us to help them. They think once we get all them built 
everybody will be within a day's walk of a clinic.
    Other parts of our foundation have done work in Latin 
America on nutrition and providing cataract operations, the No. 
1 problem impacting the adult work force in Peru, where, thanks 
to Carlos Slim, the Clinton-Giustra Sustainable Growth 
Initiative has funded 50,000 cataract surgeries in Peru.
    At the Global Initiative, we've raised about $6.5 billion 
to improve health access, clean water, and child nutrition. 
Now, of course, in Haiti with Dr. Paul Farmer, who's my deputy 
at the U.N. and the head of Partners in Health, we're going to 
try to do for Haiti, where Paul has worked for 25 years, what 
we did in Rwanda; just build an entire national health network.
    With this background I want to say that I strongly support 
the Global Health Initiative and its closely related--I'm so 
glad Senator Lugar mentioned this--food security efforts. If 
possible, I think the two things should be supported hand in 
hand. I think the bill is well conceived. It focuses on 
developing systems in the 20 Global Health Initiative-plus 
countries. It is the next logical step after PEPFAR, the 
Malaria Initiative, and what we NGOs have been doing.
    It focuses on reducing infectious diseases and 
malnutrition, increasing access to safe drinking water. It is 
user friendly. They want to have one site to treat everything. 
Separate sites for treating different conditions is still a 
horrible problem in many countries. And there is an enormous 
emphasis on maternal and newborn and child health with what 
they call a new business model of public, private, and NGO 
partnerships. It has very specific, ambitious goals and a 
scorekeeping system so you can know if you're meeting them.
    So I like all that, and I hope you will pass this bill. 
Now, 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, but it reflects the budget constraints under 
which Congress labors in the recommendations for PEPFAR and the 
Global Fund funding. If you have to make a choice, I think they 
made the right choice, because if we don't get these countries 
to the point where they can stand on their own two feet and 
take care of their own people and work themselves away from 
total dependency, we're not doing right by them.
    My goal in Haiti in this reconstruction is to be able to go 
to Haiti as a tourist, where all they need from me is to pay my 
bills. So I love the concept.
    But we've got a real problem. Bill Gates and I started 
talking about this in January in Switzerland. First, everybody 
getting AIDS medicine is living longer, which means they need 
the medicine longer, and more and more people need it every 
year.
    Second, the longer you live, the more likely you are to 
need ``second-line'' medicines. And even though we cut their 
prices between 30 and 50 percent, they're still higher than the 
first-line drugs. So far, the volumes are going up more than 
the costs are coming down for second-line medicines.
    Third, if you succeed in building national systems, then 
people will show up who aren't being treated at all now and 
once they start showing up in new clinics, they're going to 
expect to be treated. Therefore, if we're going to approve this 
budget, we need a different strategy for funding the medicine 
for the next 5 to 10 years to get on the other side of this 
divide.
    So the big question is how to get the benefits of the 
Global Health Initiative and either get more money for the 
medicines or do more with existing funds. No. 1, I believe we 
can still accelerate the reduction of commodity prices. I think 
there is more we can do to reduce drug and lab and test prices 
and other commodities in the medical system. If you look at the 
experience we've had, if we can get the prices down now, that 
will make the money go further.
    Second, we do have one new source of funds and we shouldn't 
forget it. After the Global Fund, PEPFAR, and the Gates 
Foundation, the best thing that's happened to the world in the 
last few years on this score is UNITAID, which was funded by 
the French airline tax on every overseas trip out of France. 
It's a couple of bucks. About a dozen countries have followed 
suit and a dozen more give funds to UNITAID from general 
revenues.
    We are the purchasing agents for UNITAID for pediatric and 
second-line ARV drugs. But they buy all kinds of medicines to 
help poor people across the world. That's why UNITAID was set 
up.
    The INITAID chairman, Philippe Douste Blazy, former Foreign 
Minister of France, and I just announced a voluntary private 
complement to UNITAID called MASSIVE GOOD. It will allow people 
in other countries, beginning in the United States, to make a 
small voluntary contribution when they buy airline tickets to 
fund medicines for poor people. We announced this at the U.N. a 
few days ago, and all the big ticket sellers, including online 
sellers, signed up. A McKinsey study says MASSIVE GOOD can 
produce between $600 million and $1 billion a year, and that's 
before we get China in. I hope the Chinese and many other 
European, Asian, and Latin American countries will participate. 
It's voluntary. That's the only new source of funds that I am 
aware of to help with the present and projected demand for ARVs 
and other medications.
    Third, I think the noncommodity costs of the health systems 
can be reduced through better management, with greater reliance 
on nurses and community health care workers, better training, 
and other system delivery changes which are too obscure to 
spend a lot of time on today.
    Fourth, I cannot emphasize strongly enough how much I 
believe we should use the Global Health Initiative to send a 
clear signal to the world that we are moving away from a 
dependency model of aid toward an affordable empowerment model. 
We have to build capacity. Twenty-four percent of the world's 
health care problems are in Africa, but only 3 percent of the 
medical personnel are there. We've got to recruit, train, and 
retain health care personnel who are African.
    Fifth, prevention is really still the key. If you look at 
the Caribbean, where we started our AIDS work, the last 2 years 
there have been zero mother-to-child transmissions in the 
Bahamas, the wealthiest country in the Caribbean, which had a 
substantial AIDS problem when we started--zero. But we're still 
reaching nowhere near the number of pregnant women who are HIV-
positive with medication that is 98 percent-plus effective.
    Next, Bill's going to talk about vaccinations. They work 
and they're cheap. It's very important that we increase our 
efforts there. Focusing on prevention, we ought to do more on 
clean water. Eighty percent of the people who die from water-
borne diseases--cholera, dysentery, diarrhea--are children 
under 5. My biggest worry in Haiti today is that the sanitation 
problems in the rainy season will lead to a second round of 
deaths. Procter and Gamble has a pill that costs 10 cents that 
cleans enough water for a family of three or four for 3 days.
    Sixth, I know people talk about this and nobody ever does 
it, but you are being given an opportunity, on a bipartisan 
basis, to look at whether we can substantially lower the 
overhead and transaction costs of our foreign assistance 
program. I think that we should spend more money on foreign 
aid, but we should also get more value out of the money we 
spend. We need to have a higher percentage of the aid dollar 
being spent in-country. We can lower overhead.
    I think you should look at requirements that add to the 
cost of applying for, complying with, and filing reports on 
grants. A lot of these reports are never read because they are 
not consistent with the nation's own health care plans. The 
Clinton Foundation operates with simple rules: A, we don't go 
to any country unless invited. B, we don't start until the 
country has adopted a plan. If they want us to help develop the 
plan, we do it. And C, we keep score and have a strict no-
corruption policy. That's it.
    We only had to pull out of one country. I hope you will 
take this opportunity to start a new initiative in an era of 
budget constraints to see how we can get a much higher 
percentage of the aid dollar spent in the countries that are 
affected.
    Finally, just one thing on the food issue that Senator 
Lugar mentioned. Since 1981 the United States has followed a 
policy until the last year, when we started rethinking it, that 
we rich countries that produce a lot of food should sell to 
poor countries and relieve them of the burden of producing 
their own food, so that they can leap directly into the 
industrial era. It has not worked. It's maybe been good for 
some of my farmers in Arkansas, but it has not worked.
    It was a mistake. It was a mistake that I was a party to. I 
am not pointing the finger at anybody else. I have to live 
every day with the consequences of the lost capacity to produce 
rice in Haiti because of what I did.
    I believe that this food security issue should be addressed 
on a bipartisan basis. When President Bush tried to change the 
way we give food aid so that 25 percent of it was cash to buy 
food produced in the country nearest to the need by farmers 
there, I supported it. I was one of the few Democrats who did. 
It was beaten by a bipartisan majority. The Canadians have a 
large agriculture sector more subsidized than ours, and they 
give half their food aid in that way, with the support of all 
the farm groups.
    So, anything you can do to support agricultural self-
sufficiency will reinforce your health initiatives.
    Thank you very much.
    The Chairman. Thank you very much, Mr. President.
    Mr. Gates.

STATEMENT OF WILLIAM H. GATES, COCHAIR, BILL AND MELINDA GATES 
                    FOUNDATION, SEATTLE, WA

    Mr. Gates. Well, Chairman Kerry, Senator Lugar, members of 
the committee, I want to thank you for having us here today.
    The Chairman. Is the mike on? Can you pull it close to you, 
a little bit closer? That would be great, thanks.
    Mr. Gates. I want to thank you for having me here today, 
and I want to thank you for your commitment over the years to 
investing in the health of the world's poorest people, and for 
holding this hearing today.
    I would especially like to acknowledge Senators Kerry and 
Lugar for their longstanding leadership and commitment to 
America's investments in global health. I also want to 
acknowledge the crucial contributions and partnership that we 
have with President Clinton, who is a tireless champion for 
this cause.
    I'm grateful for the opportunity to discuss the success of 
the past investments and the opportunities to make more 
progress. I will try to make my comments brief. I have 
additional material in the written testimony that I submitted.
    This is my first chance to testify in Congress since I 
stepped down from my full-time work at Microsoft and began 
full-time as cochairman of the Gates Foundation. The foundation 
has been doing work for over 8 years to drive these health 
issues and I've been very excited to be able to get more 
involved in the work and make sure the money that we spend has 
the greatest impact possible.
    Global health is the major focus of our giving and we also 
have a division working on other poverty issues and then one 
that focuses on U.S. education.
    About the same time as our foundation was getting going, 
the U.S. Government started a significant increase in global 
health spending. This committee has been instrumental in making 
that happen and making sure the money has had a huge impact.
    I wish that every American understood how well the 
investments in global health are working: the success with 
polio, where we're quite near to eradication; the success with 
malaria, where deaths in many of the target countries are down 
50 percent, including Rwanda and Zambia; the 4 million people 
receiving AIDS treatment that would have died just years ago.
    One of my favorite statistics is that since 1960 the number 
of children who die every year has dropped from 20 million to 
now less than 9 million, and things like new vaccines deserve a 
lot of credit for that.
    Now, the United States is the biggest funder of global 
health, so we deserve a lot of credit for these advances. It's 
over a quarter of the money given for global health comes from 
this country. Yet in total it represents only one-quarter of 1 
percent of the Federal budget.
    As we get these successes to be understood, I think we can 
get strong support. The image of foreign aid that people had 
during the cold war, where much of the money was political and 
there weren't controls to really measure how well the money was 
spent, those days are gone. Particularly in the health area, we 
can look at the outcomes. I think if people do, the conclusion 
would be inescapable: these investments are the most effective 
we can make for improving and saving lives.
    This is the reason that Melinda and I have decided to make 
this cause our primary focus for our foundation. We know these 
are tough times in the budget, as President Clinton alluded to. 
If the budget wasn't so constrained, I would come here and 
suggest that this GHI budget be increased substantially more 
than is the current plan. But there are tough tradeoffs and I 
know that you have to consider those. But as you do that, I 
hope you will remember the impact and the success of these 
investments.
    In terms of the Global Health Initiative proposal, I 
support it very strongly. I think it's very well done. I think 
you've got some great people involved, not only in formulating 
the plan, but who will also be there to make sure that the 
money is spent well. It increases funding for global health and 
this is important despite the incredible constraints.
    It has new strategies to make the money more effective. It 
focuses on particular countries. It focuses on the health 
problems where we have known interventions. GHI builds on the 
success of PEPFAR and the President's Malaria Initiative, but 
adding crucial health interventions focused on the lives of 
mothers and children. We know a lot more now about the 
integrated approaches that can help there, including things 
like micronutrients, support for community health workers, 
promotion of breastfeeding, voluntary family planning, and 
better vaccination coverage.
    There are two initiatives in here where I would hope 
Congress would be able to increase the funding even beyond the 
current proposals. One is the vaccine allocation, which is 
money that would go to the Global Alliance for Vaccines. It is 
phenomenal in terms of how effective it is, and it's working 
now to get some new vaccines out, pneumococcal and rotavirus, 
that between them will save over a half million lives a year. I 
know the countries involved want to get these vaccines and so 
our generosity will make the difference.
    The other area--to highlight that, I think--I hope would be 
increased is the funding for the Global Fund. The Global Fund 
is a well-run organization. The United States has been the 
biggest contributor. I think whatever generosity we provide 
there, other countries will respond in kind. The current 
approach does have a small cut in the money for the Global 
Fund, so I hope that can be fixed, particularly because this is 
a replenishment year and those other donors will be looking at 
us as they make their decisions.
    So overall this is very, very important work. We have 
evidence about the great impact that these investments have. We 
have a chance to increase them and make them more effective, 
and I appreciate the opportunity to talk about this and engage 
in a conversation.
    Thank you.
    [The prepared statement of Mr. Gates follows:]

 Prepared Statement of William H. Gates, Cochair, Bill & Melinda Gates 
                        Foundation, Seattle, WA

                              introduction
    Chairman Kerry, Ranking Member Lugar, members of the committee. 
Thank you for inviting me to testify today.
    I want to thank the committee for taking the time to focus on 
global health and more broadly for your commitment over the years to 
robust U.S. investment in global health and development. I am grateful 
for the opportunity to share some thoughts with you about the 
foundation's global health work, the progress we have made in 
addressing global health needs, and the new U.S. approach to improving 
health around the world.
    This is my first time testifying before Congress since I 
relinquished my day-to-day role at Microsoft and began focusing 
exclusively on the work of the foundation. I have often said that my 
work at Microsoft had three magical elements: an opportunity for big 
breakthroughs; a chance to make a big contribution by building teams of 
people with different skill sets focused on tough problems; and work 
that let me engage with people who were smart and knew things I didn't. 
I have found--not surprisingly--that my job at the Bill & Melinda Gates 
Foundation meets these same criteria.
    The work of the foundation reflects the essential optimism that 
Melinda and I feel about the future, and our belief that a combination 
of scientific innovation and great partnerships with leaders who work 
on behalf of the world's poorest people can dramatically improve the 
human condition. It also reflects the belief Melinda and I share that 
every person deserves the chance to have a healthy and productive 
life--a value embodied in the words and deeds of the distinguished 
members of this committee. Most importantly, we know that aid works and 
there is a track record of success in global health to prove it. All of 
us in the global health community need to build on this success through 
continued investment. We can't walk away from funding right now, even 
in the face of very difficult fiscal challenges.
    Our foundation focuses on three programs: Global Health, Global 
Development, and U.S. Programs. Our Global Health program is our 
largest grantmaking area, and our priority conditions can be divided in 
two categories: Infectious diseases, which includes diarrheal diseases, 
HIV/AIDS, malaria, tuberculosis, neglected diseases, pneumonia, polio 
and other vaccine-preventable diseases; and Family Health, which 
focuses on the leading causes of illness and death for mothers and 
newborns during and immediately after childbirth, as well as nutrition 
and family planning. The Global Development Program explores the best 
opportunities to help the world's poorest people lift themselves out of 
hunger and poverty. Our grantmaking areas include agricultural 
development; financial services for the poor; water, sanitation, and 
hygiene; and global libraries. In the United States, our goal is to 
dramatically improve education so that all young people have the 
opportunity to reach their full potential. We know that, in order for 
our students and our country to successfully compete in the global 
economy, our young people need more than a high school education. Yet 
only 40 percent of those aged 25 to 29 have obtained some type of 
college degree. Working with our partners, we invest in solutions that 
help all students graduate high school prepared to succeed in college 
and their careers, and dramatically increase the number of young people 
who complete a degree beyond high school with real value in the 
workplace.
    We invest in global health because we know that when health 
improves, life improves by every measure. Healthy, well-nourished women 
have children who perform better in school and earn more throughout 
their lives. By treating people with particular diseases, programs like 
the President's Emergency Plan for AIDS Relief (PEPFAR) help create the 
infrastructure--clinics, distribution systems, and so on--necessary to 
tackle other health problems. We also invest in health because we know 
that we can dramatically save and improve lives in poor countries right 
now, with simple, cost-effective solutions like insecticide-treated 
mosquito nets and oral rehydration therapy. Vaccines are a prime 
example of an inexpensive solution that makes a vital impact. Simply 
expanding access to vaccines that already exist can save millions of 
lives. Moreover, new advances in science have put us in a better 
position than ever to discover and develop new vaccines, drugs, and 
other interventions, and we hope donors and companies can work together 
to accelerate the pace of research.
 why i am an impatient optimist--because investments in global health 
                                  work
    I am proud that the American resolve to improve the lives of others 
has persevered, and that in the last decade President Bush and 
President Obama have both worked to increase U.S. investments in global 
health and development. I also want to acknowledge the crucial 
contributions of President Clinton, who is a tireless champion for this 
cause.
    The vision and leadership of this committee and of Congress in 
general in support of a robust investment in global health and 
development has been indispensible. You recognize that when we invest 
in the least fortunate among us, we save lives, and we make an 
important statement about the kind of leader and partner America is in 
the world.
    Last fall, I came to Washington to talk about ``Living Proof,'' a 
project that showcases investments in global health are working. 
Melinda and I spoke about the amazing results we've seen, and the 
people we've met who are alive today because they received medicines 
and other help through programs like PEPFAR or the President's Malaria 
Initiative. We came to Washington to say ``thank you.''
    Thanks in part to American investments, malaria cases and deaths 
are both down 50 percent in several African countries, including Rwanda 
and Zambia. The first malaria vaccine is going into late-stage trials 
and could be available as a new tool within the next 5 years. Four 
million people in sub-Saharan Africa are receiving antiretroviral 
treatment for HIV/AIDS, up from 155,000 five years ago, due for the 
most part to the investments the United States has made in PEPFAR, an 
initiative that this committee had a large part in shaping, and in the 
Global Fund to Fight AIDS, Tuberculosis, and Malaria. In the 1970s, the 
United States led global efforts to eliminate smallpox--an investment 
of $130 million over 10 years that has saved over $17 billion in costs 
to the U.S. alone. And the United States has been the largest funder of 
efforts to eliminate polio around the world, reducing new cases of the 
disease 99 percent since 1988.
     I am optimistic because aid works. I am also impatient. We know 
how to save lives, we have low-cost tools, but children are still dying 
because we can't reach them all with the interventions that we have. 
Solutions won't solve anything if they can't be delivered. Every human 
life is precious, and every death is tragic, and this gives me a sense 
of urgency to create and deliver what is needed. Our foundation will be 
doing everything we can to achieve this by funding research and working 
closely with other governments, donors, research institutes, 
pharmaceutical companies, and a broad range of actors committed to this 
same goal. Although the foundation can fund some of these programs, our 
resources are but a ``drop in the bucket'' compared to what's needed. 
The U.S. Government is a critical partner in this mission.
    Consider the progress with child mortality. The chart below 
demonstrates the progression of child mortality in the last 50 years. 
In 1960, more than 20 million children died before their fifth 
birthday; last year, it was fewer than 9 million. During this time, the 
number of births rose by about 25 percent. This means that we have 
reduced the number of deaths by a factor of more than two even as more 
children were born. I think this is one of the greatest accomplishments 
of the last hundred years, and it was achieved through increased 
resources and the availability of vaccines.



    Source: UNICEF, ``Progress for Children: A World Fit for Children 
Statistical Review,'' No. 6 (New York: UNICEF, 2007) and http://
www.unicef.org/media/media_51087.html (accessed September 30, 2009).

    Yet 9 million children dying unnecessarily each year is still 9 
million too many. I believe that a combination of interventions, as 
suggested by the approach of the Global Health Initiative, can cut this 
figure in half again in well under 15 years. The Johns Hopkins 
University Bloomberg School of Public Health modeled the expected 
results of applying several basic interventions to the problem of child 
mortality. They discovered that if existing and newly developed 
vaccines were widely available, an array of prevention and treatment 
techniques were applied against malaria, and simple interventions to 
care for newborns plus treatment of diarrhea and pneumonia were more 
widespread, the survival rates of babies in the first month of life 
would increase and child deaths would fall to 5 million per year. To 
achieve this, we must continue to invest in success and share best 
practices so that all countries can learn from leading examples.
    If we continue to innovate and to dedicate resources, huge gains in 
global health and development are ahead of us. If we keep pushing, we 
will be able to reduce poverty and prevent disease, which will help 
countries ultimately end their dependence on foreign assistance and 
allow more people to live healthy, productive lives without support 
from the United States or other donor governments. Already, South 
Korea, China, Mexico, and Brazil have graduated from heavy reliance on 
aid, and other nations want to follow in their footsteps.
    As a believer in the role of the scientific process in driving 
innovation--trial and error, taking calculated risks--I understand that 
some experiments in foreign assistance did not work, and some gains 
were undone by poor governance, natural disaster, or insufficient 
sustainability plans. I do not believe that the United States should 
invest increased resources in foreign assistance based on the false 
belief that more is always better. To be sure, some programs should be 
expanded. Ineffective programs should be ended. Working 
collaboratively, Congress and the administration can maximize the 
return on these important investments.
    I do know that when programs are coordinated, held accountable, and 
designed based on evidence, they will work better. The budget scrutiny 
that has come with this economic downturn can and should be used to 
force a new fiscal vigilance that is more creative and more 
constructive than simply cutting spending. We have to demand smarter 
spending. If a more equitable world is worth fighting for--and I 
believe that it is--we have to make sure we are getting as much as we 
can for every dollar. I commend the chairman and ranking member for 
recognizing this and for exploring legislative avenues to better 
evaluate the impact of U.S. foreign assistance programs, identify best 
practices, and find innovative approaches to solving global development 
challenges.
    I recognize that I am bringing this message of optimism to a body 
that is tasked with guiding our country through the harshest realities 
of our time. We are fighting wars in Iraq and Afghanistan. We're facing 
climate dangers, trade imbalances, and record deficits. The global 
financial crisis has cost millions of Americans their businesses, 
homes, jobs, and savings. We have severe budget strains at every level 
of government that, combined with the deficit outlook, have changed 
some people's view of what our country can afford.
    This crisis has affected Americans profoundly, and it has also 
reverberated throughout the world. It has increased the need for 
American generosity even as it has tested our will to give. But 
Americans have maintained that will to give--``The Chronicle of 
Philanthropy'' reported that in seven weeks, Americans gave more than 
$895 million to Haiti relief efforts
    I understand that the federal budget now under consideration will 
be one of tradeoffs, and a certain amount of spreading the pain will be 
necessary. As you and your colleagues in both Chambers consider the 
President's Fiscal Year 2011 International Affairs budget request, I 
urge you to be mindful of the many successes U.S. foreign assistance 
has achieved and equally aware of the many challenges that persist. 
With proposed fiscal year 2010 supplemental spending taken into 
account, the President's FY 2011 International Affairs budget would be 
2.8 percent above FY 2010 amounts. These increases would fund the 
scale-up of the administration's Global Health Initiative, which I will 
address in a moment. They will also fulfill the President's historic 
G20 commitments on global food security and provide resources to 
America's first Global Hunger and Food Security Initiative. The Gates 
Foundation has devoted nearly $1.5 billion to increasing global food 
security, and we are thrilled with the President's proposals in this 
area. I know that they would not be possible without the leadership 
that Ranking Member Lugar, Senator Casey, and others have shown on this 
issue, and that they will require congressional resolve to bring to 
fruition.
                      the global health initiative
    I've been asked today to discuss my views on the administration's 
Global Health Initiative (GHI). I believe GHI is an important next 
step--indeed a natural progression--in U.S. efforts to address health 
challenges around the world. I would like to touch on four points 
related to the GHI. First, I support the overall increases requested by 
the administration for global health. Like many of you, I would like to 
see a more rapid rise in the trajectory of global health funding given 
the extraordinary need for these investments. Second, I believe that 
the GHI, when taken with the recently released PEPFAR 5-year plan, 
represents a shift in approach to HIV/AIDS that will make U.S. efforts 
more effective, specifically by expanding its focus on prevention. 
Third, I am pleased that the GHI will include an increased emphasis on 
family health and myriad interventions that, when taken together and 
integrated in both approach and execution, make families healthier and 
societies more productive. Finally, I want to address the issue of 
vaccines and continued innovation-- components of the GHI that I 
believe should be afforded more focus and investment--and the power of 
research and development to achieve massive breakthroughs in global 
health.
    I do not approach the issue of global health merely as an 
interested observer. Melinda and I have made saving lives through 
investments in innovative global health technologies and programs the 
centerpiece of the Gates Foundation's philanthropy. Since the 
foundation's establishment, we have committed just over $13 billion in 
global health investments. We are proud that some of our largest 
commitments have been made side by side with U.S. investments, 
including the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and 
the Global Alliance for Vaccines and Immunizations (GAVI). So it is 
with deep personal commitment and a clear recognition of the kinds of 
resources necessary to make real progress on key global health 
challenges that I testify before you today.
    Nevertheless, it is important to note that the foundation's 
resources represent only a small part of the overall funding picture 
for fighting disease and improving health in developing countries. Our 
global health grants accounted for about 5 percent of total donor 
assistance for health in 2007. Far bigger shares were provided by other 
sources, including government and corporate donations. This comparison 
considers only donor assistance, and not expenditure by developing 
country governments or private health spending, which further reduces 
our overall share of health funding.
    The United States has been a generous donor to global health 
efforts, as demonstrated by dramatic scale-up in resources that began 
nearly a decade ago. If Congress grants the President's FY 2011 budget 
request, the United States will be on pace to invest more than $9.5 
billion in global health next year, making this country by far the 
world's largest single donor in dollar terms. At the same time, the 
U.S. provides only 0.19 percent of its Gross Domestic Product (GDP) for 
official development assistance, far less than the 0.5-1.0 percent of 
GDP provided by a number of European countries.
    In the President's May 2009 announcement of the 6-year, $63 billion 
Global Health Initiative and again in the Consultation Document 
released on February 1 of this year, the administration made it clear 
that global health is in a much different state than a decade ago when 
the United States scaled up investments in global health through 
programs like PEPFAR, the President's Malaria Initiative (PMI) and 
GAVI.
    As you know, the GHI aims for greater resources and a fresh 
approach to deploying resources in order to maximize health outcomes in 
as short a time as possible. It seeks to concentrate resources in order 
to better achieve scale in selected countries. And it utilizes targeted 
funding increases on diseases and conditions that have a devastating 
health and economic impact on countries yet are entirely preventable or 
treatable. These are laudable goals.
    For instance, the President's FY 2011 budget request would increase 
funding for neglected tropical diseases (NTDs) from $65 million this 
year to $155 million next year. According to administration estimates, 
this additional funding would reduce the prevalence of seven NTDs by 50 
percent among 70 percent of the affected population. NTDs are a 
tragedy. Lymphatic filariasis, which the GHI proposes to help eliminate 
by 2017, causes grotesque swelling of the limbs, making it impossible 
for otherwise healthy people to work or even at times to move. 
Onchocerciasis, a treatable infection that the GHI aims to eliminate in 
Latin America by 2016, is the second leading infectious cause of 
blindness. The administration's request is building on congressional 
leadership in this case. The Senate, in fact, pushed for the first 
funding, calling for $30 million explicitly for the development and 
distribution of treatments for NTDs in 2006.
                       hiv/aids, tb, and malaria
    I'm pleased that the Global Health Initiative aims to build off of 
and improve successful American platforms such as PEPFAR and PMI, and 
that it will enable a more integrated approach to health both here in 
Washington, DC, and on the ground--where we lose patients if we can't 
address their needs comprehensively.
    PEPFAR has been a truly revolutionary approach to global health. 
The $32 billion the United States has invested in AIDS relief since 
fiscal year 2004 has leveraged billions of dollars from other donors 
and resulted in countless millions of lives saved. Estimating the 
number of people alive today thanks to these investments can be 
difficult, but we do know one thing for certain: 4 million men, women, 
and children who would have otherwise gone without life-saving AIDS 
treatment are alive today thanks to the generosity of the U.S. 
Government. That's a tenfold increase in just 7 years.
    Right now, more than 5 million people are in need of antiretroviral 
drugs on top of those already receiving them. That's just a subset of 
the 33 million people living with HIV who will one day need drugs to 
stay alive. The lowest price for first-line treatment drugs is an 
average of $88 per person per year; in many cases the cost is much 
higher. The cost of personnel, lab work, and other expenses easily 
exceeds another $200 per person per year. Providing treatment to all of 
those who currently need it to stay alive would cost over $1.5 billion 
per year at a minimum. That doesn't account for the 29 million people 
who don't currently need treatment or the estimated 2.7 million people 
who will become HIV infected this year.
    We have to understand that the goal of universal treatment, or even 
the more modest goal of significantly increasing the percentage of 
people who get treatment, cannot happen unless we dramatically reduce 
the rate of new infections.
    We need to bring down treatment costs, an area in which we have 
made some progress. From 2004 to 2008, drug prices dropped as much as 
48 percent. However, even considering greater price decreases, it is 
clear when you consider likely future scenarios that there is no 
feasible way to do what morality requires--treat everyone with HIV--
unless we dramatically reduce the number of new infections. The harsh 
mathematics of this epidemic prove that prevention is essential to 
expanding treatment, and that stressing treatment without paying 
adequate attention to prevention is simply unsustainable.
    Data shows that if we scale up well-planned, evidence-based 
prevention programs we can avert as much as half of all new HIV 
infections. For example, support from PEPFAR for scaling up programs to 
prevent mother-to-child transmission of HIV has prevented more than 
300,000 babies being born HIV-positive.
    This is why I commend the administration, under the leadership of 
Global AIDS Coordinator Ambassador, Eric Goosby, for its new PEPFAR 5-
year plan that places prevention as a top priority, even as it seeks to 
maintain and expand access to treatment. This shift in emphasis should 
yield better results, in terms of lives saved, for U.S. taxpayer 
investments.
    The President's Malaria Initiative is an essential partner in the 
fight against malaria. PMI has contributed to the significant scale-up 
of malaria interventions in 15 African countries, through the 
distribution of insecticide-treated bed nets, effective treatment and 
indoor residual spraying. As coverage with these interventions 
increases, the number of people sickened by the disease declines 
rapidly. Within Africa, Eritrea, Zambia, and Rwanda cut their malaria 
burden by 50 percent or more between 2000 and 2008. As malaria cases 
continue to decline in many parts of the world, so do the number of 
deaths from malaria.
    PEPFAR and PMI are important pieces in the fight against AIDS and 
malaria. The Global Fund to Fight AIDS, Tuberculosis and Malaria is 
another. As a major investor in the Global Fund, the United States has 
been able to leverage billions of additional dollars for the world's 
most deadly diseases. Our foundation also contributes to the Global 
Fund and I consider it one of our best investments. In 6 years, the 
Global Fund has become the leading funder of malaria and TB programs 
around the world--further expanding the power of U.S. dollars for 
global health.
    I was disappointed that the President's budget request would 
decrease the U.S. commitment to the Global Fund even as the GHI has 
pledged to place more of an emphasis on multilateral approaches, and I 
hope Congress will work to remedy this. This is a replenishment year 
for the Global Fund, and other potential donors will be looking to the 
U.S. for cues as they craft their own commitments.
                             family health
    I'm pleased that the GHI approach builds on the progress that has 
been made through U.S. investments in PEPFAR and PMI by recalibrating 
those investments to strike the most effective, integrated balance of 
resources. At the Gates Foundation, we are grappling with similar 
issues. We have begun to look at how to combine various health 
interventions--such as malaria prevention and treatment; vaccines for 
childhood illnesses; antenatal health care and behavior change; 
increased access to family planning; and nutrition--in what we call a 
``family health'' framework. This framework doesn't mean that we have 
stopped investing in certain things or only invest in others. It simply 
means that we are moving beyond individual disease stovepipes and 
sharing developments and best practices. I view the GHI as seeking to 
do the same thing.
    We know that healthy mothers mean healthier children. More than 
500,000 mothers die each year in childbirth, most of preventable 
causes. When a mother dies, she leaves behind a newborn and usually 
several older children who have lost their primary caretaker. A 
mother's death destabilizes the family, causing a chain reaction that 
affects everything from her surviving children's health to their 
prospects for education and ultimately breaking the cycle of extreme 
poverty.
    When our foundation is determining how to invest our global health 
dollars, we often measure the projected outcomes in terms of dollars 
per ``disability adjusted life years'' (or ``DALYs'') saved. One DALY 
is equal to one year of healthy life lost, and takes into account both 
premature death and the deterioration of quality of life due to 
illness. Investments in family health are highly cost effective, 
especially when we make it easier for women and children to access 
information and multiple health services in an integrated setting. Up 
to 72 percent of deaths in the first month of life could be prevented 
through delivery of packages of proven interventions during pregnancy, 
childbirth and the postnatal period, in households, communities and in 
primary care and referral level facilities in low- and middle-income 
countries. Some of the interventions are scientifically innovative; 
others have existed for decades but have never before been applied 
systematically and to scale. Some key interventions that could be taken 
to scale include:

   Fortifying foods with key vitamins and minerals like zinc 
        and iodine, one of the most cost-effective interventions as it 
        can reach individuals for fewer than 25 cents per person per 
        year. Cost: $8-$30 per DALY saved.
   Promoting breastfeeding, starting immediately after birth 
        and continuing as the sole food for the first 6 months of life, 
        then transitioning to feeding appropriate foods in addition to 
        breast milk, to boost a child's immunity, prevent the uptake of 
        pathogens and ensure healthy nutrition. Cost: $2-$7 per DALY 
        saved.
   Promoting a comprehensive package of interventions for 
        mothers and newborns, including: discouraging a mother from 
        washing a baby right after she is born, which can induce 
        hypothermia and introduce an abrasion, and then an infection, 
        through the skin; encouraging ``kangaroo mother care,'' which 
        allows a baby to benefit from his mother's warmth until she is 
        strong enough to maintain his own body temperature, while also 
        promoting breastfeeding and prevention of infection; and 
        providing two very inexpensive drugs to prevent postpartum 
        bleeding so a mother doesn't hemorrhage during childbirth. 
        Cost: between $1 and $18 per DALY saved.
   Training community-based health workers and skilled birth 
        attendants who can help ensure that women in the most rural and 
        remote areas receive prenatal care, accurate information about 
        best practices in newborn care, assistance in delivering their 
        babies safely and hygienically, and advice on care seeking for 
        illness.

    Another powerful and cost-effective intervention that could have a 
dramatic effect on everything from maternal and child health to HIV 
prevention is providing access to voluntary family planning. An 
estimated 215 million women would like to determine the number and 
spacing of their children but lack sufficient access to family 
planning. Integrating family planning into other services would cost 
$1.20 per year per capita and could have a dramatic effect on lives 
saved. A recent study by the Guttmacher Institute found that combining 
maternal and neonatal health interventions with access to family 
planning services could cut maternal deaths by 70 percent--saving the 
lives of 390,000 mothers every year.
    Incorporating family planning services into programs aimed at 
preventing mother-to-child transmission of HIV (PMTCT) would prevent 
twice the number of child HIV infections and three times the number of 
child deaths than PMTCT programs alone. In fact, between 1999 and 2006, 
access to family planning services helped prevent more than 10 times 
the number of HIV-infected pediatric cases in sub-Saharan Africa than 
did the provision of antiretroviral drugs to pregnant mothers.
    I know that for some lawmakers, family planning is a controversial 
issue. The question of whether and how the United States should help 
increase access to voluntary family planning for those who seek it 
remains difficult for many lawmakers. As you wrestle with this 
question, I urge you to remember that voluntary family planning is a 
proven and cost-effective way to save lives.
                                vaccines
    As many of you may have heard, Melinda and I recently called for 
this to be the ``Decade of Vaccines.'' We committed to providing $10 
billion over the next 10 years in the hopes of saving millions of young 
lives through vaccines. We made this commitment because we know that 
vaccines are the single most effective investment we can make. We are 
making this commitment because it will make a difference, but we can't 
do it alone.
    Ten years ago, when the foundation made its first major global 
health investment of $750 million to launch the Global Alliance for 
Vaccines and Immunization, now the GAVI Alliance, immunization rates in 
poor countries were in decline and there was slow progress in 
introducing vaccines that were readily available in rich nations. 
Thanks to the work of the GAVI Alliance and other global efforts around 
polio and measles, global vaccination rates are today at an all time 
high. Yet 24 million children remain unimmunized, thereby suffering and 
dying needlessly from diseases we know how to prevent. That's not 
acceptable.
    Prior to calling for the Decade of Vaccines, we modeled what would 
happen if we could further increase access to existing vaccines from 
today's 79 percent average to 90 percent. We found that this scale-up 
could save nearly 8 million lives in the next 10 years. While the 
foundation's investment is significant, it is not sufficient. Saving 
these young lives and helping millions more children get a healthy 
start at life is quite possible, but cannot be achieved by the Gates 
Foundation alone. It will require a collective effort among donors, 
developing country governments, and the private sector. Billions of 
dollars are needed. Even with the foundation's commitments, and a 
potential commitment of $90 million by the U.S. Government, the GAVI 
Alliance alone is facing a resource gap approaching $3 billion through 
2015. The polio eradication program is facing a gap of more than $1 
billion through 2012. We all need to do much more.
    Key to the success in raising global vaccination rates in recent 
years has been the global partnership model. The Global Polio 
Eradication Initiative, the Measles Initiative and the GAVI Alliance 
have demonstrated what is possible when stakeholders bring their 
respective strengths together under a common cause.
    I am pleased that, as part of GHI, the United States has signaled 
increased support to the GAVI Alliance in addition to its ongoing 
support of programs including polio and measles. The GAVI Alliance is 
an innovative public-private partnership that harnesses the unique 
strengths of global stakeholders (including the World Health 
Organization, UNICEF, World Bank, donor governments, industry, 
developing country governments and civil society) to efficiently 
deliver vaccines to the world's poorest countries. Since 2000, the GAVI 
Alliance has reached more than 250 million children and, critically, 
saved 5 million lives.
    I want to highlight two important features of the GAVI Alliance 
model as an illustration of why partnerships of this nature are 
critical in our efforts to improve health in an environment of 
expanding need and limited resources. First, GAVI has successfully 
shaped the vaccine market, reducing vaccine prices by guaranteeing 
developing country markets for the manufacturers. For example, the 
price of the five-in-one pentavalent vaccine has declined by more than 
20 percent since the start of GAVI and 56 of the poorest countries of 
the world had introduced this vaccine by the end of 2009. Second, the 
GAVI model emphasizes the practice of cost-sharing. In 2009, 45 of the 
49 countries required to cofinance GAVI-supplied vaccines did so. This 
is a 91 percent success rate.
    The United States has been a generous donor in the area of 
vaccines, contributing $1.8 billion to polio eradication and another 
$568 million to the GAVI Alliance. We will never have a better chance 
to eradicate polio than we will in the next 3 years. The new Global 
Polio Eradication Initiative 2010-12 strategy outlines a time-bound, 
aggressive program, one which takes full advantage of new tools, 
acknowledges and overcomes previous setbacks, looks to address risks 
proactively, and builds on the lessons learned in the past several 
years. We are optimistic that this will strike at the final reservoirs 
of polio and consign this terrible virus to history. In addition, we 
now have new vaccines available to help prevent the two leading causes 
of death among young children--pneumonia and diarrhea--and a mechanism 
through the GAVI Alliance to make them available to countries in 
greatest need.
    I recognize that times are tough and it will be an uphill battle to 
fund the GHI at the level of the President's request. But, an 
investment in GAVI will give American taxpayers the best bang for their 
buck, and the committee should consider increasing the level of funding 
beyond the administration's request. Poor countries have an enormous 
desire to introduce these new vaccines to their children as they 
recognize their lifesaving potential. The opportunity is immediate. 
These early investments have positive life-long returns.
    It is our hope that with increasing commitment from the United 
States and the Global Health Initiative, that we are one step closer as 
a global community to making the Decade of Vaccines, measured by lives 
saved, a reality.
                               innovation
    Melinda and I have built our foundation on the premise that 
innovation in product, process, and organization is essential to 
realize the greatest gains possible for the world's poor. In the global 
health arena, we have placed particular attention on science and 
technological innovation, improving upon existing interventions and 
driving the development of new ones. Imagine a world with a 
significantly simplified HIV drug regimen, a malaria drug to which the 
parasite cannot become resistant, a fever diagnostic test mothers can 
administer to children in their homes to figure out whether or not the 
child has pneumonia or malaria, or a revolutionary new manufacturing 
process that cuts the time and thus the cost of making critical, life 
saving vaccines in half.
    We can save lives while saving money. Multiple U.S. Government 
agencies--NIH, the Department of Defense, Centers for Disease Control 
and Prevention, the State Department, the FDA, and USAID--have 
supported research to advance new global health solutions. The U.S. 
commitment to innovation--doing things differently, applying the best 
science and the best minds--is critical as you develop and implement 
the Global Health Initiative. I would like to underscore the need for 
investments in clinical trials, including at USAID, to ensure that 
global health investments are solidly grounded in the scientific 
evidence of what works best. I would urge you to consider incentives 
that could increase private sector investments in global health 
innovation and product development. Experience under current policies 
such as the Orphan Drug Act (1983) and the Priority Review Voucher 
provided by the Food and Drug Administration Amendments Act may offer 
insights into how to design new incentives most efficiently. I pledge 
the best efforts of my foundation to finding ways in which it can 
partner with the U.S. Government in this work.
                    the potential of u.s. commitment
    I recognize that you must be able to explain your choices to your 
constituents and show them what they get for their taxpayer dollars. 
You must be able to assure them that their money is being spent on 
efforts that will save lives, reduce suffering, and positively impact 
our country's future.
    The administration has set ambitious targets for the GHI. If 
achieved, these targets would make clear to the American people what 
their investment can yield. With the support of Congress, the GHI will 
aim to prevent 12 million new HIV infections, double the number of at-
risk babies born HIV-free, and bring 4 million people under 
antiretroviral treatment. It will seek to reduce the burden of malaria 
by 50 percent for 70 percent of the at-risk population in Africa, save 
1.3 million lives by reducing TB prevalence by 50 percent, save 360,000 
women's lives by reducing maternal mortality 30 percent in targeted 
countries, prevent 54 million unintended pregnancies, and save 3 
million children's lives. In my judgment, this effort to dramatically 
reduce needless suffering is worthy of congressional support, even in 
these times of great fiscal stress.
    I pledge to you today to devote the resources of the foundation to 
this effort as well.
    I want to thank Chairman Kerry, Ranking Member Lugar, and the 
members of this committee for the tremendous leadership they have 
demonstrated in changing the very shape of our Nation's commitment to 
global health and development. Your vision of the role the United 
States must play in the world has inspired your colleagues--in Congress 
and in the executive branch--to set ambitious goals and devote the 
resources to achieve them. Our team at the Bill & Melinda Gates 
Foundation and I look forward to continuing to be a partner with the 
U.S. Government in pursuit of health and development goals, and we are 
eager to help you move this important agenda forward in whatever way we 
can.
    It has been an honor to appear before you today. I appreciate your 
time, and I look forward to a productive conversation.

    The Chairman. Thank you very, very much, Mr. Gates. Thank 
you both again.
    Mr. President and Mr. Gates, let me ask you the first 
question if I can. You both alluded to the budget pressures 
that we face and pay-go, and you're both passionate about the 
importance of the United States being committed to this 
particular initiative. Can you help some reluctant Member of 
Congress who is feeling the intensity of the pressures of 
people unemployed in his or her State and the pressures of the 
health care bill, the deficit, the budget?
    I think this committee is powerfully committed to this. But 
we obviously have a lot of members who spend most of their time 
not necessarily thinking about this as much as you do. So could 
you reduce to simple terms for the average person in this 
country why this is so important? What is the difference that 
it makes for the United States, and why does everybody need to 
care about it no matter where we come from or what we're doing?
    President Clinton. First of all, apart from the moral claim 
that we ought to save every child we can, we live in an 
interdependent world in which we have learned the hard way 
that, no matter how brilliantly our forces perform, we cannot 
kill, jail, or occupy all of our adversaries. We have to build 
a world with more partners and fewer adversaries. That's what 
foreign policy is about, and this is an important part of our 
foreign policy. It makes a world with more friends and fewer 
enemies.
    If people think you care whether their children live or 
die, you don't have to send our young people off to war as 
often and it also saves money. The most expensive thing you can 
do in modern society is go to war. Every other investment is 
better.
    So I would say the second point is, as Bill Gates has said 
over and over and over again, this is a very good deal. You 
have now decades of evidence that public health investments of 
the right kind work.
    Just think about Haiti. If we can build a healthy Haiti and 
one where the economy works well, then that's much less 
incentive for it to be a drug transshipment point for America 
and all the problems here. We live in an interdependent world. 
Whether we like it or not, we are affected by what happens 
elsewhere. And this is such a tiny percentage of our problem.
    The final thing I would say is this may be a fool's errand, 
but for 25 years I have seen the surveys which show that large 
majorities of the American people actually support programs 
like this and would support spending a higher percentage of our 
budget on this sort of thing. The reason we can't get support 
for it is that they think we spend 5 or 10 times what we 
actually spend on foreign assistance.
    So it may be that because so much attention is now being 
paid to all these budgetary issues, you will be able to help 
people
put this in proper context. If they realized how little it 
was--and
Bill mentioned it in his testimony--I believe it would make a 
difference.
    The Chairman. Mr. Gates, do you want to add to that?
    Mr. Gates. Yes; just to add a bit. We talked about lives 
being of equal value. Well, the health interventions in this 
plan typically save lives from something like $10,000 per life 
all the way down to a few hundred dollars per life. So in fact 
we're talking about spending less than 2 percent as much as 
would be spent in a rich country. So on the path to all lives 
being treated equally is to treat these lives as though they're 
worth 2 percent of other lives.
    But that's not the only argument. As you improve the health 
of these societies, the amazing thing is that the population 
growth goes down and therefore the ability to educate, to feed 
and provide jobs becomes possible. In the 1960s when we thought 
about aid it included countries like Brazil and Mexico, and 
those countries today are actually providing aid.
    I met with the President of South Korea at Davos and he 
talked about how as a child United States aid came to his 
country. Now they are increasing their aid budget. It will be 
over a billion dollars next year. The countries we're talking 
about have terrible health problems and you've got to solve 
those problems to get them on the path to self-sufficiency.
    Finally, diseases don't know any boundaries. Both the 
science and the interventions to reduce these diseases prevent 
them from becoming worldwide problems.
    Finally in terms of how people think about the United 
States, the idea that our health budget would be 1 percent of 
our military budget, the global health budget, that's logical 
to me and I would argue for an even higher percentage, because 
this is America at its best, really helping people and putting 
them on a road to self-sufficiency.
    The Chairman. My time is almost up here, but I just want to 
ask one quick question. The balance between prevention and 
treatment. One of the things that struck me when I was in 
Africa was the recruiting system or farm system that was being 
run to fill the next treatment center. Obviously, there's a 
tension in the community about this, and I wonder if you'd 
speak to that for a moment.
    President Clinton. Well, obviously whenever you can do 
prevention it's preferable and almost universally less 
expensive. My own view is that you have to make the decision 
that that should be our policy. Then the implementation of that 
policy should be informed by what is practically possible 
country by country.
    For example, you do the right sort of bed nets with 
malaria, it really helps you to get to zero, saves you the 
money on the medicine and, better, you don't have so many 
people getting sick. I think we can eliminate malaria.
    You get to 100 percent of the HIV-positive mothers with the 
medication to stop mother-to-child transmission, you get 98 
percent-plus effectiveness. It's a prevention strategy.
    You're arguing with people about not having sex and 
abstinence and all that. I think you really have to do it, but 
we know it's far less effective than bed nets are for malaria.
    So from my point of view there's not a one-size-fits-all 
argument here. You should always prefer prevention and always 
be prepared to do what actually will work condition by 
condition and country by country.
    Mr. Gates. The toughest disease in terms of both treatment 
and prevention is AIDS. The tools we have for prevention today 
are education to change behavior, to get people to either 
abstain or use condoms. We're very hopeful that some new tools 
will be added to the toolkit.
    Recently it was proven that male circumcision actually has 
a substantial effect; reduces male-to-female transmission 60 
percent. I was a skeptic about whether there would be a demand 
from adult males to be circumcised, but in fact in the key 
countries in Africa, both in Kenya and South Africa and 
Botswana, it's been shown that there is significant demand. So 
that's a new prevention tool and in fact PEPFAR is involved 
with our foundation in funding a lot of that circumcision 
scale-up. So that's good news.
    The ultimate prevention tool would be a vaccine. Over in 
the 550 budget, the United States has significant moneys for 
AIDS vaccine research. The United States is the biggest funder 
of AIDS vaccine research and--although we don't have the 
timeframe--there's been good progress. So that would be the 
ultimate tool.
    There's another tool that may come in a couple of years and 
be important in the high prevalence countries, and that's the 
idea of either using a gel, called a microbicide, or taking a 
pill daily, which is often called prep. It's actually an AIDS 
drug, but if you take it it prevents you from getting drugs. So 
it's prophylactic. Those trials will report out in 2011 and if 
things went well we could start to be using that tool in 2012.
    So the GHI proposal does put new energy into prevention 
while maintaining commitment to treat the people who need it. 
As President Clinton said, they're going to have to be more 
efficient to be able to drive those numbers up because not only 
U.S. funding, but the global funding for this is not growing 
the way it used to, and so efficiency will be very important 
for them to balance those two missions.
    The Chairman. Thank you very much.
    Senator Corker wanted to apologize for leaving. He had to 
go to the financial regulatory reform hearing on the Banking 
Committee, but he wanted to thank you both for being here.
    Senator Lugar.
    Senator Lugar. I want to discuss for a moment the foreign 
policy implications of the work of your foundations. The Pew 
Research Center conducts annual polls around the world asking 
people for their opinions on broader U.S. foreign policy, and 
whether or not they generally have a positive opinion of the 
United States. The result of these polls often show that in a 
very large number of countries, the majority of the population, 
for some reason or other, does not like us or does not approve 
of our foreign policy. Most of us feel hurt by this rejection 
because we feel we are doing a lot of good in the world for the 
purposes of moral equivalence that you have talked about today. 
Nevertheless, that's the way the world works.
    President Clinton, in your opening statement you mentioned 
a situation where 12,000 people in a predominately Muslim area 
of Tanzania showed up for an announcement that they were going 
to be provided with high-quality malaria medication. These 
people liked what was going to happen, and they showed good 
feelings toward the announcement and those who were 
responsible. Such events certainly constitute positive 
developments related to our image abroad.
    In order to fully understand the foreign policy 
implications related to the work of your foundations, it is 
important to ask whether you consult with USAID, the State 
Department, or other relevant agencies about your objectives, 
plans of action, and the foreign policy implications of your 
activities. Even beyond that, a number of governments such as 
South Korea, Mexico, and Brazil are now pleased to talk about 
the humane foreign policy gestures they are making. So, it 
appears that you have personally discussed these foreign policy 
implications with foreign leaders.
    What extent do you think your foundations and our 
government are actually having a positive impact on foreign 
policy around the world? I ask this of both of you because as I 
have already said in the opening statement the amounts of money 
and personnel you are contributing to these objectives are 
impressive even in comparison to everything our government is 
doing, quite apart from the governments of other countries. It 
is not that you are directing these foundations to act as 
separate nation-states; nevertheless, the impact of the sheer 
billions of dollars you have dedicated to your causes is 
enormous and influential.
    So discuss, if you could, how you have taken the 
initiative--or what sort of consultation occurs among your 
foundations, our government, and other governments so that not 
only is the net result humane for those who receive aid, but 
also, you are perceived as Americans who really have the best 
interests of the citizens of these lesser developed countries 
at heart.
    President Clinton, would you speak to that?
    President Clinton. I think I can say without fear of 
contradiction that no NGO leader in American history has ever 
consulted as much as I have with the Secretary of State. 
[Laughter.]
    Senator Lugar. This is an important point.
    President Clinton. Let me say quite seriously, you alluded 
to some of this with Hillary in her confirmation hearings. I 
think this is really important. President Bush was President 
when I started all this and we tried to do the following 
things. No. 1, we tried not to go into any country where doing 
so would cause real conflict with America's foreign policy 
interests; I think more important for me than others because of 
my previous position.
    No. 2, whenever possible we try to work with PEPFAR. We 
developed a very good relationship with PEPFAR, and in turn--I 
have to give him credit because I argued that he should allow 
PEPFAR funds to be used to buy the least expensive generic 
drugs and we reached an agreement, which he honored, which is 
if the medicines that we sell in 70 countries that serve 2 
million of those 4 million people getting treatment, that if 
they passed the FDA scrutiny PEPFAR money could be used.
    But we worked through all that. In other words, my goal is 
not to go someplace where my being there causes problems for 
America's foreign policy, and whenever possible to work with 
the Americans on the ground in cooperation, as well as with the 
host government.
    But, Senator, I think the work that Bill and I and many 
others do is intrinsically good for America's foreign policy. 
It doesn't matter who is the President. You know, you see now 
President Obama being criticized by some of the people in other 
countries who criticized President Bush, who say he's not as 
different from President Bush as I wanted him to be.
    It doesn't matter who's the President now. The interests of 
the United States and the challenges we face are sufficiently 
different from other countries that nobody's going to be 
popular in all these decisions that are made. What I think we 
have to recognize is we don't want to politicize our work, but 
we want it 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 and they cut 
you a lot of slack. You can disagree with them on a lot of 
things because they know you care whether their kids live or 
die. This is not complicated.
    I believe that we don't want to overly politicize what we 
do, but 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 or 
doing something with someone that would trigger that conflict.
    Senator Lugar. Mr. Gates.
    Mr. Gates. Well, President Clinton mentioned his personal 
situation. My personal experience is that if you're rich enough 
there will be some resentment no matter what. [Laughter.]
    And the United States is the richest country in the world. 
So if you look at our popularity, it reflects many different 
things. In fact, the countries where the United States is the 
most admired, many of those countries are the countries in 
Africa, where this aid is visible and it is making a huge 
difference. In the Middle East, other factors I think come into 
play, and it is disappointing what those polls show in terms of 
attitudes toward the United States.
    In terms of the scale of spending, I do want to make sure 
it's clear that the rich world governments spend dramatically 
more than all foundations, including my foundation. Our 
foundation as a whole would be about 5 percent of the overall 
spending. So 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's the incredible countries like 
Sweden and Denmark, Netherlands, that have stayed super strong, 
1 percent of GDP. There's countries like Germany and 
particularly the U.K. that have continued to increase their 
numbers.
    So it's really that in total that's made this possible. I 
do think this work has a substantial impact on how the country 
is viewed, a willingness to take our science and our innovation 
and have it benefit the poorest people in the world.
    Senator Lugar. Thank you very much.
    The Chairman. Thank you, Senator Lugar.
    Senator Feingold.
    Senator Feingold. Thank you, Mr. Chairman.
    Mr. President, it's good to see you again, sir. Mr. Gates, 
of course welcome you. You've both presented a compelling case 
why the United States must continue to lead and invest in 
global health, and I of course agree that we have a vital role 
to play.
    I've seen firsthand, as many Americans have, the tremendous 
goodwill generated by our leadership in global health. I've 
also seen Americans of all ages, many from my own State of 
Wisconsin, who have been involved in health work abroad. In 
1999 when you were still the President, Mr. President, one of 
my most moving trips to Africa was with your United Nations 
Ambassador Richard Holbrooke, and I saw firsthand the 
devastating and destabilizing impact of HIV-AIDS then. 
Holbrooke said to me that the HIV-AIDS was not just a health 
issue, but a diplomatic and in particular a security issue.
    This is true today not only for HIV-AIDS, but, as you've 
indicated, malaria, TB, child and maternal health, and more. 
Our global health assistance plays an important role not only 
in saving lives, but also in advancing our overarching national 
security goals. I believe you both spoke about building strong 
health infrastructure earlier. As you obviously both know, many 
doctors and nurses in the developing world emigrate to Europe 
or North America for better pay and better working conditions. 
This so-called ``brain drain'' continues to put a real strain 
on health systems in many developing areas, especially Africa, 
where I've spent a lot of my work on this committee. I'd like 
to get both of your views on how the United States can help 
governments to address this problem or at least ensure that 
we're not contributing to it. And what's the role of NGOs and 
private foundations in this regard?
    Mr. President.
    President Clinton. Well, first, thank you, Senator. I worry 
about this a lot, but 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.
    But I do think the systems matter to the outcome. I think 
one of the most important things that this Global Health 
Initiative can do is to intensify the ability of countries to 
recruit, train, and retain health care workers in delivery 
models that are affordable over the long run for those 
countries. I think there are plenty of available people that 
will do it.
    What can we do? We can fund more in-country education and 
training programs. We can figure out how to help countries over 
rough spots. As I said, in Zambia the whole thing was just 
breaking down--the health care system. We did a lot of things 
and I think it's in the documents we sent, but we helped them 
to rehire 40,000 people. We set up training programs for nurses 
in Ethiopia; went in Kenya, where we built out, with the 
Partners in Health, larger systems. In Rwanda and Malawi, we 
actually were involved in training community workers.
    But let me give you an example of at least pre-earthquake 
Haiti versus Africa, where in many cases the per capita incomes 
are about the same, but one thing is different. Most African 
universities or a lot of them collapsed at the end of 
colonialism because they were supported entirely by the 
colonial governments. The Haitian private universities, a lot 
of them were supported by the religious organizations and 
others. So that before this earthquake we actually had quite a 
large number of really gifted young Haitians able to get a 
college education in Haiti.
    A young American named Connor Bohan who went there to teach 
was so moved by this that he stayed and organized an NGO to 
raise money to send Haitians to school in Haiti. He had about 
75 graduates before all this happened. Not a single one had 
left the country to work. Sixty-eight were already working in 
Haiti. Seven others were overseas doing graduate study only.
    So I think we need to seriously look at how we educate and 
train people in terms of their retention. I'm thinking about 
this in Haiti now because we've got to figure out what to do 
with these kids whose schools were destroyed and 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 the Rural Medical Service Corps grants were 
in rural America when I was a Governor in the 1970s, that 
helped us so much in our desperate infrastructure problem, and 
say, but if you stay in America, of course you can do it if you 
get through immigration, but you have to pay your loan back 
over time, but 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's 
nothing you can do about the fact that you're 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.
    That's why I think this is a good idea. You'll be amazed 
how much this Global Health Initiative will help just by 
building the infrastructure. People don't like to fail at what 
they do. They don't like to feel that they're in an environment 
where their efforts are going to be fruitless. That's one of 
the most important things about the concept behind GHI. There 
are smart people in every country in the world. If they think 
they can succeed, they're more likely to stay at home, even for 
less money.
    Senator Feingold. Now, Mr. Gates, let me just ask you about 
the malaria issue. We formed the first-ever U.S. Senate Working 
Group on Malaria recently and I'd just like your thoughts on 
the future of the fight against malaria.
    Mr. Gates. Just to add one to that, the 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. So you 
really--when somebody leaves, it's not a bad thing, because 
they're going to be sending money back. So the capacity-
building in the country, which PEPFAR has done good things in, 
our drug trials do, that's really the magic.
    In terms of malaria, these are exciting days. That is, the 
rollout of bed nets and indoor spraying, the numbers in many 
areas are quite impressive. There are some areas where the bed-
net format doesn't work as well, so we need to deliver a candle 
or a stick-type format to get the insecticide there. There are 
new tools coming. There's a vaccine in a phase-three trial. 
President Clinton mentioned the idea that getting the very 
powerful artemisinin-based medicines out by subsidizing their 
price will have a huge effect, because the older, cheaper 
medicines, there's widespread resistance to those, and only by 
getting these better drugs out will we be able to reduce the 
number of deaths.
    There's really been a lot of engagement, great people 
coming in, into this field, the Malaria No More group that the 
United States back and we back. So I think you will continue to 
see a huge reduction in the number of childhood deaths. We 
actually have some computer modeling work to try and figure out 
what areas we could get a geographic elimination over the next 
5 years. There's a number of countries where malaria's hold on 
the country is tenuous enough that that's--it's within the 
possibility to substantially shrink the malaria map.
    President Clinton. Senator Feingold, could I just follow up 
one thing? Mr. Gates, as usual, is being a little bit too 
modest here. Let me remind you of the first foreign policy 
example I gave you. We had this announcement in Tanzania in a 
rural village of 2,000; 12,000 people showed up because we were 
giving them artemisinin-based medicine that works because the 
Gates Foundation is funding it. We started in two Tanzanian 
provinces.
    This medicine was selling everywhere between $8 and $10 a 
dose. Nobody can afford that. We got it down to about 50 cents. 
But we're not at the volume levels now, given the cost of the 
component parts, to have the market take it down. All the AIDS 
drugs, the market took them down. Without the Gates subsidy, we 
couldn't do it.
    Now we're 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 quinine-based medicine. It's 
like taking aspirin for a headache. Pretty soon you're sick 
again and people die.
    So this is one dilemma you're going to face here with this 
whole Global Fund issue and the whole PEPFAR issue and the 
President's Malaria Initiative issue. We can get these malaria 
drugs down in price, but to do it we've got to figure out how 
we're going to get enough artemisinin compound and how to get 
the volumes up so that you can get the prices down the way we 
did with ARVs.
    But we wouldn't know any of that if it weren't for the 
Gates Foundation in these 11 countries in Africa. That's the 
dilemma you face. You'd actually wind up maybe getting the 
price down if you could put a little more money into this 
medicine now.
    Senator Feingold. Mr. Chairman, my time is well over. I 
just want to say that on both this issue of HIV-AIDS and 
malaria, on behalf of all my colleagues, this has been an area, 
at a time when people despair of bipartisanship, bipartisanship 
has been superb on both of these issues for years. I think 
Americans should know that that is happening here in this body.
    The Chairman. A point well made, Senator. Thank you.
    Senator Menendez.
    Senator Menendez. Thank you, Mr. Chairman.
    Mr. President, thank you for your incredible continuing 
service to this country and, for that fact, to the world, for 
what you're doing in the foundation. Mr. Gates, thank you for 
making a difference in an individual using their resources to 
actually be willing to make a difference in a really powerful, 
positive way.
    You know, I'm fortunate enough to chair the subcommittee on 
all of our foreign assistance abroad, and I'd like to take your 
experiences a little bit--and certainly I'm with you four-
square on the Global Health Initiative, but to try to extend 
out some of those experiences on how we may do better. You 
know, Mr. President, you as the United Nations Special Envoy to 
Haiti 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've had a 
tremendous response. But it's only going to get harder in the 
days ahead.
    It seems to me in some respects that Haiti is an example, 
not just of a technical challenge, but a leadership challenge 
as well. I'm wondering, as we look at Haiti and our responses 
there, are we doing enough, whether it be Haiti or overall, 
long-term thinking about how we do foreign assistance and how 
in that context are we looking at how we develop leadership at 
the end of the day within countries to help us, whether it be 
Global Health Initiatives or development assistance or other 
efforts, because we can externally provide resources and make a 
difference, but at the end of the day, whether it be today's 
Haiti or tomorrow somewhere else, the question is how at the 
same time do we create indigenous leadership to move this in 
the right direction.
    Mr. Gates, if you could comment on that as well, as well as 
that you have a unique ability through the foundation to make 
long-term commitments, and which individuals and countries can 
ultimately depend upon. And that's somewhat transformative 
versus what we do here in the Congress on an annual basis.
    So I wonder, do you have any thoughts in that regard, is 
what I'd love to hear from both of you.
    President Clinton. Well, first, I think it's 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 and his team last night. The Haitians have got 
to settle on one of a few options for a model for how this 
reconstruction process is going to play out.
    I believe the one that Indonesia adopted after the tsunami 
is a good model, something like that will give the world the 
confidence that there will be great transparency in the process 
and that it will be moving in the right direction.
    Second, Haiti has a bigger job proportionately than even 
Aceh was. But it's got some advantages. You've got a real 
commitment there on the part of the Haitian Government to the 
modernization process. Again, I think that our goal should be 
empowerment, and 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 I think you can tell 
our constituents, by the way, about whether it works. In 1998, 
4 years after the Rwandan genocide, the per capita income was 
still only $268 a year, less than a dollar a day. Ten years 
later, $1,150 a year. There is no other country in the world 
that quadrupled its per capita income in 10 years, even from a 
low base, which shows that this can be done.
    I would say to you that the Haitians had adopted before the 
earthquake a very ambitious long-term development plan to 
genuinely modernize the country and make it more self-
sufficient. It covered education, it covered economic 
development, it covered health, it covered the whole range of 
issues. It required them to modernize their government and open 
it and open the port system and the airport system.
    They're sticking with the plan and putting the response to 
the quake into that plan to amend it as soon as the post-
disaster needs assessment is completed. So I believe that we've 
got a real shot to support a successful enterprise there, 
Senator, because they think the same thing you do. They think 
they have to retain talent, they have to be held accountable. 
They want to not need us except as friends. And that's what 
we're trying to do.
    The key is in the structure and the personnel. But I 
believe, based on the decisions, the conversations we've had, 
they're going to make good decisions on that.
    Mr. Gates. There's always the challenge of which countries 
to help, the ones that are in the greatest need or the ones 
that have the best government, so that the money will be most 
effective. Right now, in Ethiopia, certainly in the health area 
they have very effective leadership. The GHI proposal talks 
about some of the ambitious goals they've set for Ethiopia. The 
government's decided to do health workers and so the U.S. money 
will allow them to succeed with that program.
    There are some things, like vaccinations, that can be done 
even in the worst areas. The vaccination rates in Somalia are 
higher than in many other countries. So if you get in, do 
grassroots work, vaccination works. Some other things, like 
getting a mother to a clinic to treat conditions that might 
come up, that's very difficult if you don't have reasonable 
governance, reasonable roads. So these programs have to be 
tailored.
    Vaccination should be done everywhere. Some of the other 
things, like really 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 idea of picking countries. 
They have a challenge with India in particular where you don't 
want to pick the whole country, you probably want the ability 
to pick parts of the country. It's just too important to the 
global health picture not to have it be involved in some ways.
    Likewise, Nigeria is a challenge. The health statistics are 
tough there and so you want to work, and yet the government 
coordination hasn't been very good. You've got constant 
tradeoffs. We've got--from our foundation's point of view, 
we've got to be in Nigeria. Polio, it's the last place in 
Africa it still is. We see some improvement from what was being 
done in the past, with the debt relief dollars, a bit better 
governance.
    President Clinton. Senator, could I just go back? One thing 
you said relates to what Senator Lugar asked me about, the 
impact of this on foreign assistance--I mean, on our foreign 
policy. Before the current coalition government took office in 
Zimbabwe, we were providing pediatric AIDS medicine and some 
other antiretrovirals, because under the UNITAID agreement two-
thirds of all the kids in the world who get this medicine get 
it from the contracts we negotiated. They didn't have any other 
way to get it.
    Now, we cleared it, but the State Department made the right 
decision. They said that, even though we're at odds with Mugabe 
and there's all these controversies, first, there's a 
humanitarian case to be made; and second, South Africa is 
wallowing in an AIDS problem that in part has been aggravated 
by people pouring across the border from Zimbabwe.
    So I think that that goes back to what Bill said. I think 
there's an inherent conflict sometimes between how good the 
government is and how much the need is, and there is no one 
rule. But you can't walk away from the humanitarian crisis, and 
often it turns out that's the best policy.
    The Chairman. Senator Cardin.
    Senator Cardin. President Clinton, Mr. Gates, thank you 
very much for everything you've done to help internationally on 
health. Thank you for being here. I think your presence here 
today helps in the challenge that Senator Kerry pointed out, 
about getting the type of support, but also the type of focus 
and priority to this issue in this Congress. So I really do 
thank you personally.
    I just want to underscore the point, President Clinton, 
that you made about capacity. It's sometimes very difficult to 
get support to build up the internal capacity of a country. We 
have a little bit easier time with disease-specific programs. 
We did with malaria and HIV-AIDS and tuberculosis. I think the 
strategy was to use those programs to be able to get the type 
of activity in that country to build its capacity so that it 
could take care of its own needs. I applaud you for using the 
funds to deal with the direct disease, but also to build the 
type of structure in the country.
    President Clinton, you said one thing that really got my 
attention. I want you to expand on this, about not tolerating 
corruption, because the countries in which you both have been 
actively involved, there's a lot of corruption. But evidently 
you've been successful in getting the funds for health to the 
people and not being diverted to fund the greed of certain 
corrupt officials.
    Is there a lesson that you can help us with? As we tailor 
foreign assistance, we look at ways of changing our foreign aid 
focus to make sure there's transparency, to make sure that 
there is oversight and accountability, so that we don't find 
that the international assistance is going to fund corrupt 
regimes.
    President Clinton. I'd be interested in that. I don't think 
I've had a conversation with Bill about this, but, you know, 
I'm not in the position I was in when I was President. When I 
was President the question was, Is this government corrupt and 
to what extent? Now I just don't want the health care programs 
to be corrupt. They can't take the money that I bring in there, 
the medicine I bring in there.
    This is a good way in to building good governance and 
honest governance in countries, because you can argue that 
corruption in health care programs kills people. The only 
country I ever pulled out of--and I don't want to cause any 
embarrassment here--insisted on paying $880 for my then-$140-a-
year AIDS drugs. And the leader of the country, I had a very 
good personal relationship with. He said: Why do you care? 
We've got lots of money now, even though our per capita 
income's low. I said: Because this is a little world and 3 days 
from now they'll know it in Africa, and if somebody in Africa 
does what you did then six people will die for every life I 
save. You've got all this money; hire somebody else to come run 
your AIDS program.
    In other words, I'm just saying this because I do believe 
that the health care issue is a good way in. I can do this and 
you may or may not want the State Department to do this or AID 
or the new Global Health Initiative, or the President's health 
and malaria initiative to do it. I can go into a place and it's 
enough for me if we run the health program honestly.
    I try to build capacity. That is, I don't buy this 
medicine. You have to understand, most of this money that we 
have some impact on we never touch. It goes directly to the 
governments and they buy the medicine. We just cut the deal, 
because I don't want them to need me. I want them to build the 
capacity.
    There is one country in the 70 where I buy the medicine 
because the President is a friend of mine and he called and 
said: Look, there was a lot of corruption in the previous 
government and I've got to get rid of a lot of people, and I 
can't start with the health ministry; will you buy the medicine 
for a year or 2? But the point is he recognized that we had to 
operate honestly.
    So my advice to you is first decide, will you only go into 
places that are 100 percent clean, or will it be enough that 
nobody messes with American money and if there is integrity in 
the health system? I would argue to you that there is less 
corruption where you improve capacity. This is worth a lot. It 
is worth a lot to save these lives and build the capacity, and 
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.
    And then you've got to watch it. But if you say this, 
you've got to be prepared to walk away. I've only had to do it 
one time. I did it and I hated it, but it was the right thing 
to do.
    Senator Cardin. You have to have accountability.
    Mr. Gates, have you confronted corruption in the countries 
in which you're operating?
    Mr. Gates. Well, fortunately, things like vaccines or bed 
nets are not that attractive for the political elite to 
stockpile. So if you can track the grant to the purchase of the 
commodity and the commodity getting delivered, then you can 
make quite sure the money's not being diverted.
    It gets more difficult as you get into personnel systems. 
That's a difficulty with education, road-building, and even 
health systems, to make sure that the work is actually being 
done, that the jobs aren't just being given to the politically 
favored, as opposed to the people who have the skill sets. That 
is not always executed on very well. We see programs like in 
Ethiopia, where that's being done well. We see places like 
India, where the results are mixed. The north, which has the 
greatest need, tends to have the most difficult challenges.
    The answer in many locations is to organize women's groups 
and to make sure they have the expectation that their kids will 
be vaccinated, that they will get a bed net. In a lot of 
locations, their activism has been key to making sure that 
nothing is lost between the money being given and the services 
being delivered.
    In the case of vaccination, if people claim that they're 
doing and they're not, it's easy to go in and do surveillance. 
There's also a disease, measles, that very quickly shows up 
people who claim to have high rates who don't.
    Senator Cardin. Thank you very much. I appreciate it.
    The Chairman. Senator Casey.
    Senator Casey. Thank you, Mr. Chairman.
    Mr. President, we're grateful for your testimony in your 
presence here; Mr. Gates as well.
    I was thinking as you were reviewing a lot of these issues 
that the impact you've both had on the world on a whole host of 
issues that relate to global health in one sense is 
incalculable, but in another sense very much measurable. I was 
noting, Mr. President, in your annual report that two, two 
among many, numbers jumped out at me: reducing malnutrition 
among more than 42 million children and providing access to 
safe drinking water for 3 million people in Asia, just among 
the many results.
    I think that's important, that we focus on results. There 
are so many ways to document the problem, so many ways to 
specify the nature and the gravity of the threat to human life. 
But the American people more and more look to us and look to 
nongovernmental entities for results.
    I wanted to focus on two areas. One is on maternal and 
child deaths, and two, on food security. Let me just cite two 
numbers from the staff memo. As usual, our staff does a great 
job here compiling this data. Sub-Saharan Africa and Asia 
accounted for 92 percent of all under-5 deaths in 2000, a 
stunning number. The second related number, the same area, sub-
Sahara Africa, Asia, accounted for 94 percent of all maternal 
deaths in 2005. Just chilling numbers.
    I guess the question I have is twofold. One is, we know 
that this year the President's 2011 budget provides $9.6 
billion for global health activities. If we had another billion 
or two to spend and you could only spend it, just 
hypothetically, on maternal and child health, I guess the 
question I would ask is: How would you spend that extra dollars 
or how should we spend it if we could only spend it in these 
areas?
    Second, in a very brief way, just the list of what works, 
because sometimes I think we have these discussions and debates 
here and we don't itemize or list what we know works and what 
we know we can invest in and get results.
    President Clinton. Well, I think if I had another billion 
dollars to spend I would--if you take Ethiopia, for example--I 
don't know if you were here when I said this. When we started 
in Ethiopia, there were only 700 clinics in the country. That's 
before the United States program got under way. We helped them 
develop a plan to go to 3,500 clinics.
    So I would go in and try to make sure that every pregnant 
mother could be checked, could be part of some community, the 
health worker network, and eventually get to a clinic before a 
baby is born and we find out what the deal is. I would make 
sure that we had adequate nutrition. I would make sure that in 
the high prevalence areas we tested for HIV status and gave the 
mother-to-child transmission drugs. And I would then fund those 
things which reduce infant mortality.
    But you talked about all these kids who died in Africa. The 
mortality rate is very grievous for babies born with HIV-AIDS, 
even though we save a lot of them. But it's horrible. Eighty 
percent of the people that die from waterborne diseases are 
under 5. They're almost all in poor countries.
    So anyway, that's what I would do. I would spend the money 
on that.
    Mr. Gates. I mentioned the drop in childhood deaths from 20 
million to 9 million. We can really think of the remaining work 
as the deaths between 30 days of age and 5 years, where it's 
really going to be vaccines that are going to carry the weight. 
We have a new vaccine, rotavirus, for part of the diarrheal 
burden. We've got a new vaccine, pneumococcus, for part of the 
pneumonia burden. Hopefully, we'll have a few more for both of 
those and we'll have a malaria vaccine.
    If you could cover those disease conditions, then you could 
cut the 30-day to 5-year piece by well over half. That would 
leave still a gigantic number in those first 30 days, and 
that's where all these words about integrated approaches come 
in, because if you get the mother starting prenatal, make sure 
she has the right vitamins, perhaps even some vaccines, make 
sure she has the clean birth kid, some tools, probably some 
antibiotics, make sure she's been given the right advice about 
keeping the baby warm, breastfeeding, vaccination, that 
integrated approach can save over half of the children that die 
during that first 30-day period.
    That's a big new focus, not only of the GHI plan, but work 
that we're doing, because exactly how you go about that is not 
well understood. The vaccine piece, we need to put more into 
research, we need to put more into GOBI. The model is pretty 
clear there. This first 30-days piece, there's a lot we know, 
but there's more that we need to know, particularly because 
creating the demand by the mothers within their culture, within 
their social practices, that they'll want these services--in 
many places you go, when you say, hey, your kids have chills, 
hey, come down to the clinic, the answer is: Oh, that's where 
children go to die; why would I take my child down there? So 
there's some new ideas on this that will be somewhat tailored 
to each local area.
    President Clinton. Senator Casey, if I could just say, Bill 
just said something; I know that maybe everybody on the 
committee understands this, but I do think it's very important 
to understand it, that, partly because of the way programs get 
funded in the countries providing aid and partly because of the 
absence of systems in poor countries, it's hard for you to 
believe just sitting here, but the most important thing maybe 
about this GHI proposal is providing a coherent health system 
and a sort of a one-stop place in developing countries.
    It's crazy they don't have enough money to do anything, 
but--this program's dealing with AIDS and another program's 
dealing with maternal and child health and another program's 
dealing with malaria. There are literally places where you've 
got to walk someplace to get health care anyway, and you may 
have to walk three or four or five places to get everything 
your family needs.
    This is what the Global Health Initiative, among other 
things, will correct and will give the rest of us sort of 
marching orders and a framework so that we can all be more 
effective and make the money that you have appropriated go 
further. I think it's really important that everybody 
understands that it's almost hard to imagine that this exists, 
but it does, and this is maybe one of the most important 
reasons for you to pass the GHI.
    Senator Casey. Thank you very much.
    The Chairman. Senator Risch.
    Senator Risch. The problem you just described, is that--I 
hate to use the word ``fault,'' but is that the consequences of 
what we're doing or not doing or the consequences of what the 
individual countries are doing or not doing?
    President Clinton. Oh, probably a little bit of both. But I 
think a lot of people in developed countries are providing aid 
with really good intentions. You know, we started the PEPFAR 
program, the Global Fund for AIDS, TB, and malaria, but you 
can't run separate programs on AIDS, TB, and malaria and 
maternal and child health, immunizing against other tropical 
diseases--I could go on, the whole list.
    What we said earlier, Senator, is that the United States 
and the other donors I think need to be in the business of 
making this a user-friendly system and also helping to build 
the capacity of the countries in which we work, and hopefully 
one day they won't need us any more or anybody else.
    But I think that what happens is if you deal with these 
things problem after problem, you have unintended consequences 
if you put the problem-solvers into an environment where there 
is no system, like we take for granted, for health care.
    Senator Risch. What you're saying then, I suppose, is that 
when these things are done they should focus, particularly at 
the outset, on system and process as much as they do on 
delivery?
    President Clinton. Absolutely. The problems--all major 
debates in rich countries about health care policy, education 
policy, they're about how do you change the system you have, 
what's the right way to do it, what's the wrong way to do it. 
There are rigidities and you know you have to keep improving. 
In poor countries they're about capacity. They have no systems, 
so that there's no predictability in the connection between 
what you do and the consequence you get.
    So I think that this is noble work. You can see the U.S. 
Government doing more of it, Bill Gates's foundation, and I--
we've been involved in all of this. I fell into this, too, by 
the way. I'm just as guilty as the next person. We were out 
there doing AIDS drugs and so proud, and we cut the price, and 
then we cut the price of the equipment, and then we did 
something on malaria. Then pretty soon we realized that the 
impact of all this was being drastically truncated in places 
where there were no health care systems where people could also 
show up and get maternal and child health or whatever.
    Senator Risch. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you very much, Senator.
    Senator Shaheen.
    Senator Shaheen. Thank you.
    I want to add my thanks to everyone else's on the panel for 
both of you, for being here today and for all of the work that 
you've done. Thank you both very much.
    For the last year, along with Senator Snowe, I have served 
on the Smart Global Health Commission of CSIS. We're getting 
ready to produce a report that will come out next week, and it 
reinforces so much of what both of you have said today. Many of 
your friends and colleagues have served on that commission with 
me.
    Mr. Chairman, I'd like to ask unanimous consent if we can 
submit in the report an advance copy of the CSIS report on 
Smart Global Health Policy.
    The Chairman. Without objection.

[Editor's note.--The CSIS report mentioned above was too 
voluminous to include in the printed hearing. It will be 
retained in the permanent record of the committee.]

    Senator Shaheen. One of the things that we talk about in 
that report is exactly what you both said about building a 
system that can deliver results. As we look at how to structure 
that kind of a system that I think is important, not just in 
terms of delivering results, but in producing a base that we 
can go back to people, whether it's funders or governments or 
the American people, and say, look, this works and we have the 
accountability, we have the data to show that.
    So can you talk a little bit more about that, about how we 
structure those systems that are accountable for people?
    Mr. Gates. Well, in some ways, compared to all the money 
you spend, this is the most accountable money, more than the 
money you spend on Medicare, the defense budget, even 
education. This money, you can say: We spent this many dollars 
and we've saved this many lives, and at levels where it's 
pretty stunning that those resources weren't there in the past.
    The piece that isn't in the 150 budget, the part that's the 
research pieces that are over in the other thing, those are a 
little tougher because we can't say to you how quickly you'll 
get an AIDS vaccine. We know it's important work. We know 
eventually one will come, but that's a long quest, probably 
more than a decade.
    But when it comes to giving money to Global Fund or PEPFAR 
or to the Global Alliance for Vaccines, there is a very direct 
measurement of how many kids' lives were saved with these new 
vaccines or how many new people were able to go on treatment. 
So I think of this--and I wish all of government had such a 
clear if you spent money then you'll absolutely get this 
result.
    There aren't many things where you can go from 20 million 
deaths down to 9 million deaths. Of the rich world government 
budgets, it was less than half a percent that caused that to 
take place.
    President Clinton. I completely agree with that. But if I 
could be the curmudgeon here, because I'm a bleeding heart 
cheapskate and we need more money for medicine, for reasons 
we've already outlined. I do think this is an appropriate time, 
Senator, for you to reexamine the transaction costs, the 
compliance costs, and the overhead costs to see if you can 
squeeze any more money out of the money that the Congress 
appropriates and get it spent in the communities which you 
intend it to benefit.
    One of the things that in the report on the Global Health 
Initiative that the administration has issued--and you'll have 
their testimony later today, and they're very good people--but 
there was a mention, in passing, of cooperation with NGOs. But 
one of the things that we really haven't worked through is 
exactly what should the nature of the government's cooperation 
with NGOs be?
    I described my relationship with the Bush administration's 
PEPFAR, but I'm in a different position. I can't and don't want 
to get U.S. Government money, although we have made our health 
initiative free-standing in the event that it's necessary some 
time.
    But you need to think about how you do these things faster, 
cheaper, better, and whether we really do have the highest 
percentage of dollars possible being spent in the countries you 
intend them to go. In my opinion, Senator Shaheen, there may be 
some things you can do to improve that.
    But I'm with Bill Gates. At least all these things are 
scoreable. You can keep score. You know what you got for the 
money you spent and you know what you would have gotten if 
you'd spent it on other things. But that doesn't mean you 
shouldn't keep trying to get more blood out of the turnip, 
because we've got desperate needs, and the more we build these 
systems the more people will show up. And you don't want to 
have 5 years from now, because this program works, riots in 
countries because they can only give medicine to 45 percent of 
the people who need it to stay alive and the other 55 you 
didn't see before you built the system.
    Senator Shaheen. Well, that leads me to raise another issue 
that has been a sensitive and controversial issue, but I think 
it's important as we're talking about that, how do we best 
invest the dollars. As we all know, family planning remains a 
controversial issue in this body, in the country. Mr. Gates, 
you mentioned in your written testimony that voluntary family 
planning is a proven and cost-effective way to save lives. 
According to the CSIS report, for every $100 million invested 
in family planning 4,000 maternal lives are saved, 70,000 
infant deaths are prevented, and 825,000 abortions are averted.
    So how can we move this debate beyond this topic being 
controversial to being another way to accomplish what we need 
to to deliver health care for people around the world?
    The Chairman. Before you answer, if I could just ask: Mr. 
President, do you have a deadline at 11:30 or so?
    President Clinton. No, I can stay until 10 to 12, I think.
    The Chairman. I think Doug Band is sitting behind you going 
``What?'' That's all right. Thank you, Mr. President.
    President Clinton. Go ahead, Bill.
    Mr. Gates. Well, I think the best way to change people's 
minds would be to have them go to the countries and see what's 
being discussed when we talk about family planning in these 
countries. Talk to the mothers who want access to the tools. 
The tools can improve. A lot of women use injections. Right now 
that's a needle, so you have to go to a health worker. There's 
a new advance where it's subcutaneous and so the person could 
actually get it at the pharmacy or administer it themselves. 
Also, the implants have been way too expensive. There's a new 
generation of those coming out that are substantially less 
expensive.
    What voluntary family planning means is bringing down by 
choice the rate of population growth and having more birth 
spacing. That's very dramatic in terms of improving maternal 
health. If you want 2 years between children, it cuts more than 
half the chance that there will be a maternal complication.
    So it's very effective. In these very poor places, the high 
population growth caused because you don't have access to these 
tools when you want them, that builds in huge problems for the 
future. So it's great to see the United States looking at these 
investments and that that receives somewhat of an increase in 
the GHI budget. It's important spending. It's an area that our 
foundation prioritizes as well.
    The Chairman. Thank you.
    President Clinton. Here's what my recommendation is. I 
don't know if it'll work or not. Ask your colleague here. But I 
think the Foreign Relations Committee should start with members 
and staff members going to see some of these places, because I 
think there is the--look, when a pro-life person hears the word 
``family planning'' they think, you know, abortion, they think 
license, they think all these things. If you could see these 
things in operation, they come across as clearly pro-family and 
profoundly pro-life.
    These poor women, they're just trying to manage their 
lives, and if they space out the births, like Bill said, they 
can do a better job as mothers, they can still work and earn 
income for the family. It changes everything for them.
    So I personally think that your best bet is for people, 
whether they're viscerally for this or viscerally against it, 
to actually see it, see how it works in real people's lives. I 
think that would change things.
    And I don't think you should give up on this. Who would 
have thought that Jesse Helms would have supported the global 
debt relief initiative in 2000? Who would have thought that by 
the time President Bush supported PEPFAR we'd have had 
everybody in the wide world on the bandwagon? I think it's very 
important just to keep working at it.
    But believe me, most people who talk about family planning 
have never seen it in operation on the ground.
    Senator Shaheen. Thank you.
    The Chairman. Senator Barrasso.
    Senator Barrasso. Thank you very much, Mr. Chairman.
    Mr. President, Mr. Gates, thanks so much for being here. I 
appreciate the work that both of you continue to do for the 
benefit of all humanity.
    Mr. President, I agree completely when you talk about 
vaccination. They're cheap and they work. And I really 
appreciate when you talk about recruiting, training, and 
retaining health care providers, whether it's nurses, nurse-
practitioners, physicians in the communities. And I appreciate 
what you say when you say you must be invited in, they must 
have a plan, and you want to make sure they're making 
measurable results.
    Mr. Gates, I agree completely, the integrated approach to 
care. I saw in my 25 years as an orthopedic surgeon how 
important that is, early detection, prevention, all of those 
things in an integrated approach, and the kind of one-stop 
shopping that you talked about, where people can go, whether 
it's for malaria, for AIDS, for whatever the disease.
    What I hear, Mr. Gates, from my colleague Senator Enzi, 
who's had a chance to visit a number of these locations, is 
that the patients and the people want to go to the Gates 
facility much more than the local, say, state-run or 
government-run facility because, as President Clinton talked 
about, they have to walk to the clinics, but apparently you've 
come up with a better way with transportation and sending a van 
230 miles around. So it's not just the health care, but it's 
all of these other ancillary things that we can do to help 
improve the systems.
    So I look forward to having a chance to visit the 
facilities as well. But I don't know, Mr. Gates, if you could 
talk about that, about how the Gates Foundation has set up 
criteria for when you decide to get involved and holding people 
accountable for a continuation of support because you actually 
do want to make sure that the value is there for the dollars 
invested and the best results can be obtained.
    Mr. Gates. The Gates Foundation gives money to the Global 
Fund because we think it's a great organization. I think we've 
given $650 million to them at this point. They work with the 
countries. They're quite low overhead in terms of how they do 
it.
    In terms of setting up clinics, there is a difference 
between high AIDS prevalence countries and low AIDS prevalence 
countries, and a little bit of a mistake was taking them all 
from high AIDS prevalence, where dedicated facilities and 
people are trained in special ways really makes sense. Because 
of the adult health care you're delivering, it's a high 
percentage, so Botswana, South Africa, Besotho, Swaziland. As 
you move to countries like Rwanda, Ethiopia, where the AIDS 
prevalence is more in the 2-percent range, there you don't want 
to create a separate structure.
    So having the judgment to look at, OK, the AIDS prevalence, 
rural versus urban, there's decisions that get made. I think 
there's a lot of learning going on. I wouldn't characterize the 
field as there's the vertical levers and the, ``health 
systems'' levers. It's all about taking a particular set of 
facts and circumstances and coming up with what the right 
approach is. Country by country, I do see that being done. GHI 
talks a lot about that, consulting with countries and picking a 
few countries to be model countries and even having some funds 
that are somewhat unprogrammed that would help them drive those 
model programs.
    President Clinton. Senator, I think you hit on something. 
You gave a specific example of a general issue that I would 
urge you to explore with the administration officials when they 
come, because nobody's got an answer to this. I can tell you, 
at least I don't. But I've already said here I strongly support 
this GHI initiative. It is well conceived. It is what we ought 
to do.
    But when you ask us, well, OK, that's fine, so what should 
the government of X's relationship be with the NGO community, 
both from a country like ours or a domestic one, and what 
should the American Government's relationship be to that 
government? For example, as I know you know, we don't give 
foreign assistance to other countries for direct budget 
support. Now, when you first hear it, it makes enormous sense 
because we want to achieve certain specific objectives--and we 
sure as heck don't want to fund ineffective government. On the 
other hand, we are now coming up and saying, we've got to build 
health care systems in this country.
    So I just want to urge you to keep pushing this and keep 
thinking through this, and use your experience as a physician 
with the health care system. If the end of this is--if the 
definition of success is they have their own health system and 
it works as well as possible given that amount of money, how 
are we going to relate to the government and how should the 
U.S. assistance program relate to the NGO community, both the 
American NGOs and the ones in the country? Try to get some 
examples.
    If you read the GHI report, there's a pretty good 
description of what they did in Bangladesh, but that's about 
it. I love the report, but you need to really work through 
this, I think.
    Senator Barrasso. Thank you, Mr. Chairman.
    The Chairman. Thank you, Dr. Barrasso.
    If I could just ask a couple of things before we wrap up. 
Africa has fewer doctors and fewer trained medical personnel 
than any other region, and apparently continues to lose many of 
those who are trained to either North America or to Europe. I 
wonder how we can help to prevent that from happening and to 
take the underserved regions and empower them to be able to 
build their indigenous permanent medical corps, if you will.
    This sort of plays off the question that was asked earlier 
about people going to the Gates entity versus others.
    President Clinton. Well, I'll give you just a couple of 
ideas. First of all, there are plenty of gifted people there 
who want to stay, that will stay if you train community health 
workers, you train more nurses, and you provide facilities. A 
lot of those doctors will stay at home and make a heck of a lot 
less money than they could here, as long as they don't have to 
fail as doctors as long as they have a health care network that 
makes sense.
    Second, I think with physicians in particular, I think we 
have to recognize that the African university system declined 
over decades as the colonial era faded away, to an astonishing 
degree. Now all these American universities are opening in the 
Middle East. I'm for it. I love it. NYU is opening in Abu 
Dhabi. You've got all these universities in Qatar. Why? Because 
that's where the money is. They pay them to come in there. I 
think it's good for us over the long run, good for America and 
the Middle East. It gives people a different look at us.
    But we maybe should think about funding the same sort of 
help in Africa where our universities could be there and be 
there in partnership with African universities and build their 
capacity even as there's an architecture school from, I don't 
know, the University of North Dakota there. I think you should 
really think about it. There's no analog. This is a very 
discreet strategy that universities are following in the Middle 
East and it's going to be good for our foreign policy, I think, 
but it's only because they're rich. We really need to do this 
where people aren't rich. I think you should really look at 
that.
    The Chairman. Mr. Gates, you and Melinda launched the 
Living Proof Project. Can you share with us what kind of 
traction that's gained since it started and what your hopes are 
for it?
    Mr. Gates. Yes, Melinda and I did about a 1-hour 
presentation, which was really a thank-you to the committee and 
broadly the U.S. taxpayers for the generosity, and telling some 
of those success stories. We got that on line at the foundation 
Web site, and we've even broken it down into pieces so you can 
look at a 5-minute video in malaria, 5-minute video in AIDS, 
and see these heart-rending stories, fortunately mostly with 
successful outcomes.
    It's been interesting. We've had a lot of the European 
governments ask us to go over and do the equivalent there, 
because again the awareness of the programs is not that broad. 
So I think over the next year we'll go to U.K. and a couple 
other countries and talk about that story, because their 
generosity is important as well.
    Global health is more visible today than it was 10 years 
ago, but not as visible as it really needs to be so that people 
feel great that this budget item continues to grow at a time 
when overall not much will be growing.
    President Clinton. Senator, if I could just echo. I think 
that what Bill and Melinda have done on this is great. In order 
to build support for this if we could humanize it I think it 
would make a big difference. If you come to my office in New 
York, you'll see a picture of a little girl whose mother and 
father were both HIV-positive, and they became friends of mine 
when they risked everything to get the medicine to prevent 
mother-to-child transmission a decade ago in Nigeria. The child 
is healthy, without HIV.
    You see a picture of a beautiful girl in her prom dress who 
at 13 weighed 75 pounds and was so weak she could not hold her 
head up at her school desk in Haiti. She had to be taken to 
school by a cab. That young woman was the first person to get 
our AIDS medicine and we became friends and she's asked me to 
send her to law school now.
    At one of our remote clinics in Rwanda, there were a boy 
and a girl living in a mud hut whose parents both died, but the 
older sister was not HIV-positive and the brother was. He 
miraculously lived until he got our medicine, and now he has a 
third-grade education at 15--he said: If I finish high school, 
can I go to medical school so other kids won't get sick?
    I think we need to tell these stories everywhere. I think 
if you can make this come alive to people through stories we 
can get all the support we can say grace over.
    The Chairman. My next question was really going to be, 
given the extraordinary accomplishments and the things that 
you've talked about that we've been able to achieve, it's 
disturbing that we are viewed the way we are in many different 
places. Now, not so much in Africa to some degree. But is there 
something more we should be doing in terms of public diplomacy 
that doesn't amount to a kind of shameless self-promotion, but 
on the other hand does better inform people about our efforts 
and desires and shared aspirations?
    Mr. Gates.
    Mr. Gates. Well, it's interesting. Governments, including 
the U.S. Government, aren't that good at telling their success 
stories. It's partly because nobody knows, should you allocate 
talent for that or not, is it appropriate or not. So when 
things do go well, there's just--that muscle, OK, how do you 
get that story out there, is not that strong.
    Coming from a corporate environment, you'd think, can we 
announce this? If we can't announce it, should we do it? So 
it's a feedback loop where you get credit for the things that 
you do well and that helps you to pick some of the right 
things.
    Here we have this phenomenal success story that everybody 
who is in the community is amazed at PEPFAR. They were thrilled 
with the President's Malaria Initiative. Getting new government 
programs off the ground quickly, with all the complexities of 
making sure money's not misspent, is very hard, and these two 
actually surprised me in both cases by having--partly by having 
able leaders. The initial leaders of PEPFAR were good, the 
current leader of PEPFAR is good. I'm certainly a big fan of 
Raj Shah, who runs USAID now and did a lot of great work at our 
foundation.
    I think to some degree you will--you could do a better job 
of telling the story, and I think you will have to rely on 
people like ourselves and other third parties to get that story 
out, because in some ways they have more credibility. Certainly 
we're trying to do that. The Internet is a wonderful tool to 
take a 5-minute video and tell these stories. So even though we 
got about 50,000 people to look at Living Proof, I went back to 
the foundation and said: I want 500,000, and then I'll ask for 
5 million.
    So we're not quite as adept, even ourselves, at taking this 
digital environment that should be so wonderful, because 
whichever thing you're interested in, you should be able to go 
right to that.
    The opaqueness of the budgeting process I do think is tough 
for people. You say, OK, there was a supplemental here and 
that's in the 150 account, and it was authorized but never 
appropriated, and now you want credit. It really is very hard 
for people who don't follow these things. What's the percentage 
increase in GHI? Well, there's about five different ways you 
could look at that.
    The Chairman. I've got news for you. It's hard for people 
who do follow it.
    President Clinton. You're going to have the administration 
come up here, and I'm with Mr. Gates. I have a very high 
opinion of Raj Shah and he worked for the Gates Foundation, not 
for me. And I love Eric Goosby, who did work with us in China, 
where we were invited by the government to go out and reach 
people in rural areas.
    This goes right to the point you're making. I had a 
fascinating experience. The Chinese asked me to go out in the 
rural areas and be on television playing with and talking to 
children with AIDS. They said: I know you think we don't have 
politics, we're just a Communist country, but we do. It's just 
like America. You get in the rural areas, people are more 
conservative. They're still scared of AIDS. So we want you to 
go out there and sell it.
    I say that because this idea of selling it is a problem 
everywhere. You don't want to be self-serving. Most of the 
people who do this work, frankly, don't care how much credit 
they get. They just want to save lives. But as a result, we're 
not very good at it, that plus the complexities of the 
government budget process.
    So I think it's something you should explore with the State 
Department, because they do have very good public diplomacy 
people there. I think the message you want to send to the rest 
of the world is: There is no way you can agree with everything 
we do. Within our country, none of us agree with everything we 
do. But you should know everything we do and view us through 
the lens of everything we do and what we stand for, where we're 
wrong and where we're right from your point of view.
    I think that if you do it like that, then you don't come 
across as self-serving. You're not trying to put a shine on 
people and you're not taking tax money and in effect using it 
for pretty smarmy ends. You're just telling people they need to 
know. It's terrible that all this good stuff's been done and 
nobody knows about it.
    The Chairman. Mr. President, Mr. Gates, a final question if 
I can. You recently made some important comments, Mr. Gates, 
about climate change. There is a growing body of literature and 
scientific evidence about the impact of climate change on human 
health, directly impacting the very goal of this Global Health 
Initiative. I wonder if, whether it's access to water or food 
security, which we've talked about a little bit, or the 
spreading of disease, could both of you perhaps quickly share 
with the committee any observations you have made or 
conclusions you have come to regarding this interconnection?
    Mr. Gates. Well, I think there's good news, that if you 
want to help Africa or any poor country mitigate the effects of 
climate change, the kinds of things you need to do are exactly 
the things you would want to do otherwise. You want better 
seeds that are more productive. You want better extension 
programs. You want better markets for their output. Probably on 
another occasion, new moves around food security, I think there 
are some important things there that the administration is 
trying to push forward. So more investment there, whether it's 
called mitigation or simply helping the agricultural needs of 
the poor; very valuable.
    Likewise, if we can get energy that's cheaper and doesn't 
emit CO2, which is a very huge challenge, but the benefits of 
that would be very dramatic and far more dramatic for the 
poorest. The richest can afford energy to get more expensive, 
but the poorest really cannot. So that's why I love the idea of 
increased R and D, particularly on technologies that, while 
meeting the new constraints, have a chance over a period of 
decades to actually be cheaper than the ways we get energy 
today. On another occasion, I'm sure I'll be back here 
elaborating more in that area.
    President Clinton. I'm reluctant to talk about this, 
Senator, on the theory that if you get into everything relates 
to everything else you muddy the water. But I think there's no 
question there are going to be health impacts. If I could just 
give you a couple of examples.
    No. 1 you mentioned. In places where the climate is getting 
hotter substantially and where water tends to be concentrated 
more in severe weather events rather than regular waterfall, 
this will cause on the one hand water shortages and on the 
other it could lead to standing water which bears waterborne 
illnesses.
    There's no question that malaria is occurring at higher and 
higher altitudes in places it didn't before because mosquitoes 
are going to places they didn't feel comfortable before. 
There's lots of evidence of that.
    In the food area, this is important because most studies 
show that Australia was the first place really hit hard by 
changing climate, as you see from the wildfires. Their capacity 
to grow livestock and raise crops has been substantially 
altered. But ironically, the next places that have been 
identified by most people who study this are the poor countries 
that already can't take care of themselves. Two of the next ten 
on the list are Afghanistan and Haiti, interestingly enough. So 
I would be worried about all that.
    In terms of energy, I think that small-scale clean energy 
and promoting self-sufficiency is really important. The best 
entrepreneur I work with in Haiti raises fish. Last year more 
than half the fish on Earth were raised, instead of caught 
naturally, in oceans, lakes, and rivers. He has a huge 
operation that he runs with a $35,000 solar unit with a battery 
that stores excess solar power and a refrigeration unit run by 
a $10,000 solar unit.
    So yes, I think the whole clean energy thing and the 
climate change debate has health implications both positive and 
negative. Maybe some time we can come back and talk about that.
    The Chairman. I appreciate that very, very much.
    Well, Mr. President, Mr. Gates, we are very appreciative. 
I'll turn to my colleagues in a moment to see if they have any 
last comments. But let me just say that 20 million to 9 million 
is an extraordinary reduction in human suffering, obviously. 
There are so many ways and so many stories that are testimony 
to the extraordinary efforts that both of you have made. You've 
both aggregated your assets and resources from different 
fields, but together I think have created a unique team and 
have had a unique impact which has served the country and 
humanity in an extraordinary way.
    I'm reminded of one of the things de Tocqueville wrote when 
he came and observed America, ``America is great because 
Americans are good,'' and he was referring to this natural 
charity that took place in America, about how people took care 
of each other and how we reached out and built community, and 
he found it quite extraordinary.
    I think in the best of ways that the two of you are doing 
that and representing us in an extraordinary way, and the 
accomplishments are beyond just measurable and words don't 
adequately describe it. We thank you. It's really an 
extraordinary story, quite superb.
    Do any of my colleagues want to comment?
    Senator Cardin. Good job.
    Senator Shaheen. Thank you.
    The Chairman. If not, we really are grateful to you for 
helping to accent how important this Global Health Initiative 
is, and we have our work cut out for us. Thank you very much. 
Thank you.
    We stand adjourned.
    [Whereupon, at 11:52 a.m., the hearing was adjourned.]

                                  
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