    [Senate Hearing 114-143]
    [From the U.S. Government Publishing Office]

                STATE, FOREIGN OPERATIONS, AND RELATED
                 PROGRAMS APPROPRIATIONS FOR FISCAL
                 YEAR 2016

                                  ----------

                            THURSDAY, MARCH 26, 2015

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:05 a.m., in room SD-192, Dirksen
    Senate Office Building, Hon. Lindsey Graham (chairman)
    presiding.
        Present: Senators Graham, Blunt, Boozman, Moran, Daines,
    Leahy, Coons, Merkley, and Murphy.

                 DIPLOMACY, DEVELOPMENT, AND NATIONAL SECURITY

    STATEMENTS OF:
            BILL GATES, CO-CHAIR, THE BILL & MELINDA GATES FOUNDATION
            BEN AFFLECK, ACTOR, FILMMAKER, AND FOUNDER OF EASTERN CONGO
                INITIATIVE
            JOHN MEGRUE, CHAIRMAN, APAX PARTNERS U.S. AND CHAIRMAN OF BORN
                FREE AFRICA
            ADMIRAL JAMES STAVRIDIS, USN, RETIRED, SUPREME ALLIED COMMANDER
                AT NATO, 2009-2013, AND CO-CHAIR, U.S. GLOBAL LEADERSHIP
                COALITION NATIONAL SECURITY ADVISORY COUNCIL
            SCOTT FORD, CHIEF EXECUTIVE OFFICER, WESTROCK GROUP, LLC, AND
                FORMER CHIEF EXECUTIVE OFFICER, ALLTEL CORPORATION

                  OPENING STATEMENT OF SENATOR LINDSEY GRAHAM

        Senator Graham. The subcommittee will come to order.
        Our hearing today is on Diplomacy, Development, and
    National Security, and we have an incredible panel of great
    Americans in their own way. Balancing the schedules of these
    gentlemen had to be very difficult, and each and every one of
    you made a sacrifice to be here. You had other places you could
    go and probably needed to go, but the fact you would come here
    and share your testimony, your experiences, your thoughts and
    opinions about the 150 account means a great deal to Senator
    Leahy and myself.
        As to Senator Leahy, we have been partners here for several
    years on this account. I have thoroughly enjoyed working with
    him and Tim Rieser, and this is one area of the Government that
    we are trying to make sure actually works. Our relationship has
    grown over time, and we are both committed to making sure that
    America stays involved in the world in a productive fashion.
        Our panel today consists of Mr. Bill Gates, Co-chairman of
    the Bill & Melinda Gates Foundation; founder of Microsoft. Ben
    Affleck, an actor, filmmaker, and founder of the Eastern Congo
    Initiative, which I visited, and you are doing great work in a
    very troubled area of the world. John Megrue is Chairman of the
    Apax Partners U.S. and Chairman of Born Free Africa and has
    been working with the United Nations particularly dealing with
    the mother-to-child AIDS transmissions. Thank you very much,
    John. Admiral Stavridis is the former North Atlantic Treaty
    Organization (NATO) Commander, is now the Dean at the Fletcher
    School of Law and Diplomacy at Tufts University. He wore the
    uniform for many years, many decades, and I really look forward
    to your view as a military commander about this account. And
    Scott Ford is the Chief Executive Officer of Westrock Group and
    former Chief Executive Officer of Alltel. And I have had the
    pleasure to see what Scott has been able to do in Rwanda
    regarding the coffee market.
        So all of you are welcome, and I will let the first
    statement be by Senator Leahy, if he would like.

                     STATEMENT OF SENATOR PATRICK J. LEAHY

        Senator Leahy. Well, thank you, Mr. Chairman. I think what
    is probably the most important is that we hear from the people
    who are here.
        We talk about diplomacy, development, and national
    security. That is really relevant, probably any time since
    World War II. We know that there are limits to what our
    military can do. And, Admiral, I am delighted you are here. We
    discussed this before. We have this huge economic and military
    power, but we ought to be showing the rest of the world some of
    the best parts of us. I talked with Mr. Gates earlier. When
    Senator Graham and I told our colleagues that they ought to
    pony up on money on infectious diseases, a country of 320
    million Americans ought to be able to at least match what Bill
    and Melinda Gates were doing.
        But also we know that we have some problems with
    development, with funding large contractors and non-
    governmental organizations (NGO's) that might make a lot of
    money for the ones putting it together, but I am worried that
    we do not see what we want to see.
        And I think that with the cuts in the House and Senate
    budget, we are going to have difficulties. I think we have to
    look at what actually makes life better for the people we are
    dealing with, but also for our own country. I like going into a
    small country and we find that one of our programs is actually
    about the only medical team that has ever been there, or the
    areas where we worked on land mines, or the school that now has
    books. Instead of one book, they have a book for everybody.
    These are the things that show what is best in America; a lot
    more than some of these huge things.
        But I have worked with Senator Graham over the years. Part
    of the time, he has been chairman; part of the time, I have
    been chairman. We try to make this as non-partisan a bill as
    possible, and we will continue to do that. He is a good friend.
    He understands this program as well as any Member of the
    Senate, either party that I serve with.
        Senator Graham. Thank you, Mr. Chairman.
        Very briefly, contrary to popular opinion, the foreign
    assistance account is 1 percent of the Federal budget. You can
    eliminate every penny we spend and not even move the debt
    needle 1 inch. So to those who constantly demagogue foreign aid
    as being the root of our financial problems, please stop
    because you do not know what the hell you are talking about.
        This account is designed to show who we are as a Nation. It
    is designed to enhance our national security. It is designed to
    deal with enemies of mankind such as radical Islam, AIDS,
    malaria, and a lot of other disease, poverty. It is designed to
    build people up so that we can live in peace with them, they
    can have a better life, and make the world a safer place. It is
    designed to have an American presence that is nonlethal. You
    cannot protect America by just dropping bombs on people.
        This account in many ways is the best line of defense in
    terms of Africa. We do not have a large military presence in
    Africa, but in a bipartisan fashion, we have had developmental
    programs fighting AIDS and malaria, trying to resolve conflicts
    in Africa. And this account has been the front line.
        The return on investment on behalf of the American taxpayer
    from this account--I will match it with any place in the
    budget. I have never seen what a small amount of money can do
    in a positive way better than here. It is $50-something billion
    and that is a lot of money, but in the budget it is a rounding
    error. The amount of money we have appropriated each and every
    year is leveraged by the private sector, and each one of you
    come from the private sector. In partnership with your
    Government, non-governmental organizations, faith-based
    organizations, the Gates Foundation, you just name it--we have
    created partnerships that every American I think should be
    proud of.
        And the day that we stop doing what this account
    represents, our best days are behind us. We will have chosen a
    path that no generation of Americans have ever chosen before,
    one of indifference, one of isolationism, one of we are not
    really responsible or the leading voice in the world. We are.
    And this account represents that philosophy. It is a good
    investment on behalf of the taxpayer. What you have received in
    rates of return you cannot measure: an entire generation of
    young African children being saved from the scourge of AIDS,
    turning the corner on malaria. In the Congo, what Mr. Affleck
    has done in cooperation with NGO's and the government is to
    take hell on earth and make it a bit better. And to Mr. Ford,
    what you have proven the private sector can do is just
    astounding.
        So thank you all. We look forward to hearing your
    testimony.
        As we speak today, there will be a vote on the floor of the
    United States Senate where a Member of the Senate is chosen to
    reduce this account by 50 percent and give that money to the
    military. Here is what I would say on behalf of the military.
    They do not want this money. They want this account to survive
    and thrive.
        General Mattis told me probably the best explanation of how
    this account plays in the world as it is. He said, Senator, if
    you do away with the 150 account, if we withdraw from the world
    and these programs go away, you better buy me more ammo. I
    could not say it better myself.
        So since Republicans are in charge, we are going to start
    from the right with Mr. Gates.

                        SUMMARY STATEMENT OF BILL GATES

        Mr. Gates. Good morning, Mr. Chairman, Senator Leahy, and
    other members of the subcommittee. Thank you for the
    opportunity to talk with you about the importance of U.S.
    foreign assistance.
        Melinda and I, in writing our annual letter for the
    foundation, talked about what great things can happen if the
    United States and other countries maintain the generosity that
    they have had through this account. Over the next 15 years,
    there are some amazing things that can be achieved.
        If we go back to 1960, we had a very dire situation. One
    child in five died before their fifth birthday. Twenty-five
    years ago, by 1990, that rate was down to 1 in 10, and since
    then it has been cut in half again to 1 in 20. With the right
    investments over the next 15 years, we will be able to cut it
    in half again to 1 in 40. That is a faster improvement than we
    have ever seen in the past.
        And there are many U.S. programs that are absolutely
    central to this decline in child mortality and to other gains
    in health and development worldwide.
        One specific program that makes a huge difference is the
    Global Alliance for Vaccines and Immunization (GAVI), the
    vaccine alliance. This public-private partnership creates a
    market for companies to develop vaccines that protect children
    in poor countries against the most common causes of death and
    severe illness. As an American, I am proud that the United
    States Government is one of GAVI's biggest donors. Since its
    inception in the year 2000, GAVI has helped immunize close to
    half a billion children and prevented over 7 million deaths. I
    can assure you that the parents of those children would be glad
    to vouch for the simple fact that vaccines are safe, vaccines
    are effective, vaccines save lives.
        Another great example of this is the fight against polio.
    The number of countries where that disease is endemic has gone
    from 125 in 1988 to just three today.
        In this year's annual letter, Melinda and I predict that
    Africa will be self-sufficient in food production within 15
    years. Here too we are seeing great progress, much of it made
    possible by U.S. assistance. The U.S. has a major impact in
    improving agricultural productivity in poor countries through
    USAID and USDA support for agricultural research in partnership
    with our land grant universities.
        In my written testimony, I discuss a number of U.S.
    programs that are delivering high returns on investment and
    having a positive impact for the global poor.
        But there is another area where foreign assistance will
    make a huge difference not only for the people of the world's
    poorest nations but for the people of this Nation as well.
        As you know, I tend to be optimistic about what the future
    holds, but there are a small number of potentially catastrophic
    events that could set back the progress of the past two
    decades. The most plausible and most frightening of these
    threats is a large epidemic. As I note in my recent New England
    Journal of Medicine and New York Times articles, I am talking
    about something bigger than the Ebola outbreak we have seen in
    West Africa. Ebola is not a disease that spreads very easily.
    What concerns me most is the prospect of an even more lethal
    disease which is also highly contagious. We have seen outbreaks
    like this in the past such as the flu pandemic of 1918 and 1919
    which had a worldwide death toll of 30 million to 50 million.
    Could an epidemic of this scale happen again? Yes, it could,
    and in today's far more urbanized and interconnected world, it
    would spread far more easily than a century ago.
        I have come to Congress on other occasions to ask for the
    sustainment of U.S. foreign assistance. I have grounded this
    appeal in our shared moral interest in preventing needless
    deaths and suffering and also in our economic and security
    self-interest. With Ebola and the very real prospect of an even
    more infectious disease, the case is now even clearer. I am
    asking you to support foreign assistance programs not only as a
    highly effective way to help other countries become more self-
    sufficient, but also as a necessary means of protecting this
    country from a future epidemic.
        The sensible place to begin is with investments in basic
    health services in those parts of the world that are most
    susceptible to outbreaks of infectious disease. Whether we are
    talking about preventing the next epidemic or building upon the
    enormous global health gains of the past two decades, the time
    to act is now. The need for foreign assistance remains strong,
    and recent events demonstrate its urgency.
        Thank you for inviting me to join you today. I look forward
    to your questions.
        [The statements follow:]
                        Prepared Statement of Bill Gates
        Mr. Chairman, Senator Leahy, members of the subcommittee--thank you
    for this opportunity to talk with you about an important subject: the
    role of U.S. development assistance in helping people in the world's
    poorest nations attain greater self-sufficiency.
        In January, my wife Melinda and I put out our annual letter. In it,
    we wrote about ``our big bet for the future''--that the lives of people
    in poor countries will improve faster in the next 15 years than at any
    other time in history.
        In my brief time before you today, I'll make three basic points:
      --First, that this ``big bet''--while ambitious--is indeed
            attainable, based on the extraordinary progress that we've seen
            in recent years.
      --Second, that achieving further gains against extreme poverty and
            disease in the world's poorest countries would have significant
            benefits for the American people.
      --And third, that these gains require sustained U.S. commitment to
            overseas development assistance. Together with the leadership
            and commitment of the countries in which we work, we can make
            historic progress--right now--against extreme poverty and
            disease.
        I'll now touch on each of these points in turn.

    First, the progress that the world has made against disease and extreme
    poverty is truly extraordinary. It should leave no doubt that we now
    have an opportunity for historic advances in the well-being of
    humanity--particularly in poor countries.

        The most important single measurement of progress in global health
    is the child-mortality rate--and its trajectory has been astonishing to
    watch.
        Worldwide, in 1960 about one child in five died before his or her
    fifth birthday.
        By 1990--25 years ago--that rate had been cut in half, to 1 in 10.
        Since then, it's been cut in half again, to 1 in 20.
        We now have the tools to halve this rate yet again, to 1 in 40, and
    to do it even faster--within 15 years.
        What accounts for this?
        One very important factor is the investment by governments around
    the world in their own nations' health and development. But that's not
    the only factor at work here.
        Global economic growth; changes in trade policy; and the spread of
    new technologies have all contributed to fundamental improvements in
    human health and well-being.
        But there's another indispensable factor: overseas development
    assistance, notably from the United States.
        Working with other national governments and donor partners, U.S.
    Government investments have contributed to these amazing declines in
    child mortality--and to other gains in health and development
    worldwide.
        I'll mention just a few specific examples of U.S.-supported
    programs that have made an enormous difference.
        One of these is Gavi, the Vaccine Alliance. This is a public-
    private partnership that pools the demand for vaccines among the
    world's poorest nations. It then provides long-term financing through a
    number of sources--including from the recipient nations themselves--to
    meet that demand.
        This creates a viable market for pharmaceutical and biotech
    companies to develop vaccines, and increases healthy competition among
    them. That, in turn, helps drive down prices for vaccines that protect
    young children from the most common causes of death and severe
    illness--including diarrhea, pneumonia, and measles.
        It's a brilliant model, and a very effective one. Since its
    inception in 2000, Gavi has helped immunize close to half a billion
    children and prevented 7 million deaths.
        I'm proud that our foundation is a contributor to Gavi--and, as an
    American, I'm proud that this country is one of Gavi's biggest donor
    nations.
        At the Gavi replenishment conference in January, the organization
    met its target amount of $7.5 billion. The U.S. made a generous pledge
    of $1 billion to Gavi over 4 years, including fiscal year 2015.
        The new replenishment round will allow Gavi to immunize another 300
    million children and save the lives of 5 million to 6 million children.
        And I can assure you, members of the subcommittee, that the parents
    of those children would be glad to vouch for a simple fact: Vaccines
    are safe; vaccines are effective; vaccines save lives.
        Speaking of the life-saving power of vaccines, another great
    example of progress and partnership has been the worldwide campaign
    against polio. Here too, the policy choices of the U.S. Government have
    been decisive.
        The United States has been a strong supporter of the Global Polio
    Eradication Initiative (GPEI)--the Centers for Disease Control and
    Prevention was one of the original partners, along with Rotary
    International, the WHO, and UNICEF.
        Since 1985, the U.S. has provided more than $2 billion to GPEI. At
    the time of the initial U.S. investment, eradicating polio seemed like
    a fantasy--the disease was endemic in 125 countries around the world
    and paralyzed about 350,000 people each year, mainly young children.
        Less than three decades later, polio is endemic in only three
    countries--Pakistan, Afghanistan, and Nigeria. Actually, we may soon be
    down to two, since Nigeria had only a handful of cases in 2014 and may
    be on the verge of eliminating the disease there. Worldwide, the number
    of polio cases last year was less than 400.
        The good news of the past couple decades even extends to some of
    the most lethal infectious diseases, such as HIV/AIDS and malaria.
        Since 2000, among children under five worldwide, deaths from AIDS
    have declined by 50 percent, while deaths from malaria have gone down
    80 percent.
        For the world population as a whole, the global incidence of HIV
    has gone down by 20 percent since its peak in the mid-1990s, and the
    mortality rate for malaria has declined by 42 percent since 2000.
        These significant gains would not have been possible without major
    programs supported entirely or in part by the Government of the United
    States: the President's Malaria Initiative, or PMI; the United States
    President's Emergency Plan for AIDS Relief, or PEPFAR; and the Global
    Fund to fight AIDS, Tuberculosis and Malaria--to which the U.S. is the
    top donor.
        In addition to historic gains against disease, we are seeing
    progress in maternal, newborn, and child health. Investing in women and
    children yields broad economic and social benefits that help build
    prosperous communities and nations.
        The U.S. has been a leader in the campaign to end preventable child
    and maternal deaths--and worldwide, more women survive pregnancy and
    childbirth than ever before.
        As Melinda and I discuss in our annual letter, we believe that even
    faster progress is possible--and necessary--over the next 15 years.
        In this year's annual letter, Melinda and I also predict that
    Africa will be self-sufficient in food production within 15 years.
        This would be an enormously significant milestone. Experience shows
    that the path for countries to escape poverty is almost always through
    agricultural development--as it was for the United States itself.
        Agriculture is also closely linked to nutrition and health. Every
    year, undernutrition contributes to 3.1 million child deaths--45
    percent of the worldwide total. It also costs low- and middle-income
    countries up to 8 percent of their economic growth potential.
        Since 1990, the world has seen a 37 percent drop in stunting as a
    result of better nutrition. The U.S. helped improve nutrition levels
    for more than 12.5 million children in developing countries last year.
        The U.S. has a major impact in improving agricultural productivity
    in poor nations through USAID and USDA support for agricultural
    research, in partnership with our land-grant universities.
        This research typically generates at least a 20:1 return on
    investment. In developing countries, the returns are even greater.
        And according to the World Bank, every dollar invested in
    agriculture is twice as effective at reducing poverty as investments in
    non-agricultural sectors.
        Given that 70 percent of all people living in extreme poverty are
    in rural areas, and most are engaged in farming, the renewed U.S.
    commitment to agricultural development represents a very sensible,
    cost-effective approach to reducing global poverty.
        In 2013 alone, the Feed the Future initiative helped nearly 7
    million farmers and food producers adopt new technologies and
    management practices. It also supported nearly 91,000 female farmers in
    homestead gardening--improving access to nutrient-dense foods;
    increasing income for women and children; and helping families become
    economically self-sufficient.

    This brings me to the second of my three points: While the lives of
    people in poor countries will improve more than anyone else's over the
    next decade and a half, that improvement will have very positive
    consequences for the people of the United States.

        One reason for this is that the American people value the qualities
    of self-sufficiency and independence--for ourselves and for other
    people around the world. We want people in poorer countries to have the
    tools to improve their own circumstances in a way that's sustainable
    and lasting for them.
        We don't want to see poor nations stay poor, or to remain dependent
    on outside aid. We want them to be able to stand on their own two
    feet--and that's exactly what the people of those countries want for
    themselves.
        When overseas development assistance is done right--as with the
    programs I've cited today--this is exactly what happens.
        We have seen this pattern play out across much of the world.
    Several countries that were once major aid recipients--South Korea,
    Brazil, Malaysia, Morocco, Botswana, to name a few--are now self-
    sufficient, and some have even become donor countries themselves.
        Several have become U.S. allies and partners, as well as export
    markets for our farmers and manufacturers: Nigeria is the third-largest
    U.S. wheat market; Angola is the fourth-largest broiler-meat market;
    and Ghana ranks as one of the top 10 rice markets.
        In short, it's in the interests of the American people to see more
    and more countries complete this development cycle--to make the
    transition from aid recipients to full participants in the
    international system.
        U.S. health and development assistance programs have been vitally
    important in helping countries around the world make that transition.
    This process is gaining momentum in many low-income nations today--
    particularly in Sub-Saharan Africa.
        But there's another major reason why progress on health and
    economic development in the world's poorest countries is in the
    interest of the American people.
        As you know, I tend to be very optimistic about what the future
    holds. But there are a small number of potentially catastrophic events
    that could seriously set back all the progress of the past few decades.
    The most plausible--and most frightening--of these threats is a large-
    scale epidemic.
        I discuss this prospect in my recent New England Journal of
    Medicine and New York Times articles; I'll talk about it briefly here
    today.
        By a ``large-scale epidemic,'' I'm talking about something much
    bigger than the terrible Ebola outbreak we've seen in West Africa,
    which has taken more than 10,000 lives.
        Ebola, for all its horrors, is not a disease that spreads very
    easily. What concerns me most is the prospect of a highly lethal
    disease that is also highly contagious.
        We have seen such outbreaks in the past, such as during the
    influenza pandemic of 1918 and 1919, which had a worldwide death toll
    generally estimated between 30 million and 50 million.
        That included about 675,000 deaths here in the United States--at a
    time when the national population was about one-third as large as it is
    today. The outbreak was so severe in this country that over the course
    of a single year, life expectancy in the U.S. fell by about 12 years.
        Could an epidemic of this scale happen again? Yes, it could--and in
    today's far more urbanized and interconnected world, it could spread
    from continent to continent, and from community to community, far more
    easily than it could a century ago.
        Members of the subcommittee, I've come to Congress on other
    occasions to ask for the sustainment of U.S. overseas development
    assistance.
        I have grounded this appeal not only in our shared moral interest
    in preventing needless death and suffering, but also in our economic
    and security interests. All these dimensions remain strong interests of
    mine, and I know they are strong interests of yours, as well.
        The Ebola tragedy has made our national interest in this effort
    clearer than ever before. I am asking you to support our assistance
    programs both as a highly effective means of helping other countries
    become more self-sufficient, and as a necessary means of protecting
    this country from a future epidemic.
        Such an epidemic might start far away, but could spread to the U.S.
    on a considerably larger scale, and with much greater speed, than any
    current form of Ebola.
        It's impossible to predict the human toll or the economic
    consequences that would result. According to the World Bank, a
    worldwide flu epidemic would reduce global wealth by $3 trillion, not
    to mention the immeasurable suffering that would accompany widespread
    illness and loss of life.
        The wise course is to invest manageable amounts now to prevent
    future outbreaks--rather than trying to contend with the unpredictable
    and potentially enormous costs of a trans-continental epidemic.
        The sensible place to begin is with investments in basic health
    services in those parts of the world that are most susceptible to
    outbreaks of infectious disease.
        As we have seen with the Ebola epidemic, the world's poorest
    countries remain acutely vulnerable to health crises that can render
    them unable to support their own people or build their own economies.
        This epidemic is also a reminder that infectious diseases don't
    respect national borders. In the interconnected world of the 21st
    century, a non-functional health system anywhere can create problems
    everywhere.
        It is imperative that we learn the right lessons from the Ebola
    emergency. Perhaps the most urgent of those lessons is the paramount
    importance of bringing health systems up to a level of at least basic
    adequacy in as many places as possible.
        The process begins, of course, with the recipient nations
    themselves--which must invest in the health of their own people, in
    partnership with external donors.
        This had already happened in enough areas of Nigeria, Senegal, and
    Mali to prevent Ebola from spreading farther in those countries--and
    thank goodness for that, since any expansion of the outbreak to large
    urban areas like Lagos or Bamako could have immensely increased both
    the death toll and the complexity of this epidemic.
        To its great credit, the United States has played a leading role in
    responding to the West African Ebola outbreak. Our challenge now is to
    maintain the effort and the investment required to ensure we're better
    prepared for future epidemics.
        This includes investment in a range of vital systems: primary
    healthcare; disease monitoring; and data collection--as well as such
    basic medical tools as vaccines, therapeutics, diagnostics, and
    transfusion processes.
        But in some ways, the main problem with U.S. epidemic preparedness
    is not our level of investment--though that will also need to improve--
    but our lack of optimal coordination across agencies.
        Within the U.S. Government, there are multiple agencies engaged in
    epidemic response at some level--either directly, or indirectly through
    the development of guidelines or technical expertise.
        These include the Centers for Disease Control and Prevention; the
    National Institutes of Health (NIH); the Food and Drug Administration;
    the Defense Threat Reduction Agency (DTRA) and the Defense Advanced
    Research Projects Agency (DARPA) at the Department of Defense; the
    Department of Health and Human Services Office of the Assistant
    Secretary for Preparedness and Response (ASPR); and several others.
        Consider the Government's response to the Ebola epidemic: Just
    within the area of research and development, we had the development of
    ZMapp, which was funded by the Biomedical Advanced Research and
    Development Authority within ASPR; a lead vaccine candidate funded by
    NIH; a diagnostic test funded by DTRA; and additional technological
    approaches funded by DARPA.
        Such diversity of agencies engaged in a shared challenge is by no
    means necessarily a problem. It can even be a strength. But
    particularly when it comes to R&D, we need better coordination and
    transparency. That includes a greater awareness of what is being funded
    and studied across agencies, so that we may avoid unnecessary
    duplication of effort; derive maximum leverage from what's already
    being done; and advance the state of research as much as possible.
        There's one more reason why improvements in cross-agency
    coordination--and, where needed, additional investments--make enormous
    sense: They will be worth it even if a large-scale epidemic never
    happens.
        That's because the measures that will enable us to respond
    effectively to a major disease outbreak are the same ones that will
    equip us to help other countries:
      --limit the spread of infectious disease;
      --reduce child mortality;
      --protect the health of expectant and delivering mothers;
      --and otherwise contribute to the increasing self-sufficiency of
            their own people.
        In other words, these are investments and policies that are proven
    to pay off for the American taxpayer--no matter what happens.

    I'll conclude with my third point: The progress we've made in recent
    years would not have been possible without development assistance from
    the United States. The progress we need to make in years to come won't
    be possible without it, either.

        Whether we're talking about preventing the next epidemic or
    building upon the enormous global-health gains of the past two decades,
    the time to act is now.
        As I've noted, this means increased investment from developing
    countries as they assume greater responsibility for their own health
    and development.
        This also means the U.S. should at least maintain global-health
    investments at the fiscal year 2015 level--and, if possible, increase
    them.
        Even though the progress we've seen is quite impressive, much
    remains to be done.
        While child mortality is declining, it remains too high in too many
    places. Nearly 22 million children worldwide remain under-immunized
    each year, and more than 6 million die before the age of 5--with about
    1.5 million of these deaths resulting from vaccine-preventable diseases
    like diarrhea and pneumonia. To address this, it is vital that the U.S.
    fully fund its recent Gavi pledge.
        Despite some gains in maternal and child health, progress on
    newborn health has lagged, and far too many women still die in
    childbirth. Cost-effective and proven solutions are available to treat
    or prevent the causes of most newborn deaths.
        These include such relatively simple and affordable measures as
    umbilical cord care; exclusive breastfeeding; and access to skilled
    birth attendants. Our ability to end these preventable deaths will
    depend on an even stronger commitment of U.S. funding for maternal and
    child-health programs.
        Toward this end, we also need to ensure that women are fully
    supported in achieving healthy timing and spacing of pregnancies. U.S.
    investment in women's access to contraceptives and information not only
    contributes to better maternal, newborn, and child health--it also
    helps girls stay in school, and expands economic opportunities for
    women throughout their lives.
        As I mentioned earlier, we may be on the threshold of a polio-free
    Africa--and of the eradication of polio itself. That's due in no small
    part to the initiative and generosity of the United States.
        But this progress is hard-won, and the final eradication phase is
    the most difficult of all. But once we achieve eradication, we can turn
    those resources and that expertise toward other global-health
    challenges. Now is not the time to let up--we need to eradicate polio
    now, once and for all.
        The Global Fund to Fight AIDS, Tuberculosis and Malaria is crucial
    to building health systems in poor countries. I urge you to maintain
    strong U.S. support for this highly effective organization.
        Continued American leadership on the Global Fund now will set the
    pace for the upcoming 2017-2019 replenishment, and will help ensure
    strong support from other donors.
        In addition, it is vital that the U.S. provide robust funding for
    PEPFAR and PMI--and maintain its current level of support for bilateral
    tuberculosis and neglected infectious disease programs. I am hopeful
    that new data will allow PEPFAR to support recipient-country efforts to
    focus resources on areas of greatest need in the campaign against HIV.
        It's also especially important that we eliminate malaria now in
    certain areas, such as the Mekong River delta of Southeast Asia, to
    prevent the spread of drug-resistant strains of the disease.
        We need to bolster funding for research and development through the
    various USAID global-health budget lines. USAID plays an essential
    leadership role on R&D, in concert with other U.S. Government programs
    funded by the Labor-HHS bill--including through the National Institutes
    of Health; the Centers for Disease Control and Prevention; and the Food
    and Drug Administration.
        The U.S. Government is also uniquely qualified to make vital
    investments in agricultural development. I urge continued strong
    support for the Feed the Future program--as well as for land-grant
    university research programs and the Millennium Challenge Corporation.
        The Global Agriculture and Food Security Program has helped to
    ensure that developing countries have sound investment plans for
    agriculture--and that they put their own resources against those plans.
        This program exemplifies a rising trend in global development and
    health: an emphasis on deriving leverage from the contributions of
    other donors--and from the domestic resources of the recipient nations
    themselves.
        This makes development assistance an even better investment for the
    Congress, and for the American taxpayer. The need for such investment
    remains strong, and recent events demonstrate its urgency.
        Thank you for inviting me to join you today. I look forward to your
    questions.

        [Clerk's note: The 2015 Gates Annual Letter and articles
    from the New England Journal of Medicine and the New York Times
    are included as an appendix at the end of the hearing
    transcript.]

        Senator Graham. Thank you.
        Mr. Affleck.

                        SUMMARY STATEMENT OF BEN AFFLECK

        Mr. Affleck. Thank you very much. It is an honor to sit
    here in this room and speak before you great Senators. Thank
    you both very much for having me here. I am humbled by this
    esteemed panel. Thanks for having me follow the greatest and
    most important philanthropist in the history of the world.
        I am sure I am going to come off great.
        But, no, truly, it is an honor to sit next to Mr. Gates who
    has done such extraordinary things in technology and in
    philanthropy and I understand on your way in doing so in
    bridge.
        Chairman Graham, Ranking Member Leahy, distinguished
    members of the subcommittee, I want to thank you deeply for
    inviting me to testify here today. My name is Ben Affleck. I am
    the founder of Eastern Congo Initiative. We are a grant-making
    and advocacy organization working with and for the people of
    the Democratic Republic of Congo.
        I want to offer a special thanks to the chairman for
    holding today's hearings. Senator Graham, like others on the
    subcommittee, has proven time and time again to be a genuine
    champion for smart, effective U.S. foreign assistance. In
    August 2013, amid renewed violence in the region, Chairman
    Graham led a delegation to Eastern Congo, bringing five Senate
    colleagues along to see firsthand the potential of the region.
    This marked the largest ever delegation of U.S. Senators to
    visit this war-torn region. So thank you, Mr. Graham, for your
    confidence in the people of Congo and for learning more about
    what can be done.
        And to Senator Leahy, I would be remiss if I did not
    acknowledge my co-star in Batman, roles marginally smaller than
    mine, but I understand you are quite good. Good morning, sir.
        Members of the subcommittee, I am here today to offer a
    case study of the difference our Nation's foreign assistance
    and diplomacy is making, where small, targeted public and
    private investments are transforming communities in need,
    advancing our Nation's interests, and creating opportunities
    both in the countries we assist and here at home.
        You have undoubtedly heard a bit about Congo, about its
    challenges and about the worst of its past: two decades of
    armed conflict; an estimated 5 million deaths due to violence,
    disease, and starvation; 2.7 million people who remain
    displaced today; and the appalling levels of sexual violence.
        But these statistics tell you nothing about Congo's future
    or about the extraordinary and resilient people working every
    day to rebuild their nation.
        Despite the many challenges, the Congolese people refuse to
    be defined by their country's past, and in spite of those who
    may question the effectiveness of our foreign assistance, I can
    tell you firsthand that U.S. diplomatic and financial
    investments in Congo are working.
        U.S. foreign assistance accounts for only 1 percent of the
    entire Federal budget and vastly less than 1 percent of that 1
    percent is allocated to the Democratic Republic of the Congo
    (DRC). Yet, from that fraction of a fraction, we are seeing
    important, powerful progress. Let me give you an example of
    what I mean.
        In the late 1970's, Congo was one of coffee's leading
    exporters, but because of conflict and diseased crops,
    production today is less than 10 percent of what it once was.
    Congolese families lost a vital source of income, and the rest
    of us lost some of the world's greatest coffee.
        Three years ago, Eastern Congo Initiative (ECI) saw an
    opportunity to revitalize Congo's coffee sector. In our work,
    we had met struggling rural farmers living on less than a few
    dollars a day. And we knew that with the right partners we
    could help give the skills and resources they needed to
    transform their communities. And we were thrilled that the
    United States Agency for International Development (USAID)
    agreed. Our Government made the bold decision to help us create
    a public-private partnership, together with ECI, the Howard G.
    Buffett Foundation, and the Catholic Relief Services.
        Together in only 2 years, we have trained and supported
    4,500 coffee farmers across four cooperatives to dramatically
    increase the quality and quantity of their crop and to help
    maximize farmer profits. We brought in global trade specialists
    to build an ethical supply chain that keeps money in the
    pockets of farmers and their families.
        But what we have been able to achieve together does not end
    there. Prior to ECI's involvement, these coffee farmers had no
    access to financing, no line of credit. Imagine trying to start
    a business without any capital. You simply cannot, let alone in
    an emerging economy like Congo's.
        So to close this gap, we brought in experts. We approached
    Scott Ford's company, Westrock Finance, which has worked
    alongside these cooperatives to dramatically scale their
    businesses in environmentally sustainable ways. I should add
    that Scott was part of that historic delegation with Mr. Graham
    that visited Congo in 2013.
        The final puzzle piece was getting this coffee into
    American homes. So ECI brought in another investor, which was
    Starbucks. In the coming weeks, Starbucks officials will travel
    to the eastern region of Congo to begin a partnership with us
    to develop Congo as a key source of high-quality coffee.
    Starbucks has already purchased 40 tons. It may not be a lot
    for Starbucks, but it is a heck of a lot in eastern Congo, I
    assure you. It is the entirety of the cooperatives' very first
    export, representing millions of cups of coffee that will be
    sold in U.S. markets.
        Involvement by the world's largest coffee company is a
    clear testament to what is possible for Congo. This is not
    charity or aid in the traditional sense. It is good business.
    From a relatively modest investment, farmers' incomes have more
    than tripled, and they can now afford to send their children to
    school, put food on the table, and access proper health care.
    As a result, the world has a new source of high-quality coffee.
        This public-private partnership has transformed the lives
    of thousands of families in eastern Democratic Republic of the
    Congo (DRC), all made possible because USAID agreed that it
    could be done. But we think this is just the beginning of what
    is possible.
        Next month, ECI will launch an economic development fund
    that is focused on expanding our existing work not only in
    coffee but in cocoa and other strategic crops. As a result of
    our new fund, we will work with at least 10,000 additional
    farmers over the next 4 years to build their business capacity,
    improve the quality and quantity of their products, and secure
    direct access to premium markets.
        This work is scalable. This work is replicable. And in just
    5 short years, it will have a transformative impact on nearly
    100,000 individuals living in eastern Congo.
        None of this would have happened without USAID, without
    their commitment--a relatively modest commitment, I might say--
    and without private sector partners willing to operate in one
    of the highest risk environments in the world.
        With proper training and strategic investments, agriculture
    will become a driving force for Congo's economy, supporting the
    more than 60 percent of Congolese--that is 40 million people--
    whose families rely on agriculture as their primary source of
    income.
        Simply put, we believe that a country with enough arable
    land to feed a third of the world's population should not
    struggle to feed its own people, to send its own kids to
    school, or afford basic health care.
        Senators, this brings me to my final message. The next 2
    years represent a critical turning point for DRC. With local
    elections scheduled for later this year and national elections
    in 2016, DRC enters an incredibly important window of
    opportunity for an unprecedented democratic transition.
        Direct and consistent engagement by Secretary Kerry, the
    Special Envoy's office, and Ambassador Swan have helped Congo
    reach this moment. As you know, your former colleague, Senator
    Feingold, served as Special Envoy until just a few weeks ago.
    His leadership and the 15 trips he made to DRC during his 18-
    month tenure was the very definition of direct and consistent
    diplomatic engagement, and we thank him for his service.
        U.S. leadership played a vital role in the recent, yet
    fragile, progress toward peace and stability. To ensure this
    progress does not come undone, we urge you to join ECI and
    other groups like Open Society, Humanity United, Human Rights
    Watch, and the Enough Project in calling on the administration
    to appoint a new Special Envoy without delay.
        Senators, if we continue to make smart and effective
    financial and diplomatic investments, we will help foster the
    next generation of Congolese entrepreneurs and leaders who will
    carry their country forward to stand as a model for the region
    and the continent.
        Thank you, and I look forward to answering your questions.
        [The statement follows:]
                       Prepared Statement of Ben Affleck
        Chairman Graham, Ranking Member Leahy, distinguished members of the
    subcommittee, thank you for the invitation to testify here today. My
    name is Ben Affleck and I am the founder of Eastern Congo Initiative, a
    grant-making and advocacy organization working with and for the people
    of the Democratic Republic of the Congo (DRC).
        I want to offer a special thanks to the Chairman for holding
    today's hearing. Senator Graham, like others on this subcommittee, has
    proven time and again to be a genuine champion for smart, effective
    U.S. foreign assistance. In August 2013 amid renewed violence in the
    region, Chairman Graham led a delegation to eastern Congo, bringing
    five Senate colleagues along to see firsthand the potential of the
    region. This marked the largest ever delegation of U.S. Senators to
    visit this war torn region. Thank you Mr. Graham for your confidence in
    the people of Congo and for learning more about what can be done.
        And to Senator Leahy, I would be remiss if I did not acknowledge
    the second biggest Batman fan in the room. Good morning, sir!
        Members of the subcommittee, I am here today to offer a case study
    of the difference our Nation's foreign assistance and diplomacy is
    making--where smart, targeted public and private investments are
    transforming communities in need, advancing our Nation's interests and
    creating opportunities, both in the countries we assist and here at
    home.
        You have undoubtedly heard a bit about Congo--about its challenges
    and the worst of its past: two decades of armed conflict; the estimated
    5 million deaths due to violence, disease, and starvation; the 2.7
    million people who remain displaced today; and the appalling levels of
    sexual violence.
        But these statistics tell you nothing about Congo's future, or
    about the extraordinary and resilient people working--everyday--to
    rebuild their nation.
        Despite the many challenges, the Congolese people refuse to be
    defined by their country's past. And, in spite of those who may
    question the effectiveness of our foreign assistance, I can tell you
    first-hand that U.S. diplomatic and financial investments in Congo are
    working.
        U.S. foreign assistance accounts for only 1 percent of the entire
    Federal budget, and vastly less than 1 percent of that 1 percent is
    allotted to DRC. Yet from that fraction of a fraction, we are seeing
    important progress.
        Let me give you an example of what I mean.
        In the late 1970s, Congo was one of Africa's leading coffee
    exporters. But because of conflict and diseased crops, production today
    is less than 10 percent of what it once was. Congolese families lost a
    vital source of income, and the rest of us lost some of the world's
    greatest coffee.
        Three years ago, ECI saw an opportunity to revitalize Congo's
    coffee sector. In our work, we had met struggling rural farmers living
    on less than a few dollars a day. And we knew that with the right
    partners, we could help give them the skills and resources they needed
    to transform their communities.
        And we were thrilled that USAID agreed. Our Government made the
    bold decision to help us create a public-private partnership bringing
    together ECI, the Howard G. Buffett Foundation and Catholic Relief
    Services.
        Together, in only 2 years, we've trained and supported 4,500 coffee
    farmers across four cooperatives to dramatically increase the quality
    and quantity of their crops. And to help maximize farmer profits, we
    brought in global trade specialists to build an ethical supply chain
    that keeps money in the pockets of farmers and their families.
        But what we've been able to achieve together doesn't end there.
        Prior to ECI's involvement, these coffee farmers had no access to
    financing, no line of credit. Imagine trying to start a small business
    without any capital. You simply can't, let alone in an emerging economy
    like DRC.
        So to close this gap, we brought in the experts. We approached
    Scott Ford's company, Westrock Finance, which has worked alongside
    these cooperatives to dramatically scale their businesses in
    environmentally sustainable ways--I should add that Scott was part of
    that historic delegation with Mr. Graham that visited Congo in August
    2013.
        The final puzzle piece was getting this coffee into American homes,
    so ECI brought in another investor: Starbucks. In the coming weeks,
    Starbucks officials will travel to the eastern region of Congo to begin
    a partnership with us to develop Congo as a key source of high-quality
    coffee. Starbucks has already purchased 40 tons--the entirety of the
    cooperatives' very first export, representing millions of cups of
    coffee that will be sold in U.S. markets.
        Involvement by the world's largest coffee company is a clear
    testament to what's possible for Congo. This isn't charity or aid in
    the traditional sense, it's good business. From a relatively modest
    investment, farmers' incomes have more than tripled, and they can now
    afford to send their children to school, put food on the table and
    access proper healthcare. And as a result, the world has a new source
    of high quality coffee.
        This public-private partnership has transformed the lives of
    thousands of families in the eastern part of DRC, all made possible
    because USAID agreed it could be done. But we think this is just the
    beginning of what's possible.
        Next month, ECI will launch an economic development fund focused on
    expanding our existing work not only in coffee, but in cocoa and other
    strategic crops As a result of our new fund, we will work with at least
    10,000 additional farmers over the next 4 years to build their business
    capacity, improve the quality and quantity of their products and secure
    direct access to premium markets.
        This work is scalable. This work is replicable. And in just 5 short
    years it will have transformative impact on nearly 100,000 individuals
    living in eastern Congo.
        None of this would have happened without USAID's commitment and
    without private sector partners willing to operate in one of the
    highest risk environments in the world.
        With proper training and strategic investments, agriculture will
    become a driving force for Congo's economy, supporting the more than 60
    percent of Congolese--that's 40 million people--whose families rely on
    agriculture as their primary source of income.
        Simply put, we believe that a country with enough arable land to
    feed a third of the world's population should not struggle to feed its
    own people, to send its kids to school or access basic healthcare.
        Senators, this brings me to my final message. The next 2 years
    represent a critical turning point for DRC. With local elections
    scheduled for later this year and national elections in 2016, DRC
    enters an incredibly important window of opportunity for an
    unprecedented democratic transition.
        Direct and consistent engagement by Secretary Kerry, the Special
    Envoy's office and Ambassador Swan have helped Congo reach this moment.
    As you know, your former colleague Senator Feingold served as Special
    Envoy until just a few weeks ago. His leadership and the 15 trips he
    made to DRC during his 18-month tenure was the very definition of
    direct and consistent diplomatic engagement, and we thank him for his
    service.
        U.S. leadership played a vital role in the recent--yet fragile--
    progress toward peace and stability. To ensure this progress does not
    come undone, we urge you to join ECI and other groups like Open
    Society, Humanity United, Human Rights Watch and the Enough Project, in
    calling on the administration to appoint a new Special Envoy--without
    delay.
        Senators, if we continue to make smart and effective financial and
    diplomatic investments, we will help foster the next generation of
    Congolese entrepreneurs and leaders who will carry their country
    forward, to stand as a model for the region and the continent.
        Thank you and I look forward to answering your questions.

        Senator Graham. Jennifer and Violet are very proud. Very
    well done.
        John.

                        SUMMARY STATEMENT OF JOHN MEGRUE

        Mr. Megrue. Good morning and thank you, Chairman Graham and
    Ranking Member Leahy and members of the subcommittee, for
    allowing me to come today and talk to you about something that
    we all are, which we are all very passionate about, which is
    foreign aid. I have had a chance to get to know many of you on
    congressional delegations (CODEL's) and visiting hospitals and
    clinics around Africa, so I understand the kind of pushback you
    get here at home at times. But I thought I would share a
    business perspective on why I think foreign aid has been so
    effective and so important.
        By way of introduction, I am a business person. I spent 30
    years in private equity buying companies and owning companies
    and, with a team, trying to make them bigger, better, more
    efficient. But I am here because I have spent more than the
    last 10 years working in Africa on issues around health care,
    agriculture, education, and specifically the last 3 years, I
    started an organization called Born Free, which is fighting the
    transmission of HIV from mothers to children.
        And in my philanthropy, I have followed three basic rules
    or criteria, if you will. One is that I work on things that are
    fast; two, that are doable; and three, that have great
    leadership that I can partner with.
        And in mother-to-child transmission, just looking at each
    of those briefly--fast. The statistics around mother-to-child
    transmission led by the U.S. foreign aid are really astounding.
    In 2003, there were 600,000 babies born HIV-positive. Ninety
    percent of those died in the first 5 years of life. Last year,
    we were down to 200,000, so a 65 percent decrease in just over
    10 years. This year, I think it will be less than 150,000, so a
    75 percent decrease. These types of improvements are unheard of
    in global health. I know that we can eliminate mother-to-child
    transmission in the next few years.
        Secondly, I mention that it is the things that are doable.
    Mother-to-child transmission is doable for two main reasons.
    One is that the science is very clear and it is proven, and
    secondly, that it is cheap. Having worked on other issues like
    education, agriculture, there are always significant debates
    about how to solve problems. But in the case of HIV,
    antiretroviral medicine is very clear, and it is now very
    cheap. And so when you invest your money, when others invest
    their money on the ground, we know what hits the ground
    effectively and without any debate about whether we are doing
    the right thing.
        And the last thing I mentioned is great leadership, and my
    experience in business says that is probably the most important
    of the everything we go after. And I talk about leadership in
    three areas.
        First, on the ground in Africa, we work very closely with
    government leaders, with health ministers, and community health
    care workers all over Africa. And of course, you do not get to
    the kind of statistics that I just mentioned, those kinds of
    improvements, without those frontline people making it happen.
        But also, and perhaps surprisingly, U.S. corporations. I
    work with many U.S. multinationals, including Chevron, General
    Electric, Johnson & Johnson, Estee Lauder, Mylan, MAC
    Cosmetics, and others who are all investing alongside the U.S.
    Government in this particular issue. And they are not just
    doing it because of corporate and social responsibility. They
    are doing it because it is good business. This is going to be
    the fastest growing market over the next two decades, and so
    they are committed to making these kinds of investments
    alongside the U.S. Government.
        And last is the U.S. Government and the leadership that it
    is providing. I have worked closely with the leaders at USAID
    and at the President's Emergency Plan for AIDS Relief (PEPFAR).
    I know them well, and I can assure you they are doing a great
    job. They are making tough decisions to make sure that our
    money is spent efficiently. And for me as a philanthropist and
    for many others--I am sure the people at this table--knowing
    that that leadership is there keeps us inspired to be able to
    partner with the U.S. Government.
        And I will share one final thought, and that is that we
    have a clear exit strategy in areas like this. This is not
    funding that is going to be required from the United States
    forever. Three years ago, I was co-hosting a CODEL. We were in
    Cape Town South Africa. We brought together some of the largest
    business people, philanthropists, the health minister for a
    lunch. And at the end of the lunch, one of the leading business
    people stood up and said two things. One, they said thank you
    to the U.S. Government, and secondly, they said how important
    our investment has been in South Africa getting over the hump
    and really starting to beat HIV and in particular mother-to-
    child transmission. They said, but we will not need your help
    forever. We will pick this up.
        And so I came back. I looked up the statistics, and sure
    enough, in 2003, we were 100 percent of the HIV response. In
    2008, we were 50 percent of the HIV response, and now we are
    down to about 25 percent of the HIV funding response. And we
    are seeing those stories around Africa where these countries
    feel an obligation to pick up these investments.
        So I know with continued investment, that we will eliminate
    mother-to-child transmission. It will be one of the greatest
    accomplishments of this generation and I think an incredible
    accomplishment for the U.S. Government and our foreign aid to
    be the leader in that.
        But I would say going into the budgets today, now is not
    the time to blink. This is not the time to slow down when you
    are really winning a battle like this, and I would like you to
    know there are people like myself and other panelists here that
    are there on the ground, very active, making sure that our
    money is well spent.
        So thank you for giving me a chance to talk, and I look
    forward to answering any questions.
        [The statement follows:]
                       Prepared Statement of John Megrue
        Good morning and thank you Chairman Graham, Ranking Member Leahy,
    and members of the subcommittee for the opportunity to be with you here
    today on Capitol Hill to discuss these critical important issues. I am
    also honored to be part of this distinguished panel of witnesses.
    Because of America's unwavering, bi-partisan leadership, we are
    incredibly close to eliminating mother to child transmission (MTCT) of
    HIV/AIDS throughout the world. As an American, a humanitarian, and a
    financial investor, I strongly believe that we must sustain the cost-
    effective investments we have made in PEPFAR to achieve this important,
    and once unimaginable goal.
        We have seen unprecedented progress in the fight against HIV/AIDS.
    We have gone from zero to nearly 10 million people on Antiretroviral
    Treatment (ARV) each year. We have saved more than 4 million lives, and
    prevented over 1 million HIV infections in children. Because of this
    progress, we have the historic opportunity to witness a generation born
    free of HIV. Momentum is building to reach this target. My
    organization, Born Free Africa (BFA), is committed to our goal of
    ending mother to child transmission by December 31, 2015.
        My philanthropy has been guided by three simple business
    principles. I have chosen to invest my time, money, and resources in
    areas that meet three criteria: they need to be fast, doable, and have
    great leadership. It is with this private sector perspective, or this
    lens, that my views on our foreign aid investments are shaped. I can
    therefore comfortably speak on the effectiveness of our investment in
    the areas and these diseases where I work and about the efficiencies,
    the payback rates, the challenges, the return on investment, and
    scalability.
        First is fast: the area where I focus, ensuring that babies are
    born HIV free, is one of the great success stories in global health
    history. Twelve years ago there were 600,000 HIV positive babies born
    per year. Four years ago the number was down to 440,000, down 25
    percent. Last year it less than 200,000, down 65 percent, and this year
    I believe it will be well below 150,000, down 75 percent from its peak.
    The speed of success in dropping these numbers is unprecedented. I have
    no doubt that we can virtually eliminate mother to child transmission
    of HIV in the next few years.
        Second is doable: the science is clear and the interventions are
    cheap. On many other critical issues like education reform, water and
    sanitation, agriculture, and energy, there are debates about the right
    way to solve the problem, or even about what the problem is to begin
    with. The science of antiretroviral medicine to fight HIV/AIDS is clear
    and proven. A pill costs less than 30 cents per day for a pregnant
    woman living with HIV to take during the prescribed period. Given this,
    my investment, and the investment by the U.S. Government, hits the
    ground with full effect, with no debate about science or methodology,
    and without overwhelming cost.
        Third, and finally, great leadership: smart investments require
    sound leadership, and HIV programs in Africa are lucky to have strong
    leaders from all sides of the partnership. We rely on leaders in sub-
    Saharan African countries and Ministers of Health who are the core
    drivers of the success we are seeing in mother to child transmission.
    We also rely on leadership and funding that U.S. corporations provide.
    I work with U.S. companies including Chevron, Johnson & Johnson, Estee
    Lauder, Mylan, General Electric, and many others that invest both their
    time and money to fight these diseases. They are doing it not only
    because of an obligation to corporate social responsibility, and not
    only to improve local government relations. They invest in these issues
    because these countries are their fastest growing end markets. This is
    where they see their greatest growth coming from over the next two
    decades, and they know that investing in healthcare initiatives there
    will ensure that the markets are strong for the future and for their
    bottom lines. Lastly, and most importantly, we rely on leadership from
    the U.S. Government and its agencies, including PEPFAR and USAID. Both
    of these organizations have incredible leadership--teams who are
    adeptly refining their strategies, using data to drive their decisions,
    and making smart, forward-thinking judgment calls in the face of a
    changing landscape. These are exactly the kind of people we want
    running our investments. The U.S. Government is the largest bilateral
    funder of foreign assistance for health, we guide and influence the
    funding from the rest of the developed world, and we provide
    infrastructure and assistance far beyond our financial resources. As a
    businessman, a private philanthropist, and a co-funder of these issues,
    U.S. Government leadership has been critical to my interest and to our
    success.
        Based on these principles, I started Born Free Africa because I
    realized that the private sector has a critical role to play in
    contributing to eliminating mother to child transmission of HIV. In
    2001, over half a million children were infected with HIV, and 90
    percent of these cases were transmitted from their mothers. When I
    first heard these figures, I was floored. With simple, once daily
    treatment, 98 percent of children can be born HIV free. I decided to
    use my experience from the private sector to identify gaps in the
    response to MTCT and accelerate its elimination. And so BFA was
    launched.
        BFA is a group of private sector leaders who lend our business
    acumen, skills, and resources to accelerate the pace towards a
    generation born HIV-free in the African countries most affected by this
    dreadful disease. BFA leverages our corporate experience to partner
    with African governments and business communities to recruit, develop
    and empower local management talent who then work within their own
    governments to amplify and expand the work of the partners,
    governments, donors and policy makers to eliminate mother to child
    transmission of HIV. Infusing business sensibility and injecting
    corporate talent into African Ministries of Health helps accelerate
    progress toward no child being born with HIV. Rather than duplicate or
    fragment, we seek to leverage on-going efforts. Our only agenda is
    contributing to elimination, and we work hard to fill gaps thereby
    maximizing the work of those around us, and having the greatest
    possible effect on outcomes.
        Allow me to provide an example of how BFA operates. Nigeria
    accounts for over 25 percent of the number of children newly infected
    with HIV among the 21 high-burden countries that have been prioritized
    for MTCT programs. From 2007 to 2010, there was only a 2 percent annual
    decrease in the number of children newly infected with HIV. Given this,
    BFA decided to work with the Nigerian Government to accelerate
    progress. We created a core group of private funders who came together
    to pool their resources and invest catalytically in Nigeria's scale up
    of PMTCT and its journey toward elimination by leveraging small
    investments against Nigeria's more than $500 million annual response to
    HIV.
        Together, our partners, including Chevron, the MAC AIDS Fund,
    Johnson & Johnson, the Elton John AIDS Foundation, the Children's
    Investment Fund Foundation, and Mylan, all saw the value of investing
    in Nigeria and in collaborating to support a team within the Federal
    Ministry of Health to eliminate mother to child transmission of HIV. We
    support 12 local Nigerians who work within the Ministry of Health,
    where they act as behind the scenes advisors, doers, and leaders in
    support of the existing government teams. These individuals utilize
    best practices from the private sector, including data-driven planning
    and effective performance management, to promote the ongoing scale up
    of PMTCT services at the primary care level. After a renewed focus,
    increased attention, and smarter implementation, there has been a 10
    percent decline in MTCT from 2010-2013. Additionally, in 2013, Nigeria
    tripled the number of clinics offering PMTCT services, and from 2013 to
    mid-2014, the country saw a 100 percent increase in coverage of
    pregnant women living with HIV initiating treatment.
        Let me be clear that the progress we are all making simply would
    not be possible without PEPFAR, and the enormous and historic support
    of the United States Government and then American people. In my view,
    PEPFAR is the cornerstone of what the world has been able to achieve in
    the last decade. Put another way, PEPFAR spurned myriad partnerships
    among donor and endemic countries, and brought billions of dollars of
    new money to the fight. Sequestration with a flat cut to PEPFAR's
    budget would stop this progress in its tracks. We can deploy the best
    trained business minds, with the most committed and knowledgeable
    scientists, doctors and nurses, and the savviest technocrats, but
    without PEPFAR, and without your sustained leadership and the
    commitment, eliminating MTCT would be nothing more than a dream.
        As an investor, I put my own money into BFA because I know that I
    can leverage the enormous investments made by the United States, and
    because I know it works. Like with any smart business investment, we
    have the data to prove it. In the last 5 years, there has been more
    than a 40 percent decrease in the number of new infections among
    children. But our work is not finished. In 2013, fewer than 200,000
    children were infected with HIV passed down from their mothers. This
    remains unacceptable.
        In an age of seemingly infinite disagrees, we can all agree that no
    child, anywhere, should be born with HIV. We have the tools and
    knowledge to block this transmission. The only thing stopping us is a
    lack of resources to ensure more access. We cannot back down from this
    fight now, not when we are so close to achieving elimination of one of
    HIV's most devastating byproducts. I am confident that with continued
    investment, eliminating mother to child transmission of HIV will be one
    of the greatest accomplishments of our generation.
        Thank you, Mr. Chairman.

        Senator Graham. Thank you.
        Admiral.

                  SUMMARY STATEMENT OF ADMIRAL JAMES STAVRIDIS

        Mr. Stavridis. Terrific to be with everybody this morning.
    I want to begin by thanking the Chairman and the Ranking Member
    for asking me to testify and waiving the height and the hair
    requirements, looking at my other vastly better looking
    colleagues here today.
        I think the last time I saw Mr. Affleck was on the deck of
    an aircraft carrier in the Arabian Gulf, and he was out there
    doing a United Service Organization (USO) thing with Robin
    Williams, and I remember that day very well and thank you for
    coming out and seeing us and your support to our military, sir.
        I am here because I am a member of the U.S. Global
    Leadership Advisory Council for National Security, and a group
    of about 160 senior retired military officers are part of that.
    And I wanted to kind of pick up where some of my colleagues
    have left off, which is to say from a military perspective how
    important this kind of work is. We have a very strong and
    capable military. Thank you to the Congress for that.
        But we cannot create security in this 21st century simply
    with hard power. We need the tools of soft power which are what
    my co-panelists are talking about, and they are really
    diplomacy and development in a nutshell. And I would say, to
    summarize, we are very good at launching missiles today. We
    could improve at how we launch ideas. And diplomacy and
    development allow us to do that. So cutting this kind of work I
    think is a mistake at this time.
        I will give you some practical examples. Senator Leahy and
    I, when I was the Commander of U.S. Southern Command before my
    time at NATO, worked together on Colombia. This is an area
    that, if you go back 15 years, looked a lot like Syria does
    today, a complete humanitarian disaster, millions of people
    displaced, high levels of violence. As Ben was describing in
    the Congo, it was an absolute disaster. We created something
    called Plan Colombia, which had a military component, but more
    importantly, it funded development and diplomacy, human rights,
    all of the soft power parts fitted together with the hard
    power. Today, Colombia is a nation that has not only improved
    vastly but is in a position to continue forward as an absolute
    linchpin strategically for the United States in the South
    American context.
        In my time as a NATO Commander, I witnessed the same sort
    of effect in the Balkans. If we think back to the Balkans, 10
    to 15 years ago, again it looked a lot like Syria does today,
    8,000 men and boys killed in a single day at Srebrenica,
    extraordinary levels of violence, rape, torture. Yet, today in
    the Balkans, when they want to solve a dispute, they do not
    reach for a rifle. They reach for a telephone to call the
    European Union, to call the United States. Why? Because we were
    able to use some hard power but combine it with the soft power
    tools of diplomacy and development, which are the long game.
        I will give you a third example and it is current. It is
    what we are doing today in Afghanistan where Senator Graham has
    served as a reservist coming on active duty in Afghanistan
    working on the judicial process there. This is soft power. Do
    we need hard power in Afghanistan? Absolutely, unfortunately.
    But the long game is diplomacy and development. You need both
    those things. When you bring hard and soft power together, you
    create smart power. That is what I would advocate for, and to
    try and do defense without diplomacy and development, I will
    simply repeat the quote that Senator Graham gave us earlier, as
    my very good friend, Jim Mattis, will tell you, if you scrimp
    on the development and the diplomacy, you are going to end up
    buying more ammunition. And as Secretary Gates, who was
    interagency before interagency was cool, would tell you, we
    cannot kill our way to victory in these situations. We need
    hard power, but we need these tools, development and diplomacy,
    as well.
        I look forward to your questions, Senator.
        [The statement follows:]
                 Prepared Statement of Admiral James Stavridis
        Chairman Graham, Ranking Member Leahy, members of the subcommittee:
    I am delighted to join you today as we reflect on America's leadership
    role in the world, and the responsibility that leadership requires.
    This subcommittee, under your guidance, will determine the resources
    needed to protect our Nation and advance our values. Your decisions
    will help set the course for American security and prosperity.
        Today, I want to salute this subcommittee and your leadership. You
    have been steadfast over these years of turmoil and threat in providing
    a steady hand at the wheel of U.S. foreign operations. More
    importantly, you have established a bi-partisan atmosphere of respect
    and problem solving that is rare in this rancorous town, and should
    give some hope to the American people.
        Mr. Chairman, I have come today to offer my military analysis, my
    firm belief that security, prosperity and peace are not simply an
    outgrowth of kinetic action and the tools of war. We need a balanced
    approach, what has been called a smart power model, which combines all
    the tools of statecraft, to include diplomacy and development,
    alongside defense. Moreover, we need to enhance our understanding in
    global affairs. As we say at The Fletcher School, we need to ``know the
    world''. Finding our way to a balance between hard power and soft power
    is smart power--the key to our security in this turbulent 21st century.
        My message to you today is direct. Now is the time to double down
    on smart power.
        I am part of a group of over 160 retired 3 and 4 star general
    officers who have planned for war, fought wars, and sought a path to
    peace. We know from hard experience, from command responsibility, that
    war alone, the military instrument alone, does not bring security. We
    all serve on the U.S. Global Leadership Coalition's National Security
    Advisory Council, which I co-chair, with my good friend, Marine General
    Tony Zinni. We support the USGLC, a broad based network of 400
    businesses and non-governmental organizations (NGO's), national
    security and foreign policy experts, and business, faith based, and
    community leaders in all 50 states who support what I have referred to
    as a ``smart power'' approach of elevating development and diplomacy
    alongside defense in order to build a better, safer, world.
        Mr. Chairman, I speak as part of the large coalition of military
    officers and veterans who embrace not just the notion of a balance
    between defense, diplomacy and development, but an enhancement, a new
    vigor in the concept of smart power that will help us meet the
    challenges ahead.
        In my 37 years in military service to this great Nation, and now as
    the Dean at the Fletcher School of Law and Diplomacy at Tufts
    University, I have had the unique opportunity to see both the global
    battlefield and the global marketplace of ideas. There is no doubt in
    my military mind that we face new, unconventional security threats that
    will continue to test our ability to out-think our opponents and
    confront brutal ideologies.
        But they are not the sum of my concerns. I also see serious threats
    to global health and economic prosperity. Narcotic trafficking and
    criminal gangs undercut democracy and development in Central and South
    America and their violence washes up on our shores as well, sadly
    accompanied by human trafficking and even human slavery. Extreme
    poverty still claims lives and dashes hope around the world. Indeed,
    the world is burdened by these assaults on dignity and justice. Civil
    wars and insurgencies, lawlessness and crime infect parts of Asia and
    Africa, the Pacific nations as well as the Atlantic. In sum the world
    is a dangerous place.
        But danger comes with opportunity. I believe that over the long run
    we can turn peril into promise, but only if we meet the world's high
    expectations for our strength, wisdom and vision. We need to invest in
    our ability to exercise global leadership in a wide variety of ways.
        For this Nation to excel, we need to understand the interplay of
    economics and development, politics and diplomacy, culture and
    business, surveillance and security. We need robust funding for what I
    consider the new strategic triad of United States national security--
    defense, diplomacy and development. There is no doubt in my mind that
    our strength, our own security, rests on congressional support for all
    the tools of American leadership.
        The United States has a very strong and capable military. No one
    can match us on the sea, in the air, and in ground maneuver. While
    there will continue to be a need for that hard military power, Mr.
    Chairman, we simply cannot lead without using other tools as well.
    Competitor nations, competing ideas, challenge us with dark and
    repressive visions of life. But we must show the world, indeed reassure
    the world that:
      --When disaster strikes, we are there
      --When famine and disease threaten, we are there
      --When there is a hope for diplomacy, we are there
      --When people search for a better ideas and positive solutions on the
            global social networks, we are there.
        We are very good at launching missiles--we must improve at
    launching ideas.
        What is the price tag for a better, safer world? I would argue that
    the non-military aspects of our power bring a strong return on our
    investment, both in the public as well as the private sector. The funds
    we allocate to foreign aid, diplomatic security, humanitarian relief,
    education, and the many other international programs can save us from
    spending far more to put boots on the ground in troubled regions. It's
    exceptionally cost-effective.
        By bolstering funding for our presence in the world, we reduce the
    burden on our men and women in uniform. As many senior military have
    said in one way or another, without funding diplomacy and development,
    you ensure that we will end up spending more on hard power.
        The programs supported by this committee advance the values and
    interests of this country. I saw this day after day in every one of my
    senior military leadership assignments. I saw the value of public-
    private partnerships. The foundations and charities represented on this
    panel demonstrate unique commitment, compassion, and innovation. They
    strive to solve many of the world's enduring problems. They are on the
    ground, working hand in hand to improve lives. Whether it is in health,
    education, job creation, or local governance, these activities improve
    lives.
        Their work and commitment is matched by the outstanding work done
    in our Nation's `headquarters'' for diplomacy and development. These
    headquarters--centers of excellence, if you will--are key to U.S.
    security and prosperity.
        The State Department, the Agency for International Development, the
    Millennium Challenge Corporation, Peace Corps, and many others, are
    national assets to achieve our foreign policy and national security
    goals.
        The dedicated men and women in these agencies and departments, the
    NGO's working alongside these professionals, all comprise a great
    resource for our country. In the course of my career I relied on these
    experts constantly to provide economic development and effective
    diplomacy, whether in Southern Command implementing Plan Columbia to
    combat narcotics trafficking or as the Supreme Allied Commander of NATO
    in Afghanistan fighting against the Taliban.
        These are steady and slow efforts, requiring patience and
    persistence. But there are results. Colombia, a nation once synonymous
    crime and violence is now experiencing an economic and tourism boom.
    Afghanistan experienced its first peaceful transfer of power, and new
    opportunities for economic development, especially in the mineral and
    natural resources area, are reducing dependence on poppy farming. There
    is no question that the civilian side of our international presence is
    crucial to our success. I honor the men and women civilians who live
    and serve overseas just as I honor those who serve in uniform. We share
    a commitment to this great country and a peaceful world.
        The United States leads the world, not just in our military
    strength, but in the private sector, both business and NGO outreach. I
    support those programs where professionals can go back and forth
    between public and private activities, where those with a great depth
    of knowledge can contribute to the policy process and program
    development. There is an abiding value to experience, expertise, and
    steady involvement in a region or sector, in the military and diplomacy
    and development work. I hope those in public service in these areas can
    lengthen their tours in country, enhance their regional concentrations,
    to match the standards of commitment shown on today's panel.
        I want to know that the expert on Bosnia or Afghanistan or Kenya
    has followed events there for years, remembers the head of state as a
    young professional, senses mood and political dynamics. As a military
    leader, I relied on our diplomatic experts who anticipated policy
    opportunities, who knew that the leader of the opposition worked with
    us a decade ago, and now is in a position to provide positive
    contributions. I want to know that a development project, tried years
    ago can now work better with micro financing or in partnership with the
    private sector. I value experience.
        Under the outstanding leadership of Raj Shah, outgoing
    administrator of USAID, we are ``bending the curve of development'' to
    pull nations out of poverty, open opportunities, and search for local
    solutions matched by technology and innovation in healthcare, infant
    survival, agricultural production, and environmental protection. In
    this regard, we are reviving the idea of resilience, optimism, and
    problem solving.
        These vibrant efforts can be seen in the Partnership for Growth
    program in El Salvador, Tanzania, Ghana, and the Philippines. Mr.
    Chairman, just last week, I saw an article noting the dramatic decline
    in corruption in the Philippines, reflecting both the development
    objectives of these programs with the technology of social media to
    crack down on corrosive corrupt business and government practices. This
    is resilience and problem solving. More importantly, as a country
    strengthens in its governance, as prosperity grows and stability takes
    root, America finds itself with new partners, new allies, in addressing
    global threats. I first saw the proven record of smart power in South
    Korea, a country which rose out of war torn poverty to a first world
    success. It was that combination of development assistance and strong
    diplomatic connection that turned a problem into promise. And this
    success enhanced American security.
        Mr. Chairman, the programs funded by this subcommittee leverage
    American concern into American security.
        I can attest to this connection personally. When I had to decide
    about military deployments in harm's way, I knew that in so many cases,
    the professionals at State, USAID and the NGO community ``had our
    warriors' back'' and supported our understanding of complex
    humanitarian crises. They cared for refugee and displaced children
    through three bone chilling Syrian winters. They connected aspiring
    computer scientists in Burma to U.S. high tech firms to speed an open
    society. They tended the sick, nourished the hungry, educated youth,
    and confronted injustice. These kinds of professionals are a gift to
    this Nation and we need to tap their knowledge and experience
    throughout the national security community.
        On the diplomacy front, U.S. State Department experts represent our
    Nation bravely in over 180 nations around the world--often at high
    personal risk, as we have seen most recently following the horrific
    attack on Ambassador Mark Lippert in South Korea (a former member of
    this subcommittee's staff). Our diplomats are working tirelessly in the
    midst of high tension scenarios from Iran to Ukraine to East Asia.
    Strategic diplomacy and effective development can avert war, reconcile
    aggrieved groups, and alleviate humanitarian tragedy. As a military
    professional, I have always known that the use of hard power must be
    the last resort, and that effective diplomacy can help reduce the
    chances that we need to reach for the combat instrument.
        But to be effective, we need a coordinated effort, between State
    and USAID, and all the other agencies of the U.S. Government engaged in
    the international world--Department of Justice, Homeland Security,
    Agriculture, Drug Enforcement Administration, on and on--all have a
    vital role to play.
        My own experiences in Latin America as Commander of Southern
    Command, in the Balkans as the Commander of U.S. European Command, and
    in Afghanistan as the NATO Supreme Allied Commander all reflect the
    need for strong interagency and private-public partners.
        Our approach must be international, interagency, and private-
    public--all undergirded by effective strategic communications. If we do
    that well, we achieve smart power.
        Mr. Chairman, all of these efforts, our international, interagency,
    and private-public partnerships, are a vital investment for this
    Nation, an investment that must constantly be refreshed. The support
    this subcommittee provides is the seed money--the venture capital, if
    you will--for U.S. leadership in the world.
        Mr. Chairman, just as we invest in technology or invention to
    achieve future wealth and advancement, we need to invest in these
    professionals and their programs, in diplomacy and development and
    other international, interagency, and private-public partnerships to
    achieve prosperity and security.
        But these investments require political will and talking straight
    to the American people. Polls show that the American people have no
    idea how little this country actually allocates to International
    Affairs. In fact, they think we spend 20 to 25 times the amount we
    actually do--which leads to unfounded calls to cut these programs.
        With a mere 1 percent of the entire U.S. Federal budget, the
    International Affairs Budget supports all of America's civilian tools
    of diplomacy and development.
        Mr. Chairman, the United States is active around the world--in
    Europe, Asia, Latin America, the Caribbean, and Africa. No other
    country can compare. We set the standard for others to follow.
    Americans, in both public and private efforts, helped tackle Ebola,
    almost eradicated measles and polio, brought food and shelter after
    disaster, and brought encouragement to those searching for a way ahead.
    We have been leaders in all these areas--humanitarian, development and
    active diplomacy. Our diplomatic and development communities create the
    conditions for effective political and military coalitions. Because of
    our team approach, we have strong bilateral and multilateral ties which
    bring stability, peace and prosperity to the world.
        Let me close by commenting on one region in particular which
    threatens this stability, prosperity and peace: the Middle East. And in
    this regard, I urge you, from my vantage point as a military commander
    and now as a dean in higher education that now is a time, as I said
    earlier, to double down on smart power. We need to bring the talent of
    this great nation, the development experts, the scholars, the diplomats
    together to enhance our understanding of this specific challenge. We
    shouldn't be scaling back funding. We need to scale up funding.
        Our goal should be state-of-the-art diplomacy and development. To
    do this, we need to support smart research, smart new diplomatic and
    cultural initiatives, working with our allies, to confront the ideology
    of those drawn to the fight. We need a sophisticated grounding on this
    ideology, a world view so different than our own, so that our efforts,
    in diplomacy, development and defense, can be successful. We need hard
    power in the short term of course to face the spread of the Islamic
    State and support our allies. But we also need counterterrorist
    financing and effective intelligence. And for the long term, we need to
    support educational reform, intellectual development and opportunity.
    Combining hard and soft power over time: that is smart power.
        Chairman Graham, Ranking Member Leahy, members of the subcommittee,
    these are serious times. We need to be creative and innovative, we need
    to be wise and knowledgeable. This Congress has the power to plot our
    course to continued global leadership by robustly funding diplomacy and
    development, and thus enabling smart power. I look forward to working
    with this committee in any way I can to support this vital effort.

        Senator Graham. We have Senator Boozman from Arkansas, and
    Scott is from Arkansas. So I think you may want to say
    something about our next witness.
        Senator Boozman. Well, very much so. And I apologize. After
    Scott testifies, I have got to run to a Veterans Affairs
    hearing talking about over-prescribing opioids. So there are
    all kinds of important things that are going on.
        But I do want to thank all of you for being here. I am very
    familiar with the work that you have done. You are great
    examples of people that are using your time, your resources for
    those that simply have no constituency at all in the sense of
    representation.
        Scott, it is a real honor to have you here. Scott is the
    guy that just felt called to jump out and do something for his
    fellow man and, as a result, through his efforts and hard work,
    I think has raised the gross domestic product (GDP) of Rwanda
    about 1 percent by giving them a worldwide ability to sell
    their coffee at the international market. So again, we
    appreciate your example, appreciate all you have done, as the
    other witnesses.
        Thank you, Mr. Chairman.
        Senator Graham. Mr. Ford.

                        SUMMARY STATEMENT OF SCOTT FORD

        Mr. Ford. Senator Graham, Senator Leahy, Senator Boozman
    from the great State of Arkansas, thank you very much. Nice to
    be here with you.
        We could play a bit of a game here. One of these is not
    like the other. I am just from the private sector. I did not
    even know a lot of this was going on when I stumbled into the
    coffee business in Rwanda a few years ago, but I have learned
    the important powers of how the private sector and the public
    sector, even from the United States, can meet in places like
    East Africa and radically change people's lives. And I think
    that accrues to our collective--both continent's collective
    benefit.
        I was the CEO of a company called Alltel Corporation until
    we sold it to Verizon in 2009.
        I had been doing charity work in Rwanda for several years
    before that, and I had spent some time, considerable time, with
    the President of Rwanda, Paul Kagame. I discovered in some of
    those discussions that he and I--we are a bit of an outlier in
    this regard. We had a common philosophy around the role of the
    state and what it can and cannot do and the role of business
    and what it can and cannot do.
        I will sum it up to say this. The crux of our conversations
    centered around a shared belief that the state, through its
    attendant bureaucracies, can from the top down bring safety and
    security, political freedom, even religious freedom. But it is
    materially limited in its inability to bring economic freedom.
    It is the final fruit of the tree, if you will. It is economic
    freedom that is actually only created in the private sector
    when people that have learned how to organize and manage a for-
    profit business, then mentor other people in that process.
        Paradoxically, the group that benefits the most from a free
    market private enterprise system is not the richest of the
    rich. They are everywhere in the world. It is actually the
    poorest of the poor. President Kagame challenged me, if I ever
    got an opportunity to come back to Rwanda, to invest in the
    business that in his words said help the poorest of the poor
    taste the benefits of the free market system, he says, because
    once they do, they will not settle for a government that will
    not give it to them.
        So I went back. Alltel sold in 2009, and I went back,
    frankly, not sure that I could find anything to do in Rwanda.
    But I thought, well, I will honor the request and I will go
    look and I will at least be able to report that I looked.
        I got to Rwanda and I found out that there--I looked at a
    whole host of things too long to go through here, but I ran
    into the fact that 20 percent of the people in Rwanda make
    their income, their cash income, from the coffee business and
    that there were just two exporters that dominated the coffee
    trade. I then figured out that they were not paying the highest
    price for the coffee to the farmers that they could have and
    that there was room for a third party to come in and pay more
    to the farmers and still make a profit because I have to make a
    profit or I do not get to sustain the work.
        So we started looking through how could we go into the
    coffee business. We really did not know much about it. We just
    bought an old, abandoned, bankrupt mill at auction. We
    revitalized it and we hung a shingle out and we went into
    business. In the first 6 months of our operations, we saw the
    price that the farmers in Rwanda received increased 30 to 50
    percent. That was the power of somebody just setting a
    reasonable price in terms of the cost of the product.
        In addition, we have invested money on helping them to
    improve their yields, helping them to improve the quality. All
    of this translates directly into income. We were successful in
    Rwanda.
        We expanded into Tanzania with Tembo Coffee Company. We
    then partnered with Falcon Coffees out of the United Kingdom
    and we finance and procure coffee from other parts of East
    Africa. I think we are one of the largest specialty exporters
    out of Uganda, Ethiopia, and now behind the leadership of the
    Eastern Congo Initiative and really closely right behind. It is
    kind of like going to--we had the United States ask us would
    you go to Congo. And I said not without Batman.
        When Batman showed up, we went to eastern Congo, and we
    have actually been doing the logistics and financial support of
    his project as we try to get that coffee out to market.
        I do not know what I was thinking, but we started a coffee
    roasting business. It is restaurantcoffee.com because I am
    running out of time. Thank you for the ability to make the
    plug.
        Starting these businesses from scratch in this part of the
    world--my wife and my father stood with me, and everybody else
    said I was a madman. But we have seen $100 million of
    incremental income go into the pockets of the Rwandan farmers
    from our being on the ground there over the last 6 years. That
    is a 50 percent increase in their standard of living. How do
    you impact 20 percent of the United States with a 50 percent
    increase in their standard of living? I do not know how to do
    it, and I could not have believed it was possible in just the
    private enterprise system.
        But it was because we got there and there were groups that
    were funded by the U.S. Government and by philanthropists like
    Mr. Affleck and Mr. Gates, like TechnoServe, the Eastern Congo
    Initiative, the German Investment and Development Corp., all of
    these groups that are spending money to help the co-ops on the
    ground get their act together, get their accounting together,
    be able to function as a community under the rule of law. That
    is all supported by NGO's that are supported in turn by the
    U.S., and we have been building on that to translate the income
    differences into the Rwandan farmer.
        I will say this as a final moment. I recognize in today's
    panel that we are just one company operating in a limited
    sphere of influence. I am good with that. But I hope that we
    serve as at least an example of what an American private sector
    actor can look like when we align with likeminded
    organizations. We can produce benefits that the poorest of the
    poor can literally taste. And I think that accrues to America's
    credit.
        If you want to ask questions about that and how that
    ripples into policy and things, I would be glad to answer it.
    But it is an honor to be here today, and I appreciate the
    invitation.
        [The statement follows:]
                        Prepared Statement of Scott Ford
        Chairman Graham, Senator Leahy, and members of the subcommittee, my
    name is Scott Ford and I thank you for this opportunity to share a
    brief history of Westrock Coffee's entrepreneurial activities in East
    Africa.
        In 2004, after being involved in post-genocidal charity work for a
    few years, and while still CEO of Alltel Corporation, I took my three
    sons to visit Rwanda. While there, I had the opportunity to spend
    considerable time with President Paul Kagame. I discovered we were
    like-minded in our view that the free market system of open,
    competitive trade is the only system that offers sustainable economic
    hope--along with personal dignity--to those most deeply mired in
    poverty.
        The crux of our conversation centered on our shared belief that the
    State--through its attendant bureaucracies and the rule of equally
    applied law, can, from the top down, ensure Safety and Security,
    Political Freedom, and even Religious Freedom--but that the State,
    beyond policy making, is relatively powerless to bring about true and
    lasting Economic Freedom. Prosperity, in other words, can only be
    created from the ground up, so to speak, by private individuals who,
    upon learning how to organize and operate a for-profit business,
    support and mentor others in that process. And paradoxically, the group
    that experiences the greatest relative benefit of genuine economic
    prosperity in a society is actually the poorest portion of the
    community.
        In light of our common economic views, President Kagame asked me to
    join his Presidential Advisory Council and challenged me to someday
    return to Rwanda to invest in its future. Five years later, after
    Alltel was sold to Verizon, I returned to explore opportunities to
    follow through on his request to help build a company that would, in
    his words, ``help the poorest of the poor taste the benefits of the
    free market system''.
        After looking at several business opportunities, I settled on
    coffee exporting for a number of reasons but primarily because there
    were only two major market participants operating in the coffee export
    sector in Rwanda. It was clear; there was room for a third participant
    to make a reasonable profit while paying considerably more for coffee
    than was being offered to farmers at the time.
        Rwanda, it turns out, was an anomaly in terms of typical coffee
    industry practices, but knowing nothing more about the coffee industry
    than that, we founded Rwanda Trading Company and purchased, at auction,
    a bankrupt, abandoned, coffee-processing export mill in the capital
    city of Kigali. Our intent was to make a profit and to attain enough
    market share that the other two exporters would have to increase the
    price they paid to farmers in order to stay competitive with us--
    thereby giving every farmer in the country--whether they sold to us or
    one of our competitors--an immediate and substantive raise! In our
    first 6 months, we saw the price paid to farmers rise between 30
    percent and 50 percent compared to the established local market price.
        In addition to impacting the price paid to farmers, we continue to
    invest to help them improve their yields and quality and make certain
    that our mill employees are paid and treated in a manner that is fair
    and honorable.
        Based on the success of our coffee business in Rwanda, we expanded
    our export operations into southern Tanzania as Tembo Coffee Company
    and have partnered with Falcon Coffees in the United Kingdom to finance
    and procure similarly sourced coffees from other parts of East Africa
    including Uganda, Ethiopia, and most recently, behind the leadership of
    and in cooperation with the Eastern Congo Initiative, the Democratic
    Republic of Congo.
        In order to directly connect East African coffee farmers with the
    American consumer, we started a coffee roasting operation in Little
    Rock, Arkansas, which roasts and packages coffee under the Westrock
    Coffee brand and is available through retailers such as Kroger, BI-LO/
    Winn-Dixie, Walmart, and online at westrockcoffee.com. We also offer
    coffee service to corporations, airlines, restaurants, and hotel
    chains.
        Starting these businesses from scratch has been risky, but the
    impact our efforts have on the employees and farmers we work with is
    the reason we continue to expand. Last year, in Rwanda and Tanzania
    combined, we employed over 140 people full-time and 1,150 part-time and
    financed and procured coffee from over 60,000 individual coffee
    farmers.
        Collectively, we estimate that the sum total of our coffee
    activities in Rwanda alone, over the past 6 years, put upwards of $100
    million directly into the pockets of small-holder coffee farmers, and
    our experience indicates this income most immediately goes to
    educational and nutritional advances for their children.
        Additionally, where need and opportunity align, we build community
    water facilities and partner with governmental and social impact
    organizations like Heifer International, the Eastern Congo Initiative,
    TechnoServe, the German Investment and Development Corporation, and
    others--many of which are partially funded by the United States
    Government and private citizens like Mr. Gates and Mr. Affleck. We also
    work with OPIC, through which we purchase political risk and investment
    insurance, and with fellow members of the private sector that help
    finance the tremendous working capital requirements of these ventures.
        Senators, I appreciate your time and the invitation to share our
    story. I recognize that we are just one company operating in a limited
    sphere of influence, but I hope we serve as an example of how an
    American private sector participant--when aligned with like-minded
    organizations--can produce benefits that are, quite literally, tasted
    by ``the poorest of the poor'' around the globe--I hope and I believe,
    to America's credit.
        Thank You.

        Senator Graham. Thank you all. That was excellent.
        So we will have that debate later on, and I will take some
    of your words to the Senate.

                            IMPACT OF SEQUESTRATION

        Mr. Gates, you have been doing this quite a while in your
    private sector role. If the budget cuts are enacted that we are
    talking about under sequestration, scenario A, but if we
    actually adopted what is being proposed in the Senate today, a
    50 percent reduction, how would that set us back from your
    point of view?
        Mr. Gates. Well, I am very enthused about the progress that
    is being made. And so it would be a tragedy as we see how close
    we are on polio eradication that if we do not put out those
    resources now, that disease will spread back and the amount of
    money that you would have to invest to get back to where we are
    would be absolutely gigantic.
        If you look at a disease like HIV, through the President's
    Emergency Plan for AIDS Relief (PEPFAR) and Global Fund,
    millions of lives are being saved, and if you cut those
    programs back, there simply will not be enough medicine to keep
    people on treatment. The United States has been an incredible
    leader there, has done a great job of drawing other governments
    in. It is only through our generosity, though, that that other
    money is activated. So if we cut back, I think we will see
    other funds going away as well. Other governments, as a
    percentage of their economy, are often quite a bit more
    generous on foreign aid, and even so, because of the size of
    the economy, because of the technical expertise we bring, the
    U.S. finds itself in a leadership role that I do not think
    anyone would be able to step up to. So it would be a huge
    setback for childhood health, maternal health, disease
    eradication, all these things that we are devoting our lives to
    work on.
        Senator Graham. Thank you.

                             SECURITY ENVIRONMENTS

        Mr. Affleck, you have been, I think, very involved in the
    security environment. All these development programs, whether
    it be private sector, whatever, you have to have enough
    security so that people from outside the region can come in and
    help. What is your evaluation of training the security forces
    as an American role? I mean, what benefit do we have not just
    on the hard side, soft side, but actually training indigenous
    forces? And how important is that to you in terms of your
    potential success?
        Mr. Affleck. Well, I think one of the greatest issues
    facing the Democratic Republic of the Congo (DRC) now
    particularly in the east is the lack of a security sector. Not
    only that, but in fact there are times where the Congolese Army
    (FRDC) preys on the population itself, a sort of philosophy, a
    legacy handed down from the Mobutu days. We are not going to
    pay you. You guys live off the land, euphemistically. And this
    is an area that we are working in, but really this is a top-
    down area. It requires leverage from the United States and
    local regional actors to say--you know, include trying to end
    corruption, trying to get soldiers paid. And those are
    difficult things.
        But one of the hardest things about that is to train
    soldiers properly, and we are uniquely suited to do that and we
    have been doing that. And the role of the United Nations
    Organization Stabilization Mission in the Democratic Republic
    of the Congo (MONUSCO), who has also been doing it, is somewhat
    controversial, but it is absolutely something that is required,
    particularly in light of what we are talking about, which is
    this sort of nascent public-private partnership building
    sustainable economic models where people are not just making a
    living but they are being set up. Their capacity is being built
    so that they can continue to make a living so that they can
    contribute to their society, so that you can see the ripple
    effect of this virtuous cycle. And that aspect of security is
    really important.
        You have areas in the north where we are doing work with
    coffee collectives that are under threat from the Alliance of
    Democratic Forces for the Liberation of Congo (AFDL), which is
    an al-Shabaab-associated militia out of Uganda. When you have a
    state--and I am not saying anything new here--that in parts is
    failing, it is more vulnerable to that kind of extremism. When
    you have a state where people are more prosperous, they are
    able to resist that more effectively. In speaking to what the
    Admiral said, I am certainly no expert, but it makes sense to
    me when I hear folks like you and the Admiral say let us spend
    money this way before we spend money on bombs.
        But this kind of training is something that we can do. It
    is relatively inexpensive, and we are the greatest in the
    world, without exception, at knowing how to build and train
    militaries.
        Senator Graham. So the reason I asked that question, for a
    small security investment, relatively small, not thousands of
    boots on the ground, but sort of in a mentor, training role, we
    can enhance everything you are trying to do in the private
    sector.
        Mr. Affleck. Absolutely. You protect our ability to make
    those investments. You make people confident about making
    investments.
        You know, what Scott is doing--he is being modest. He is
    essentially gap financing in places in the coffee industry
    where people just are not willing to do it. And that is the
    biggest impediment to business. And not only is he doing it,
    but he is getting his investors a legitimate return. He is
    making it capitalism and demonstrating that it is possible. In
    order to do that, you have got to have a window of safety. And
    that is one of the things that we are trying to expand in DRC
    and with a little bit of money, a little bit of investment from
    the United States, we can create enough safety that we can
    encourage investment, public-private partnerships, the likes of
    which I talked about in my testimony.
        Senator Graham. Well, it is sort of a commercial for the
    United States Africa Command (AFRICOM) too. I mean, they do go
    together here.

                   IMPACT OF SEQUESTRATION ON HEALTH PROGRAMS

        John, if we do the budget cuts under sequestration that is
    being proposed or adopt the amendment that is being proposed
    today, what does that do to all the success you have had in
    mother-to-child AIDS transmission?
        Mr. Megrue. Well, not surprisingly, the leadership that the
    U.S. has and continues to provide is critical to the success.
    And many people follow us. The Department for International
    Development (DFID) from the UK, Germany, and most of the
    developed world have followed our lead on this. And so when we
    are making these kinds of investments in infrastructure, in
    medicine, in treatment and training, to pull the rug out to the
    magnitude of the kind of numbers that are being proposed today
    really brings it to a complete stop. It is not the kind of
    thing you can just meter back at these kinds of magnitudes that
    are being discussed. It halts it.
        In a disease like HIV, what that does is instead of
    starting to in the case of mother-to-child, dropping it
    dramatically, in the case of HIV overall, which is now
    stabilized and starting to drop, you would see an explosion
    right away. So from my perspective and the team on the ground,
    we are really worried about that kind of move.
        Senator Graham. Admiral, I know you are not wearing the
    uniform today. Do you think it would be smart to take money out
    of this account and give it to the Department of Defense (DOD)?
    And do you think DOD really wants the money coming from this
    account?
        Mr. Stavridis. I think it would be a huge mistake. As I
    hope I have articulated, you have to put these tools together
    to create real affect in security.

                               SECURITY TRAINING

        I want to underline the indigenous troop and training point
    that Ben was making in response to your comment, Mr. Chairman.
    And I will put a number on it. To sustain an American forward
    in combat in a place like Afghanistan or Iraq is about $1
    million a year for an enlisted troop. We can finance, train,
    and put effective Afghan troops, for example, in the field, as
    we do today, for literally pennies on the dollar compared to
    that. So the efficiency of this I think is very, very important
    to underline.
        And I will also go back to what Mr. Gates and Mr. Megrue
    were saying, along with Mr. Affleck, which is the cost here is
    minimal. You leverage the private sector. And at the end of the
    day, our security is like an iceberg. The tiny tip of it that
    sticks up is the high-end capability. The mass of what we can
    create is frankly in the private sector.
        So I think for those two reasons, taking money away from
    development and diplomacy and putting them into defense where
    we have strong levels of resources would be a significant
    mistake.
        Senator Graham. I am a little over my time, but I will ask
    one last question.
        Scott, would it be possible for you to have done all of the
    transformation in terms of the coffee business and creating
    more disposable income without the Government infrastructure
    that exists today?
        Mr. Ford. No. I mean, if you do not have that part of the
    apparatus in place, guys like me have nowhere to go.
        Senator Graham. Thank you.
        Senator Leahy.
        Senator Leahy. Thank you, Mr. Chairman.
        The chairman has mentioned that efforts that are going to
    be made to cut this budget even further. The House and Senate--
    the budget numbers were announced that those were cuts,
    certainly well below the fiscal year 2015. The House even more
    so, and they have talked about even beyond that.
        I am thinking, Admiral--you mentioned the Colombia project.
    I do remember our time working on that. You may be interested
    in knowing I was at lunch with President Santos down there at
    one point, and he went out of his way to praise you and the
    project. So I mention that for whatever it is worth.
        But let us assume that these cuts--we had level funding
    from last year. Of that, $50 billion is--of that $50 billion, a
    large part of it is used to run the State Department, our
    embassies, our consulates, pay our diplomats. A portion is used
    to fund ongoing programs we are committed to, treaty
    obligations like the United Nations.

                              ADDITIONAL RESOURCES

        Let me ask this question of all of you, and let us say
    there was $5 billion in there up for grabs. We spend it anyway
    you want. Any suggestions? Mr. Gates, you and I have talked
    about this many, many times in my office. Where would you spend
    it?
        Mr. Gates. Well, there is an amazing number of NGO's that
    work on areas of agriculture, areas of health, and I am sure
    they would make a very strong case for any increase that would
    be available.
        The basic health structure in Africa is very weak today,
    and as I said, that weakness means that if an epidemic shows
    up, we would not see it soon enough to go stop it and it would
    spread in the global economy very, very quickly, faster than
    the Spanish flu did back in 1918.
        Senator Leahy. In fact, you did an op-ed piece just a
    couple of days ago in the New York Times. You talked about
    that.
        Mr. Gates. Right.
        We are very much at risk unless the basic health and health
    surveillance systems in Africa get improved. The current budget
    lets us do that at a certain rate. If there were additional
    dollars, we would accelerate improving that basic
    infrastructure. And the beauty of that is that although it is
    an insurance policy to prevent an epidemic, which would come to
    these shores, it is also, year in and year out when there is
    not an epidemic, an amazing thing to lift people up and
    accelerate the time at which these countries will be self-
    sufficient, both big contributors to the economy and able to
    educate their own people, and provide health services.
        So health and agriculture are pretty basic things, and the
    formula for how you get better seeds out there, you get credit
    out there, and you build primary health care--a lot has been
    learned in a very sort of business-like way of looking at which
    countries have done it well and spreading best practices. That
    is so much stronger today than 10 years ago or 5 years ago that
    extra money could be used very, very effectively.
        Senator Leahy. Mr. Affleck, in the Congo--and I have read a
    number of the things you have said about it. There you have
    seen things that you thought might work and it did not. On the
    other hand, you have seen things that have pleasantly surprised
    you that worked. Suppose, using your experience, you were told,
    okay, we are going to make you the czar of that $5 billion, how
    would you spend it?
        Mr. Affleck. The first thing I would do is surrender that
    title.
        Look, we financed a survey because one of the criticisms we
    got was, hey, you cannot work there. Hey, it is too dangerous.
    Hey, there is nobody on the ground. Our theory was we want to
    support community-based organizations. We want to show up and
    tell people what to do. I know I am the little guy on this
    panel. So I can speak for the little guy and the grassroots
    guy, which is to say that when we looked around, we saw a lot
    of grassroots organizations. These coffee and cocoa collectives
    are a perfect example of that. And we saw with our economic
    development fund alone, it is expandable and scalable. All
    across this part of the country, you have many, many, many
    NGO's, local Congolese-based NGO's, who are doing extraordinary
    work who are really wanting only for money. We can submit for
    the record the survey that we did, but it is definitively
    illustrative of it is not a question of where the money could
    go, but of need.
        I will say that I take that your real point is around
    sequestration, around cutting the budget. And really, there are
    two ways to go. As I said, this is a very nascent process--
    these public-private partnerships, our ability to bring locals
    into this partnership and have them commit to it, have them
    believe in it. It is not like you have a line of people ready
    to sort of sign up to this exact way of doing things. And we
    ask them to change their practices and so on in order to create
    a virtuous cycle, in order to have a contagion of success. And
    that is what we have seen so far in just 2 or 3 years.
        And I can tell you that taking away those checks, all of a
    sudden pulling the sheet out from under that will have the
    exact opposite effect. There will be a vicious cycle. People
    will say, well, you cannot work with them. Well, you cannot sit
    down with them. You cannot believe what Americans say. This
    kind of process is never going to work. We would rather revert
    to traditional aid where we sort of stand around and hope
    someone gives us a check.
        Senator Leahy. I do not want to put words in your mouth.
        Mr. Affleck. You would not be the first.
        Senator Leahy. If that happened and you had to try to
    replicate it a few years from now, it is going to cost you a
    heck of a lot more. Is it not?
        Mr. Affleck. All the costs that we spent would be gone, and
    then it would be twice as hard and twice as expensive to try to
    do it again, to rebuild the infrastructure, to re-gather the
    personnel, to try to reassemble what we had built and overcome
    a history of mistrust, a history of disappointment, and frankly
    people who had gone elsewhere, whether it is to do more or less
    agriculture somewhere else, or in the case of eastern Congo,
    having joined a militia, having gone to work in an illegal
    mine. There are a lot of other places that people could be
    working if they are told there is no longer a job for them
    farming cocoa or farming coffee.
        Senator Leahy. Thank you. My time is just about up. I do
    not know if any of the other three witnesses want to take a
    stab at this or all three, whatever you wish.
        Mr. Megrue. Sure. I would just follow up on what Bill said.
    There are so many needs in Africa, but the area that I see the
    greatest leverage on our investment is investing in health care
    infrastructure and not in physical plant and equipment, but
    really in talent. The African health care systems are just
    sorely understaffed. And what we have seen is by providing what
    is essentially quite inexpensive talent to health ministers,
    health commissioners, around very specific issues, whether it
    is malaria, tuberculosis, HIV, et cetera, their rate of
    improvement is extraordinary. So in states like Rivers State in
    Nigeria where we have seen a 300 percent increase in 12 months
    of mothers on treatment or Bayelsa State where we have seen 160
    percent increase, that is done by inserting some people that
    the health commissioners in that case can use to mobilize their
    people and train their people in the right way.
        Senator Leahy. Admiral.
        Mr. Stavridis. Senator, I would say very quickly I would
    take a significant chunk of it and do what you see in this
    panel, which is using State and AID that have the
    bureaucracies, leverage the private-public partnerships. And
    you see both at State and at AID small numbers of people who
    are expert at doing exactly that.
        And then I have to give a shout out within this account for
    the Peace Corps which I think is incredibly underfunded and
    undervalued. Yet, every year at the Fletcher School where I am
    the Dean of the School of International Relations, our largest
    cohort walks in the door and they are Peace Corps volunteers.
    And I hear their stories, and I know their impact in the world.
    It is so wildly disproportional to the tiny amount of resources
    they get.
        Thank you.
        Senator Leahy. Mr. Ford.
        Mr. Ford. You do not have to spend it all. You could put it
    to work in credit because credit is the lifeblood of commerce,
    and credit is what is dried up and missing. The U.S. banks have
    withdrawn completely from financing anything like what we do.
    The European banks which used to finance it have withdrawn
    completely. Our coffee business, all that we have talked about
    today, funded by individuals, happens to be from the State of
    Arkansas and the State of Texas who just care, and otherwise,
    it is the Chinese that have come in. So if you have got access
    to that kind of money, credit could use it too.
        Senator Leahy. You are preaching to the converted. Thank
    you for all that you do.
        Senator Graham. Amen.
        Senator Daines.
        Senator Daines. Thank you, Mr. Chairman.
        It is not often up here on Capitol Hill when you get to
    have an inspirational morning. But I want to thank you. I want
    to thank you each for your passion, your compassion, your
    generosity, your kindness, as well as your vision. And I am
    grateful for that that this morning.

                          TECHNOLOGY AND GLOBAL HEALTH

        Mr. Gates, I heard rumors you had a background in
    technology. I have had great respect and watched what you have
    done for our country, as well as now for the world. Before I
    came on the Hill, I spent 28 years in the private sector as
    part of a cloud computing company we took public before--you
    know, people back then thought cloud was something to do with
    the weather, and we found it was something different than that.
        But I would be curious around your thoughts of how you see
    technology affecting global health over the next 15 years. You
    have called that the big bet for the future.
        Mr. Gates. Well, it is amazing how quickly these
    innovations that are initially designed to be used in rich
    countries--how quickly they can become very powerful tools in
    the poor countries that we are talking about. We are looking at
    using cell phones now to track the supply of medicines. It has
    been very difficult to run supply chains in these countries,
    and so often when you want malaria medicine or HIV medicine or
    reproductive health tools, they are just not available. So we
    are going in right now together with USAID and others and
    looking at this supply chain capability and saying we should
    know whenever there is a stock out. And as soon as you have
    that kind of information system, you are able to raise the
    reliability very, very dramatically.
        A lot of the challenges in primary health care have to do
    with the workers showing up and the quality of their work, and
    by simply tracking their activity, having them take photos when
    they come in in the morning to show that they are there, taking
    a photo of what is in the clinic, that it is well maintained,
    we see a way to very efficiently improve the quality of the
    services delivered. And so this digital realm is giving us this
    unbelievable gift of patient tracking, supply tracking, labor
    quality.
        And then, of course, over in the biological realm, the
    innovation there of creating new vaccines, new drugs, giving us
    the tools that will give us a chance to say that malaria, after
    we finish polio, will be the next disease that we will go after
    eradication.
        So without that help of new technology, many of the goals
    that we have just would not be realistic. Because of
    breakthroughs, some funded by the National Institutes of Health
    (NIH), some funded by foundations like ours, most funded by the
    commercial sector where it is simply a reuse of the same cell
    phone or Internet technology, that is why we can be so
    optimistic about what a little bit of aid money could do to
    help these countries.

                                     POLIO

        Senator Daines. Mr. Gates, you mentioned polio. As a
    Rotarian, I have been excited to be part of that effort, and
    what you all did there--we are very, very close now to
    eradicating polio in the world.
        How can that story of the eradication of polio be a model
    for future success when we look at other public health issues
    that need to be tackled in order to bring parts of the world
    both out of poverty and into economic success and stability?
        Mr. Gates. Well, polio has been an amazing campaign, and
    Rotary has been the lifeblood of keeping the energy there, even
    as it proved to be more difficult than was expected back in
    1988. Today we have not had a case of polio in Africa for over
    6 months. So the only two countries we have seen cases in in
    the last 6 months are Pakistan and Afghanistan. And even there
    where it is difficult, the government, the army, the NGO's are
    coming together. And so we are very optimistic that in the
    years ahead, we will see the end of polio.
        There are a lot of lessons about how you orchestrate
    people, and it is a commitment of the polio eradication
    campaign that we will not just get rid of this disease, but we
    will leave behind far stronger health systems. For example, in
    the case of Nigeria, as we did polio eradication there, we saw
    that the basic structure of the way they budgeted, the way they
    managed the supply chain was not handled very well, and now
    through polio-funded initiatives, that is being put on a much,
    much stronger basis.
        And so the success of polio will let us pick other
    diseases, including malaria, to go after with the confidence
    that we have learned how to do it.
        Senator Daines. Thanks, Mr. Gates.

                          PUBLIC-PRIVATE PARTNERSHIPS

        Mr. Megrue, I was struck by your testimony as well as being
    a voice for the voiceless, these babies that are now being born
    HIV-free.
        Regarding the public-private partnership that has been
    described--we will be discussing the funding issues today with
    a vote-a-rama on the floor of the United States Senate. And
    expanding our thinking even beyond the funding side of this,
    what other barriers do you see that we could work to remove or
    incentives to create to foster more of what you all are doing?
        Mr. Megrue. I think there are two pieces of that. Of
    course, there is corporate investment and then private,
    philanthropic investment. I think the U.S. does have a chance
    to accelerate and sort of match funding ideas that they have
    experimented both with other governments, as well as with
    corporations and large foundations like Mr. Gates, because
    there is a big leverage point to have leadership like the Gates
    Foundation can provide to make sure not only--which he does
    with his investments but that he can do in a highly leveraged
    way with the U.S. Government's funding next to him. So we see
    that in many countries. We are working right now and moving
    into Kenya and Uganda and Angola and other places. But the U.S.
    Government's investment in time and energy there has been
    central to creating the kind of dialogue that allows us to
    leverage what somebody like we can do.
        Senator Daines. Thank you.
        Mr. Ford, given your background as well in the private
    sector and jumping into what you have done, any thoughts on
    that as well, other barriers that we could work to remove,
    incentives to create to foster what you are doing?
        Mr. Ford. It is a bit of a stretch, but the U.S. banking
    system, from what I can see--I knew a lot of bankers. We did
    the largest leveraged buyout (LBO) that had ever been converted
    to a sale in the history of the U.S. in one check. I knew about
    every banker in the country. None of them would go with us to
    Africa, and they all pointed to the regulations facing them
    that caused them to say we do not know how to comply, and so we
    do not know what they are and we are withdrawing. And I had
    them tell me that face to face one after another after another.
        How that factors into what we are talking about here today
    is not clear to me, but it is the reason we had to revert to
    gap funding by individuals for projects like this.
        Senator Daines. Thank you.
        Senator Graham. Senator Merkley.
        Senator Merkley. Thank you, Mr. Chairman.

                                      GAVI

        Mr. Gates, thank you for the work of your foundation. And
    you started out your testimony talking about the Global
    Alliance for Vaccines and Immunization (GAVI), the vaccine
    initiative, and the basic numbers presented in your testimony I
    believe translate to about 25 bucks per vaccine and about 1,500
    per life saved. I have heard the international vaccination
    effort described as the single most cost-effective way to
    influence global health. Is that a fair way to put it?
        Mr. Gates. Yes, absolutely. There are two things we do by
    vaccinating children. One is that we save lives, and as you
    said, that comes down to less than a few thousand per life
    saved. But also for every life we save, there are about four
    children who would have grown up malnourished, that is, their
    brain and their body would not have fully developed. And if you
    look at the burden on the countries here, it is not just the
    level of deaths, it is the level of sickness so that even when
    those kids do get a chance to go to school or eventually
    participate in the economy, the fact that their health has been
    so poor completely holds them back. And so the vaccine
    investments would make the top of the list in terms of enabling
    them to support themselves.
        Senator Merkley. So the U.S. contributed or pledged $1
    billion, including 2015, as you mentioned in your testimony.
    Was that the amount you hoped for, or should we have done more?
        Mr. Gates. We were very pleased that the U.S. made an
    increase. In that case, every 5 years, that fund gets
    replenished. We are a big contributor to the fund. We got a lot
    of other countries to step up in a big way. Actually the UK is
    the single biggest contributor to that. We are the second. The
    U.S. Government would be third. So there is always room to do
    more, but we were pleased with the increase.
        Senator Merkley. Thank you. That was diplomatic and well
    stated.

                                      DRC

        Mr. Affleck, you have been traveling to east Congo since
    2007 I believe. How did you get engaged in the challenges of
    central Africa?
        Mr. Affleck. I originally got--back then, there was a lot
    of activity going on around western Sudan, and I got asked to
    be part of that. And I really did not know a lot about it, and
    I did not want to be a dilettante. So I started doing a lot of
    reading and studying and meeting folks. And then I was shocked
    to see the degree to which, the scale of which the wars in
    central Africa and particularly in Congo, the great war of
    Africa, was dwarfing what was going on in Sudan, not to
    diminish that obviously. And I figured, A, if I had never heard
    of it and, B, if it was as big a tragedy as was being
    described, that ought to be a place I should get involved.
        And so Whitney Williams and I started this organization,
    started traveling there, and we went around to about 11
    countries around Congo and really just started looking at it
    and thinking without the sort of assumption that, well, I am a
    celebrity, I must be able to help, I thought, well, what can I
    do. What can be done? And ultimately we decided that we wanted
    to help foster a lot of these community-based groups that were
    not able to get money from the United States, that were not
    able to get the kind of capacity building because they were too
    small. And we wanted to be dexterous and we wanted to be
    nimble.
        And really, once I had been to Congo a few times, there was
    no turning back. You see people suffering as much as these
    folks are suffering, fighting as hard as they are fighting. And
    I thought I would get there and find people just cowering and
    on the ground, and instead you find people going to the market,
    trying to get a job, trying to take care of their family in the
    midst of, as Senator Graham was there, grenades going off and
    all that stuff. Life flourishes and people try and people
    exhibit kindness and compassion and they want to take care of
    their families. And I was so moved by that spirit that I
    thought this is the place where I belong, and I want to try to
    do whatever I can.
        Senator Merkley. Well, I want to celebrate the model of
    looking around the world and saying is there something that I
    can have an impact on for every American to think about because
    we are part of the global community and to take it as seriously
    as you have taken it and to look for real solutions.
        You said in your testimony something that caught me a
    little off guard. I would have said ``really?'' and that was a
    country that could feed a third of the world. Could you expand
    on that a little?
        Mr. Affleck. Yes. Well, it has just got a gigantic amount
    of arable land. It has got the world's second biggest
    rainforest in the world. I mean, Congo is a massive country. A
    lot of it is under-populated. There are huge jungles, the
    hydroponics there could power all of southern Africa. And it is
    also extremely wealthy in copper, tin, tantalum, coltan,
    charcoal, lumber, gorillas. I mean, it has every conceivable
    natural resource. In fact, that may be one of the great
    tragedies of it. There were six or seven countries there during
    the war trying to grab at what they could, diamonds. It has
    incredible potential.
        And it suffered from King Leopold and the Belgians and
    Mobutu, down to the Rwandan genocide that sort of spilled over
    into Congo. So it has had a lot of bad luck, but it has got a
    tremendous amount of hope. And the people are great people.
        And now is the time. You know, they are taking these steps
    into democracy, and they are occasionally taking to the streets
    to demand that the democratic changes are transparent. It is an
    exciting time, but it requires our engagement, our continued
    engagement, a new envoy, continued engagement from the
    Secretary to support these commitments that both folks in the
    private sector, and Raj Shah I know left a couple of weeks ago,
    whatever it was, but his commitment to USAID there and all over
    the world is important. And I think it is morally important
    that we maintain the continuity of those commitments.
        Senator Merkley. Well, thank you for your hugely
    substantive engagement, and I am pleased that USAID has paid
    attention. I appreciate that Russ Feingold brought his
    expertise to bear from his Senate experience and the whole
    combination, many people coming together to make a difference.
        An election is coming up in a few months?
        Mr. Affleck. There are elections, but again, this is why it
    requires engagement. It is a little complicated. The president
    initially attached elections to a census, sort of got it
    through the lower house, and then once it went to the upper
    house, people objected to it. So he retracted. They are having
    this de courtage--my French is not great--which basically means
    they are going to carve up the existing provinces into fewer
    provinces, a process of decentralization, which is
    fundamentally popular in a country that big. However, people
    are suspicious that because they are not really ready for de
    courtage, it is a way of postponing presidential elections.
        The long and the short of it is diplomacy does not cost a
    nickel, and we need to be engaged diplomatically. There is a
    lot of suspicion in many African countries of some of the
    former colonial powers. There is nothing but a lot of respect
    and admiration for the United States and our people, and we
    ought avail ourselves of that diplomatically.
        Senator Merkley. It is tremendous. Thank you.
        And my time is out, but for the balance of the panel, each
    of you are doing really important, valuable work. So often
    international aid is framed as, well, why should we be helping
    overseas when there are so many challenges here at home? And
    that is a question worth asking, but let us look at it also the
    other way. Given the gravity of issues around the world, should
    the U.S. as a leader in the world not be engaged? And does it
    not contribute to the relationships and the partnerships that
    help address world security issues as well? And you mentioned,
    Admiral, about the soft power side. So while we are doing
    really positive things for quality of life, we are also doing
    things that are valuable to the United States. Thank you for
    all of your work.
        Senator Graham. Senator Murphy.
        Senator Murphy. Thank you very much, Mr. Chairman.
        Thank you. Your work really is truly inspirational and
    hopefully we will have, in part, a shaming affect on the United
    States Congress as we engage in a debate that will make your
    work harder.

                                SECURITY IN DRC

        Mr. Affleck, I wanted to continue talking about the work
    that you have done. A few months ago, a story came out that the
    World Food Program had run out of money to serve Syrian
    refugees, the consequence of which was pretty clear. These were
    individuals who had no choice but to feed themselves and their
    family. And so if they were not getting that sustenance from a
    legitimate source like the World Food Program, then it was
    groups like ISIS itself where they were going to be forced to
    turn to for a paycheck and for a square meal for them and for
    their family. And so as we were battling ISIS, we were making
    decisions to underfund humanitarian resources that had the
    effect of driving people to the very organizations that we are
    trying to eliminate in the region.
        And I imagine this plays out in the Congo where you have
    choices to be made. You have militias from the Lord's
    Resistance Army to M-23 that are offering help to these people
    in the form of small paychecks and sustenance, and if they do
    not have legitimate sources of income, I imagine that that just
    drives recruitment into a lot of these illegitimate sources and
    just creates more of the kind of problem that we are trying to
    solve.
        So I would just love to hear you talk a little bit more
    about how this plays into the security dynamic inside Congo.
        Mr. Affleck. In countries like this, you see a clear
    correlation between increased security and increased economic
    development, as you pointed out. It is really not debatable.
    And you know, like Hezbollah in southern Lebanon, when they
    step in and fill those roles, it creates problems. As I was
    talking about the Alliance of Democratic Forces for the
    Liberation of Congo (AFDL), they essentially are present in
    areas where our coffee manufacturers and our cocoa farmers
    rather are present.
        Now, if this all goes away, if the funding is removed, if
    we are not there, it creates a very different environment.
    Either people have to flee or they have to join up with whether
    it is them or the Democratic Forces for the Liberation of
    Rwanda (FDLR), as you said, the M-23 or the many, many Mai Mai
    militias, oftentimes people are forced to join militias just to
    protect what meager things they have. And if they just have a
    job, if they just have a purpose, they will stick with it,
    frankly, under really, really difficult circumstances. And it
    is when people run out of options, that they either go work for
    slave labor in some mine and be exploited or engage in all the
    kinds of activity that we collectively understand as either
    abhorrent or virtually sort of slave labor. And it is really,
    really important that we support the civil society that is
    burgeoning in these countries and support the economic growth
    so that people have a place to go.
        I think you make a very good point. And Congo, as it
    becomes better developed, will no doubt become more peaceful.
        Senator Murphy. Admiral Stavridis, one of the challenges
    that we have is figuring out who to fund. We have an interest
    in making sure that the money goes immediately to the best
    purposes, which often means funding really well organized
    nonprofits, but in the end, we have an interest in good
    governance. And so there are reasons to run the money through
    local governmental institutions.

                               FUNDING MECHANISMS

        I know the answer is different in each place, but as we
    look at some of the most dangerous places in the world, parts
    of Africa that we are talking about today or the Middle East,
    what is your recommendation and guidance as to the source of
    this funding?
        Mr. Stavridis. Thanks, Senator. I think you hit the nail on
    the head in that it is different in each of these different
    venues. But as a general proposition, using an agency like AID,
    Millennium Challenge, or State as a vetting kind of authority
    can be very helpful.
        Secondly, depending on the individual state--and most
    recently, for example, Afghanistan. We have had a lot of
    controversy about whether this aid should flow through Kabul or
    go directly out into the field. There are even micro-climates,
    if you will, wherein you can be confident in Mazar-e-Sharif in
    the north, relatively confident in Herat in the west, but you
    ought to be a little more concerned as you get down toward
    Urozgan province or into Kandahar. So the point is there is no
    substitute for local knowledge, local expertise. You should
    kind of turn first I think in this case to the U.S. Government
    as a vetting authority.
        And I want to close by saying I am very encouraged by some
    of the reforms that Raj Shah put in place at AID to improve the
    capability in this particular, very important aspect of things.
        Thank you.
        Senator Murphy. I just want to close with a question to
    you, Mr. Gates. You are, obviously, a technology expert, as
    Senator Daines noted, but you also know something about
    marketing. And we are in a position today, as we have noted,
    where most Americans think we are spending about 23 percent of
    the budget on foreign aid. And the reality is even worse than
    it first appears. Yes, we are spending only 1 percent, but if
    you go back to the peak of foreign aid, the Marshall Plan, at
    that point, we were spending .3 percent of GDP on foreign aid,
    a program that I think everyone agrees has a good deal to do
    with the world order that we are living in today. We have got a
    94 percent decline in foreign aid spending as a percentage of
    GDP since 1950. And yet, people still believe that it is a much
    bigger share of the budget than it is.

                        PUBLIC PERCEPTION OF FOREIGN AID

        What is your quick recommendation as to how we change
    people's perception? What are the two or three most salient
    points from a marketing perspective to make people understand,
    to make our constituents understand that we have got to be
    dramatically increasing the share of the Federal budget or at
    least a portion of the Federal budget that we are spending on
    well-run programs?
        Mr. Gates. As you say, most people grossly overestimate
    what portion of the budget is going to these things. And if you
    ask them, hey, what portion should go, they will say 2 or 3
    percent, and of course, our response is, great, we would settle
    for that in a second. That would be a gigantic increase.
        In terms of the share of budget or share of the economy,
    the U.S. is relatively low compared to other countries. In
    fact, the UK as an example raised their level up to be over
    three times what our level is at a time where they had very
    substantial deficits. And it was a decision that the relative
    impact of the aid dollars was very, very high.
        It is unfortunate that the historic picture people have of
    aid is clouded somewhat by aid given during the Cold War where
    it was more about the bad guy or who was our friend than about
    the humanitarian impact. Today, the aid budget is not burdened
    by those things, and we are able to go in with the same
    business-like thinking that I applied at Microsoft and said,
    hey, is this money being spent the best way that it possibly
    could.
        And the percentage of the USAID budget where our foundation
    is doing something in partnership with the U.S. Government is
    very, very high. So we get the analytic capabilities of USAID
    that are better today than ever, combined with ours and that of
    other people. And so there is a lot of learning that is going
    on in areas like agricultural and livestock. It is very
    exciting the new things. We are finding how to get new seeds
    out and how to raise the productivity and how to create self-
    sufficiency.
        And so if people knew how small it was and how careful we
    are to make sure that there is impact, I think we would get
    strong support for the modest level that we are hoping to
    maintain.
        Senator Murphy. Thank you to all of you.
        Thank you very much, Mr. Chairman.
        Senator Graham. Senator Moran.
        Senator Moran. Mr. Chairman, thank you very much.
        Mr. Gates, nice to see you again. We have had a
    conversation for several years about eradication of polio in my
    role and capacity on the Labor, Health and Human Services, and
    Education, and Related Agencies Appropriations Subcommittee. It
    seems to me we are making significant progress. Thank you to
    your foundation for working so closely with Rotary
    International.

                                     POLIO

        But there have been outbreaks of polio in Kenya, as I
    understand, cases that are now being reported. How close are we
    and what more is it going to take to finally put this
    circumstance to an end?
        Mr. Gates. Yes. The first half of 2014 was a concern
    because we had cases that had come up in Syria, cases that had
    come up in Somalia that spread to Ethiopia and Kenya.
    Fortunately, those outbreaks are now under control. And the
    country we thought would be the last, Nigeria, has not had a
    case since July 24th. And so if we are lucky and if we go
    another 6 months without finding a case, then we would be quite
    sure Africa may have seen its last case.
        And so the focus now in Pakistan and Afghanistan is very
    intense, taking some of the same tactics that worked in
    Nigeria. And I would say we have a period of relative stability
    where the area up in the federally Administered Tribal Areas
    (FATA) that the Taliban controlled where kids were not being
    vaccinated--because the Pakistani army has gone in there, we
    now have access to enough children that we can succeed in
    Pakistan. So we are very hopeful.
        And the polio budget, which is a combination of some of the
    foreign assistance account and the Centers for Disease Control
    and Prevention (CDC) budget--that has made a huge difference.
    There was an increase there. CDC is an amazing organization, a
    great partner. I was down there, spent the day with Tom Frieden
    just a few weeks ago talking about Ebola and polio and how we
    work together. Very impressive. And the extra resources are
    making a difference.
        Senator Moran. Well, congratulations on your success and
    thank you for your commitment.

                              EBOLA VIRUS DISEASE

        Let me ask just the panelists generally. What has been the
    consequence of the effort by the United States and the world
    community in regard to Ebola? What are lessons that are
    learned? What does it tell us that we ought to know to prevent
    circumstances such as this from occurring with this disease or
    any other medical health affliction? What can we learn from the
    world response to the arrival of Ebola in West Africa?
        Mr. Affleck. That is you, Bill.
        Senator Moran. My press staff is going to be disappointed
    that I did not get an answer from Ben Affleck.
        Mr. Affleck. Believe me, you made the right decision.
        Mr. Gates. Well, all the things we do to build up
    stability, particularly what is called the primary health
    system that reaches out even to the poorest, most rural areas,
    when you do not have good primary health care, that means an
    epidemic can get started without the global awareness to go in
    there and intervene at the early stage. And because infectious
    diseases are exponentially explosive, the 6 months that we
    missed in Guinea because we did not know what was going on,
    that is what led to it being such a gigantic outbreak.
        We are very lucky in this case that the agent was not more
    infectious. We are lucky that finally when it was recognized
    last August, that the world, particularly the United States
    CDC, has done a phenomenal job here. The U.S. military came in
    with the logistical capabilities that were lacking there. That
    was invaluable.
        But we are likely to see sometime in the next 20 years a
    far worse pathogen than Ebola, and by having high-quality
    primary health care, good surveillance in Africa where it is
    very likely to emerge, we will be able to catch it at the early
    stage and not have it become like a 1918 Spanish flu. So it
    really underscores the investments we have made and the need to
    do even better on the surveillance front.
        Mr. Stavridis. May I comment on that, Senator?
        Senator Moran. Yes.
        Mr. Stavridis. I just want to pick up on what Mr. Gates
    said about the--there is a role I think for militaries here.
    This is a classic example of soft power. The militaries, in
    which we invest so much, have not only hard power warfighting
    capability but enormous logistics muscle, manpower, a
    capability directly impacting the medical field. So as a kind
    of ``point of the spear'' response to get all of the real
    professionals in there, I think there is a role for the
    military.
        I will add that speed is really the key particularly if a
    pandemic morphs the way that Mr. Gates is talking about. Think
    World War Z. There are examples not only in the real world but
    in fiction that would tell us we need to be ready for this. And
    I do want to just underline that.
        Senator Moran. I appreciate you indicating that because I
    think the initial response by many Americans when the idea of a
    military was going in to battle Ebola was that is not what we
    train military men and women for. That is not their mission.
    Why are they being called on to do that?
        Mr. Stavridis. A good way to think of that is an on and off
    switch. You know, life is not an on and off switch. In other
    words, we do not fund this magnificent military just to be in
    combat, on, or to sit in a barracks, be a ship tied at the
    pier, or an airplane that is on a runway somewhere, off. It is
    a rheostat between hard power, which we need at times, but also
    to bring this logistics, this expertise, this information, this
    intelligence to bear in a crisis like this at speed. We can
    dial that rheostat toward the soft power at that moment, and it
    is a very effective way, cost-effective way to use our
    military.
        Senator Moran. I appreciate that answer, and I would use
    this opportunity to thank Kansas Guard members who were called
    to duty in the fight against Ebola in Africa.
        And, Mr. Gates, I would reiterate what you said about CDC.
    All Federal agencies are subject to criticism. I am a fan and
    supporter of Dr. Frieden and the efforts--Ebola and many other
    aspects of what CDC is doing, including prevention here in the
    United States and community health center.
        Thank you very much to the panel for being here.
        Senator Graham. Senator Coons.
        Senator Coons. Thank you, Chairman Graham, for calling this
    hearing, and I would like to just follow the line of
    questioning my good friend, Senator Moran, has been leading.
        I had the opportunity to visit Liberia for the third time
    in December 2014 and to visit with our troops and missionaries,
    nurses, doctors, folks from the uniformed Public Health
    Service, many of the troops from the 101st, and to see the work
    they were doing on the ground. I also saw the impressive impact
    of the collaboration between significant private sector donors,
    between continent-wide organizations, and between grassroots
    community groups. I would like to explore two different points
    on that if I could.

                              EBOLA VIRUS DISEASE

        First, Mr. Gates, as you referenced, we may well face a
    pathogen more lethal, more rapid in its spread than Ebola in
    the coming decades. In fact, it is likely we will.
        We have made some significant progress in vaccines as well,
    developing both a field test for Ebola, and making progress in
    vaccines for Ebola brings some real hope about this particular
    episode hopefully coming to an end within the next few months.
        In addition to the importance of having an African CDC for
    early warning, how do you see the path forward on vaccine
    development and strengthening the capabilities for rapid
    characterization and rapid deployment of a vaccine in the face
    of a more lethal pathogen?
        Mr. Gates. Well, it is amazing to how the little the world
    has prepared for a serious epidemic. The U.S. has done more
    than any other country, but even there we have not done enough.
    The Ebola vaccine--and there was actually an Ebola treatment
    called ZMapp--was partially ready, but the time it took, even
    using very unusual regulatory approval and trial processes, the
    time was too long for it likely to have any impact on this
    particular epidemic. And so our state of readiness was not as
    strong as it needs to be.
        We do need to draw on other countries to also contribute to
    these efforts. We do need to take the various agencies of the
    U.S. Government who work on this and make sure that we have an
    overall strategy. One thing that I have called for is that we
    ought to do--in the same way we do war games to simulate
    challenges coming at us on the military front, that we ought to
    do germ games where we look and see how we would respond. The
    last time that was done in the United States, 2001, Dark Winter
    looked at a smallpox epidemic, and the resources proved
    inadequate in that case. So there is a good foundation. There
    is a lot of good science. NIH is the leader in many of these
    things. And so the idea that tools could be created quickly--
    that is a possibility, but we are not there yet to say that we
    are prepared.
        Senator Coons. Well, I think there are important lessons
    for all of us to learn here, both about the strength of
    community health systems, the capabilities of community
    responders, and the huge cost we ended up having to invest and
    the significant loss of life that could have been avoided. I do
    hope we take your advice and work together in a responsible way
    to make sure we have those capabilities.

                         NATURAL RESOURCE EXPLOITATION

        Let me talk next, if I could, about natural resource
    exploitation. As you know well, Ben, eastern Congo has been a
    victim of lots of different ways for illicit exploitation of
    natural resources. Wildlife trafficking has caused real crises
    in the Congo Basin and other places on the continent, as well
    as illegal mining and extractive misuses of natural resources.
    And we are increasingly focused in a bipartisan way in Congress
    in how that also helps fund and fuel extremism, and both
    transnational both criminal and terrorist organizations. So I
    would be interested, Mr. Affleck, to hear what you have seen in
    eastern Congo about this.
        And, Admiral Stavridis, if you would talk about how this
    intersection between issues that are typically the concerns of
    conservationists and wildlife advocates have now really been
    put on the radar for national security issues.
        Mr. Affleck. Well, first of all, Senator, I want to say
    thank you very much for all the work you have done. You are
    just one of these great unsung heroes on these issues--or maybe
    partly sung. I do not know how ``sung'' you are, but you are a
    hero.
        Senator Coons. I sing off key, so not well sung.
        Mr. Affleck. But thank you very much.
        I can just speak to what I have seen and experienced, which
    is, as you point out, there are a tremendous amounts of
    resources there, you know, gold, tin, tantalum. It goes on and
    on. And almost all of them are dominated either by militia
    groups or by a sort of quasi-mafia military organization. Then
    really, that also has the same effect of empowering people who
    are not doing great things and have a pernicious effect on the
    country itself.
        I talked about the Alliance of Democratic Forces (ADF) in
    the north. There is the Democratic Forces for the Liberation of
    Rwanda (FDLR), which is the former Armed Forces of Rwanda (ex-
    FAR), the people who committed the genocide essentially in
    Rwanda and the organization that they founded and maintained
    inside Congo, which they are now sort of taking on half-
    heartedly.
        But, you know, what happens is when these industries are
    unregulated, they are controlled essentially by low level
    mobsters who then have allegiance to higher level
    organizations. And you have a country that has consistently
    been on the top 10 list of failed states. And so you have a
    security sector situation that is wide open to be exploited and
    manipulated.
        I think there are two things to do. One is to try, as best
    we can, to help them regulate these industries, which is going
    to meet with a ton of resistance. And two is to try to really
    examine--look at these groups, see where the money is going,
    see what they do. One of them is an extremist Muslim group.
    Others are just as violent and hideous but subscribing to
    different religions. The truth is it is there. It is happening,
    and none of these extremist organizations, none of these
    militias survive, even though the cost of an AK-47 there is 40
    bucks. None of them survive without these resources.
        I do not know if you saw the movie Virunga, which is quite
    good, that park which is fighting for its life, quite
    literally. One of the things that is undermining them is there
    is a charcoal trade, which is illicit and makes a lot of money,
    things like timber that you would not expect. But all the
    resources that are there are being swallowed up by these
    illegal organizations who pay tariffs to the various powers
    that be. And it is one of the things bedeviling this country
    and preventing it from achieving real progress.
        Senator Coons. Absolutely. Thank you for your leadership on
    combating this and making it better known.
        Admiral Stavridis, how are we doing at bringing together
    our military expertise and resources and the fight against
    illicit wildlife trafficking, illegal mining, and how does that
    destabilize vital allies in the region?
        Mr. Stavridis. We focus insufficiently on this as a
    security problem. As Mr. Affleck correctly points out, it is
    the corruption and the financing that comes out of it that then
    undermines these fragile democracies, creates ungoverned space,
    and leads directly to security challenges which are global.
    And, of course, it is not just in the Congo. It is in Latin
    America and the Caribbean. It is in Afghanistan. It is in the
    Caucasus. It is very concerning. And we tend, as always, to
    look first to the hard power solution, but this is a case where
    many of the soft power things we are talking about, creating
    jobs, education, opportunity, you play the long game and you
    have a better chance of creating security.
        I will close by saying another aspect of this is the routes
    that come out of it. So if you are moving natural resources
    that you have stolen or you are moving cocaine or opium, these
    routes create the opportunity to move weapons, extremists, and
    at the really dark end of the spectrum, weapons of mass
    destruction. So that is another shrimp on the barbie of concern
    I will throw out there.
        Thank you.
        Senator Coons. Mr. Chairman, would I be overstaying my
    welcome if I asked a last question?
        Senator Graham. Not at all.

                                 MOBILE BANKING

        Senator Coons. If I might, to anyone on the panel who
    chooses to respond, mobile telephone technology has transformed
    the possibilities of connection to the modern economy through
    mobile banking, real-time knowledge about everything from
    incidence of violence to grassroots political movements.
    Campaign incidents in Kenya, for example, were first documented
    using an open-source platform that Ushahidi built. Some real-
    time knowledge about the spread of Ebola and being able to do
    tracking was significantly facilitated through cell phones,
    which have now penetrated 70-80 percent of many of African
    countries.
        How do you think we might partner with African nations to
    both unlock the potential of access to resources for the
    empowerment of small holder farmers and women's cooperatives
    through mobile banking? And how might we strengthen the ability
    of citizens to engage in the fight against corruption, against
    wildlife trafficking, against extremism through the platform of
    mobile communications? Any member of the panel who chooses to
    answer.
        Mr. Affleck. Is this a technology question?
        Senator Coons. Yes, sir. That does suggest a first answer.
        Mr. Gates. It is very exciting what we are going to be able
    to do over the next decade. I would say we are just at the very
    start of that. In the case of Ebola, we were not able to track
    movements as well as we would have liked to. Having in place
    the ability to look at the data and make sure that we were not
    violating people's privacy--that was not set up. I think now
    that we have, in a delayed way, looked at that data, what we
    would have known better--that is a great impetus to move
    forward.
        In terms of the Congo, the technology that is even more
    basic but is very critical is the satellite photography. The
    U.S. military, of course, has funded the creation of those
    technologies. Now, in civilian hands, people like Digital Globe
    are able to show us, knowing the population of DRC, knowing
    where the farming is taking place. We are doing a lot of
    funding people to do surveys like that because we have
    medicines for things like sleeping sickness, and figuring out
    where are the people and how do we get it out logistically,
    which is incredibly difficult in the DRC. It is only because of
    these digital satellite platforms and over time the increased
    penetration of cell phones. We think even in tough countries
    like that we will be able to get in and do great things.
        As people are able to do digital transactions on the cell
    phones, things like remittances, getting back with lower fees,
    countries being able to understand their economy in a much
    better way, taking government payments that has always been
    inefficient and actually fairly corrupt before it gets out to
    the recipient that can be done to the woman's cell phone, that
    can make a huge difference.
        So there is a ton of pilot programs involved in this. Many
    of them are involved in what you said, preventing corruption,
    by actually documenting what is going on when it goes on. If
    you ever have to go back and say, oh, did this seminar take
    place or what this payment made, the paperwork when it really
    did and the paperwork when it really did not, it is not easy to
    distinguish. But if you get photos taken while things are
    taking place, it is very possible to make it almost impossible
    for the money to go astray. So there is a lot of promise.
        Senator Coons. Well, thank you. I appreciate the answer.
        Mr. Stavridis. Can I add? Just a practical example of what
    Mr. Gates just said is in Afghanistan where we pay 352,000
    Afghan troops, but we have moved that to a mobile system. A,
    they do not have to go back to their village to take their
    tattered stack of currency, and B, it is documented. The
    corruption piece washes out.
        And another technology that I think is interesting here is
    unmanned aerial vehicles, drones, which have a bad rep for a
    lot of reasons. But here is a place where they can be used very
    effectively to do the kinds of surveillance that Mr. Gates is
    talking about in Africa and in other areas to look at crops, to
    look at tracking, to look at who is trying to go after the
    black rhino, et cetera.
        Thanks.
        Senator Coons. I think there is huge potential for us to
    make a difference.
        Mr. Chairman, I will allow Mr. Affleck a last----
        Mr. Affleck. Just briefly, as Mr. Gates said earlier,
    existing cell phone technology is extremely potent from what I
    have seen. It is just a question of training and exploiting
    what is already there. And it makes a big difference. And one
    of the steps that we have seen in Congo that has been proposed
    and I think will be incredibly helpful is to use cell phones
    for banking ultimately so that if you are a soldier, the money
    actually gets to you because it is transferred directly to you.
    The way it works now is you make literally no money. I mean,
    you should see the FRDC's barracks. They are like tent cities.
    This is your national army? You know what I mean? Guys stealing
    pots and pans, and that is why you have these rapes and that is
    why you have this impunity. And this is not evil people. They
    want to be soldiers. They are put in this position. But if the
    pay did not have to go through seven officers who all took
    their cut and the guy before the soldiers who took the final
    cut, you would revolutionize the way that the armed forces work
    there, and they would go from being a really protective force
    to one that is a pernicious force. That is just one that I know
    of, but Mr. Gates said there are many, many more.
        Senator Coons. Well, thank you. I would like to thank the
    whole panel for your contributions and for your testimony
    today.
        Mr. Chairman, I want to specifically thank you for your
    real leadership over many years in making sure that our
    investments in foreign assistance contribute to our national
    security, and appreciate your calling this hearing today.
        Senator Graham. I thank the whole subcommittee. We have got
    a hard stop at noon, but Senator Blunt is here. So he will be
    our last inquisitor.
        Senator Blunt. Well, Chairman, thank you.
        We had the Secretary of Labor at our hearing who was not
    nearly as popular as your panel, I am sure.
        I will have some questions for the record.
        Let me just say that for the work that this panel
    represents, the great private sector partnerships that are
    going on out there with what we do in areas like PEPFAR, the
    mother-to-child AIDS transmission successes are incredible. The
    ag research successes are incredible. What is happening in the
    Congo. And this really brings a level of attention to your
    leadership and the work we are doing here and also the
    importance of finding successes that we can talk about where we
    started a program, we worked with local partners, and at some
    point, we were able to walk away and leave that program with
    somebody else. It is the kind of thing that creates an
    understanding and an appreciation for the importance of what
    this subcommittee does. And the partnerships here are
    incredibly important in encouraging our role to make a
    difference around the world.
        So, thank you, Chairman, and I will have some questions for
    the record.
        Senator Graham. Well, thank you, Senator Blunt. You have
    been on every trip I have ever put together. This is a great
    subcommittee, Republicans and Democrats.
        Senator Blunt. I would like that struck from the record, if
    you do not mind.
        Senator Graham. And we have gone to great places like the
    Congo, places I think most people appreciate you going because
    it means a lot to us.
        In 2 hours, we are going to vote to cut this account in
    half. So this is a perfect day for you to be here. You made a
    compelling case. Scott, we need some financing we do not have
    today. I think I have learned a lot from the hearing. You have
    made a compelling case that we are inside the 10-yard line on a
    lot of these problems, mother-to-child AIDS transmission. The
    Congo may be turning a corner. Bill, polio. We got all this
    stuff on the run. And in 2 hours, the Congress, the Senate is
    going to have the chance to cut this account by 50 percent.
    Only in America. Only in Washington.
        So in about 30 seconds apiece, tell me why that would be a
    good idea or a bad idea. Scott.
        Mr. Ford. The footprint that America has in Africa, which
    is the only place I have got any direct experience, and the
    goodwill that we have inured there through the public and
    private sector engaging with the Rwandan leadership, with the
    Congolese leadership, and Uganda and Tanzania--to withdraw
    right before we win the game is to throw a pass when you are on
    the 1-yard line.
        Mr. Affleck. I thought that was a good play.
        Senator Graham. I am sure you just made yourself a big hit
    in Seattle.
        Admiral.
        Mr. Stavridis. I would say that we ought to look hard at
    what is efficient here, and the tiny cost of this account, as
    it is represented in the President's budget, is pennies on the
    dollar. It is like preventative medicine, which we have talked
    about a lot today. Do you want to spend money on massive
    treatment once the disease has taken place? That is hard power.
    Or would you rather have a program that is preventative, that
    looks at health on a day-to-day basis? That is soft power. It
    is much less expensive. You need both. There are times when you
    have to have hard power, but that balance between hard power
    and soft power, that is smart power. Let us be smart and not
    cut the development and diplomacy tools. They are absolutely
    necessary.
        Thanks.
        Mr. Megrue. Thank you, Senator.
        One of the most basic business tenets that we learn early
    in our career is do not withdraw or blink when you are past the
    tipping point of success. And we are past the tipping point of
    success with this account in so many ways. We have heard today
    national security and others.
        And Senator Murphy asked earlier, how do we explain this to
    the American public. And I think part of it is explaining some
    of these incredible successes, whether it is polio or what we
    have been able to accomplish in malaria or mother-to-child
    transmission or so many others. And I think it is getting that
    message out there that will cause people to step back and
    realize that making a cut like you are talking about or
    proposing a cut like you are talking about--this is the wrong
    time to do it. And that the local governments will be picking
    this funding up on their own, as they have been.
        Mr. Affleck. I think it would be politics at its worst, as
    you said, Chairman, demagoguery, and really, truly
    shortsighted.
        What I have seen personally are people who now have a job
    that did not used to have a job are moving into the
    marketplace. It is a model. Even more so than 10,000 farmers,
    you would be destroying a model in its earliest, most nascent
    phase, that is to say, business and investment is strong and
    powerful aid. It gives people a sense of self-confidence and a
    sense of meaning in their lives. And it brings goods to the
    market, the practice of which has built this country and has
    proved to be beneficial to producers, to consumers, and to the
    people who live in those communities.
        And that model that is now starting to be practiced would
    be diminished, and that I think would be a real tragedy because
    ultimately that model is not only going to save the American
    taxpayer a lot of money, it is going to bring the American
    taxpayer--it is going to elevate the economy of the American
    taxpayer. It would be a crying shame because we are really on
    to something great.
        Mr. Gates. Yes. I would go back to something Senator Graham
    said at the beginning, which is that the impact per dollar in
    this budget, particularly the health and the agriculture pieces
    that I know best, is probably more impactful than any money the
    U.S. Government spends. Yes, there should be a very high bar
    for spending money outside the United States in terms of the
    benefits to the people back here and to the impact that money
    has. But if you cut, say, $3 billion from this budget, we are
    saving lives for $1,500 per life saved and even better benefits
    for the survivors. So that is over 2 million children a year
    that would die for lack of those resources.
        Something like $3 billion a year--and the cut being
    proposed is way larger than that--that matches all the money
    that our foundation spends in this area. We get a lot of
    visibility, but people should understand the U.S. Government,
    through its broad set of programs that we are partnered with,
    is about 10 times in its total foreign aid budget all the money
    we spend. And that is the basic underpinning of why we are
    seeing the great progress we are seeing on things like polio,
    and it is the foundation for making sure that a mass epidemic
    is caught at an early stage.
        Mr. Affleck. Can I just say one more thing, Chairman,
    briefly? I think there is the sense that, well, if we do this,
    this is what we are doing, and these are not our priorities.
        In our family, my wife does extraordinary work with early
    childhood education in the United States in the Appalachians in
    West Virginia, in Kentucky, and the central valley of
    California. It is something she cares deeply about, and she is
    extremely effective at it. And we are all very, very proud of
    her and impressed. I do work in the Congo.
        We see that as a microcosm of what this Government can be.
    We can do both. We can do all of these things. We can apply our
    values to our relatives, to our neighbors, be they outside our
    national borders or be they within. I believe that is what
    America is.
        Senator Graham. Well, thank you all. It is probably the
    best hearing I have attended in a long time. Each of you in
    your own way represent the best of our country, and I think
    this account represents the best of America. And in 2 hours, we
    are going to go fight for it. Thank you.

                              SUBCOMMITTEE RECESS

        The hearing is adjourned.
        [Whereupon, at 11:58 a.m., Thursday, March 26, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

                                    APPENDIX

        [Clerk's note: The following material was submitted by Bill
    Gates and the Bill & Melinda Gates Foundation to be included in
    the hearing record.]
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            [From the New England Journal of Medicine, Apr. 9, 2015]

                     The Next Epidemic--Lessons From Ebola

                                (By Bill Gates)

        The ongoing Ebola epidemic in Guinea, Sierra Leone, and Liberia is
    a huge tragedy. The impact on the 22 million people who live in those
    countries goes far beyond the Ebola deaths. The health systems and the
    economies of the three countries have been largely shut down during the
    outbreak. The world has a lot of work to do to make sure the case rate
    drops to zero--in the week leading up to March 1, 2015, there were 132
    new confirmed cases reported. It will also need to make sure a good
    healthcare system is built and enough food and other basics are
    available. Without catch-up vaccination for the children who have not
    gotten vaccines during the epidemic, for example, the increase in
    measles deaths alone could outnumber the deaths from Ebola.
        The only good news from this epidemic is that it can serve as a
    wake-up call to help us prepare for a future epidemic that spreads more
    effectively than Ebola does. There is a significant chance that a
    substantially more infectious epidemic will come along over the next 20
    years; after all, we saw several of them throughout the 20th century,
    including the Spanish flu of 1918-1919, which killed at least 30
    million people, and the ongoing HIV pandemic. In fact, of all the
    things that could surprise people in a negative way by killing more
    than 10 million people, by far the most likely is an epidemic, from
    either natural causes or bioterrorism.
        Ebola is far from the most infectious disease we know about. During
    the epidemic, almost all of the secondary infections have taken place
    after the patient was very sick. Most people are infected while taking
    care of a patient at home or in a hospital, or by touching the body of
    someone who died from Ebola. This means there has been very little
    spread to strangers other than healthcare workers and those providing
    emergency transportation. This factor has helped keep the number of
    cases below 0.5 percent of the general population, and it allowed a few
    tactics--such as persuading infected people to get isolated and
    treated--to slow the epidemic.
        By contrast, other disease agents (measles and flu, for example)
    are far more infectious because they can spread through the air, rather
    than by direct contact. People may not even be aware that they are
    infected or infectious. These agents make it possible to infect lots of
    strangers in the marketplace or on a plane, so the number of cases can
    get large very quickly. And successive waves of infections can come
    just days apart, leaving little time to mount an effective response.
        When I heard that the Ebola epidemic had reached urban areas, I had
    a dreadful feeling that we might not be able to keep it from spreading
    to many more countries with weak health systems. It was only when I got
    a chance to start looking at the case data with colleagues at the
    Institute for Disease Modeling that I saw the relatively confined
    pattern of the infections and began to think the geographic spread
    could be controlled.
        I am concerned that as the intensity of the problem fades from the
    world's attention, we will miss the opportunity to learn from the Ebola
    epidemic and be better prepared for the next one. Even if the system we
    have today worked perfectly, it would not contain a more infectious
    disease.
        It's useful to compare our preparations for epidemics with our
    preparations for war. Defense budgets and investment in new weapons
    dwarf investments in epidemic preparation. NATO has a mobile unit that
    is ready to deploy quickly. Although it's not a perfect system, they do
    joint exercises where they work out basic logistics like how fuel and
    food will be provided, what language they will speak, what radio
    frequencies will be used. When soldiers sign up to serve, they know
    what the risks are and who will take care of them if they're injured or
    killed.
        Few if any of these things exist for an epidemic response. The
    world does not fund any organization to do the broad set of coordinated
    activities that are needed for the next epidemic. The last serious
    simulation of an epidemic in the United States, the Dark Winter
    exercise, took place in 2001. The International Health Regulations
    (IHR), adopted by the United Nations after the SARS outbreak of 2002-
    2003, were intended to improve the world's ability to prevent and
    contain outbreaks. But few countries have met their commitments under
    the IHR. Nor have most countries established an Emergency Operations
    Center that can be activated within 2 hours of identifying an outbreak,
    a commitment made under the 2014 Global Health Security Agenda.
        Because there was so little preparation, the world lost a lot of
    time trying to answer fairly basic questions about how to deal with
    Ebola. In the next epidemic, these delays could cause a global
    disaster.
        The problem does not lie solely with any single institution--it is
    a global failure. The world needs a global warning and response system
    for outbreaks. (WHO has a group with a similar name--the Global
    Outbreak Alert & Response Network--but it is severely understaffed and
    underfunded.)
        In this essay, I describe what I think that system might look like,
    based on lessons learned from the Ebola response. Many details will
    need to be worked out. I have not seen a rigorous projection for what a
    complete system like the one I describe would cost, but the World Bank
    has made some projections that give a sense of the cost of inaction.
    For example, it has estimated that a worldwide flu epidemic would
    reduce global wealth by $3 trillion. It has also projected that Guinea,
    Sierra Leone, and Liberia will lose 12 percent of their GDP this year
    because of Ebola; if a global epidemic were as costly, the worldwide
    impact would be more than $7 trillion, not to mention the immeasurable
    misery caused by millions of deaths.
        The key point is that the world is not nearly as prepared for a
    massive epidemic as it needs to be. While Melinda and I remain
    committed to our work on improving the health of the poorest, I hope
    this paper--in spite of whatever shortcomings it has--helps spark
    conversation and action to prepare for an epidemic that could have
    global consequences.
                  public health and primary healthcare systems
        There is a critical need to reinforce basic public health systems.
    These are fundamental systems that include primary healthcare
    facilities, laboratories, surveillance, critical care facilities, etc.
    As many commentators have pointed out, Ebola has spread much faster and
    more widely in countries whose health systems, and especially primary
    care systems, were severely weakened by years of conflict and neglect.
    Countries with stronger health systems have been able to respond more
    quickly.
        Strengthening primary healthcare systems provides a double benefit.
    One, it improves our ability to prevent, detect, and respond to
    epidemics. The other benefit is to health more broadly. Primary
    healthcare facilities are where women go to seek preventive services
    like family planning and vaccinations for their children, and to get
    treatment for a sick child. Without a functioning health system--
    including adequate numbers of trained health workers, good supply
    chains, disease surveillance, information systems, and policies that
    enable access by the poor--it is very hard for a country to end the
    cycle of disease and poverty.
        Good health is so fundamental to well-being and development that
    even if there were no chance of another epidemic ever occurring,
    healthcare systems would be a worthwhile--and life-saving--investment.
    The fact that they also bolsters our ability to deal with the next
    epidemic is all the more reason to invest in them.
                              disease surveillance
        There is no systematic disease-surveillance process in place today
    in most poor countries, which is where a natural epidemic seems most
    likely to break out. The Zaire strain of Ebola had not previously been
    seen in West Africa, so the region wasn't as prepared as central
    Africa, where it has shown up more than 20 times over the past several
    decades. Although Medecins Sans Frontieres (MSF) reported a rise in
    Ebola cases in Guinea last spring, there weren't adequate resources on
    standby to go into the area and do the requisite sampling to determine
    how widespread the outbreak was. Even once the crisis was recognized,
    there weren't resources to effectively map where cases were occurring
    and in what quantity.
        We need to invest in better disease surveillance and laboratory
    testing capacity, for normal situations and for epidemics. Routine
    disease surveillance systems should be set up so they can detect early
    signs of an outbreak beyond their sentinel sites and be efficiently and
    quickly scaled up during epidemics. They should be tied in to the
    national public health laboratories to enable robust monitoring and
    response as part of a country's healthcare system. The data derived
    from the testing needs to be made public right away. A lot of the
    laboratories in developing countries have been financed by the polio
    eradication campaign, so there should be a plan for what capacities we
    need once that campaign is over.
                                   personnel
        Once it became clear that a serious emergency was under way,
    recruitment of local clinicians and the flow of trained personnel into
    the affected countries should have been very high. It wasn't. There was
    no comprehensive plan for what was needed. No training centers were
    standing by. The United States, Cuba, China, and other countries
    stepped forward with volunteers, but few of them were trained in what
    treating Ebola patients effectively would entail. All of this happened
    over 2 to 3 months, when it needed to happen within days. It is
    fortunate that MSF was able to mobilize volunteers faster than any of
    the governments.
        We need trained personnel ready to deal with an epidemic quickly.
    One approach is to think of them in three tiers: (1) an incident
    manager for each Emergency Operations Center (EOC), in charge of
    coordinating efforts by the medical care providers, military,
    volunteers, and others at the country level; (2) experts in
    epidemiology, surveillance, outbreak response, social anthropology, and
    other areas who can provide surge capacity for the response; and (3)
    respected community leaders who can lead the local engagement efforts
    and community workers who can implement programs and give accurate
    information to the public in local dialects.
        There should be updated lists of people at all levels--especially
    the first two--documenting their availability and capabilities. There
    should be standby training centers and a plan to quickly recruit
    community leaders as soon as the EOC is activated. There should be an
    explicit understanding about how to compensate and insure the
    volunteers, and information about what is expected of them so they can
    decide very rapidly whether to sign up. Countries should commit to
    manage a pool of volunteers and send a certain number of people with
    various skills and equipment within a week of an emergency, with plans
    for evacuating them if they are exposed. We should also leverage the
    talent at schools of public health around the world. The earliest
    people to go in should be surveillance experts, logistics experts, and
    clinical staff. Finally, countries should have plans in place for
    supporting volunteers when they come back. In this epidemic, returning
    health workers have lost their jobs and experienced discrimination,
    which may have made others reluctant to sign up.
                          transportation and equipment
        When an epidemic strikes, transportation will be a critical
    problem. Roads and airports in affected areas will be overwhelmed by
    swarms of people trying to get out. Volunteers will be more likely to
    sign up if they know they will be able to get out when their duty is
    done or if they get sick.
        There are very few organizations in the world that can move
    thousands of people to different locations on the globe with a week's
    notice--especially given that, in an epidemic, some of the transport
    needs onboard isolation so that passengers can't infect each other or
    the crew. The United Nations has to borrow transportation equipment to
    support its military missions. The World Food Programme can move people
    and food during a famine but has nowhere near enough capacity for an
    epidemic.
        The Ebola epidemic might have been a lot worse if the U.S. and U.K.
    Governments had not used military resources to help build health
    centers, manage logistics, and fly people in and out of the affected
    countries. The militaries also provided command and control capacity to
    help organize the different groups working on Ebola. It is fortunate
    that they were not too busy with other emergencies to help out, and
    that the Ebola epidemic is happening in countries that are open to
    working with them. We should not assume that this will always be the
    case.
        The world should identify trained military resources that will be
    available for epidemics. In a severe case, almost every middle-income
    and rich-world military would have to come together with their
    resources. Countries might hesitate to deploy resources abroad that
    might be needed at home, which could create a paradox where the world
    allows an epidemic to spread from the primary sites and reach lots of
    countries.
        Transportation is not the only critical resource. Severe epidemics
    also require tents, protective suits, bleach, portable power sources,
    portable air conditioning, medical supplies, and more. We should have a
    list of supplies needed to stop an epidemic that reaches 10 million
    people, which would be 100 times what we experienced in the Ebola
    epidemic. Because face masks, protection suits, medical tents, and
    other medical supplies could see extreme demand, there should be an
    analysis of which items need to be stockpiled or subject to being
    commandeered so we don't run out. Militaries and agencies that deal
    with humanitarian crises stockpile items like these for natural
    disasters and refugee crises, and they should get support for expanding
    their supplies to what is needed for epidemics.
        I have experience with one item that--although it wasn't critical--
    shows how unclear the decisionmaking process is. By early September, it
    was apparent that health workers in protective suits would get so hot
    that it was difficult for them to care for their patients. I asked a
    group of people who work for me on technology for keeping vaccines cold
    to refocus on keeping the medical workers cool. Within days, they had
    found existing commercial and military technology that could help. But
    there was no unified mechanism for getting this equipment to the
    treatment centers. The team had to create new distribution channels by
    working directly with local treatment centers and organizations like
    Partners in Health and MSF. I am not saying this was a critical issue,
    but it illustrates how there was no coordinated process for getting new
    equipment designed and distributed to the people who need it.
                                  data systems
        Given all of the actors involved in an epidemic and the importance
    of allocating resources quickly and efficiently, it is critically
    important to have good data about what's going on. Unfortunately during
    the Ebola epidemic, the case database has not always been accurate or
    up to date. Some of this is because of the chaos of the situation, but
    it is also because there isn't good technology and training available
    or clear rules about making the data accessible.
        Today the default is that countries must sign off on making data
    about their citizens available, but because that process is unclear, it
    happens slowly or not at all. For future epidemics it should be
    possible to have a system to digitally enter information like suspected
    cases, locations, survivors, etc. into a database that is instantly
    accessible to organizations engaged in the response and the agencies
    coordinating their work. The rationale for not waiting for each country
    to release the information is clear: An accessible database would be a
    critical global public good. The groups that work on the Ebola data--
    including WHO, the CDC, and others--could write up a specification or
    revise the International Health Regulations for what we need next time.
    Based on what we've learned with Ebola and polio, I think some
    combination of foundations and technology companies can find the
    resources to make sure a robust system, including the training
    materials and back-end systems, comes together within the year.
        Experts will also need computer models to predict what might happen
    and which interventions should be prioritized. The ideal is to have
    multiple strong modeling groups who can focus full-time attention on an
    outbreak. They should have access to satellite photography and analysis
    so they can understand how people are moving in the region. And with
    appropriate privacy safeguards in place, cell phone records can help
    modelers understand population counts, social connections, and
    movement.
        If the data systems are going to work, we also need to improve
    Internet and cell phone connectivity. During the Ebola crisis, there
    has been a lot of discussion about enhancing the Internet and cell
    phone networks in the affected areas, but there was far too little
    progress. As a result, much of the case reporting has been done on
    paper and then sent to a central location for data entry. We should be
    able to use cell phone systems to get messages out to everyone and to
    poll people about what they are seeing. Key centers should have high-
    bandwidth Internet capacity via satellite, and wi-fi capacity should be
    added in key areas so that digital tools can help with reporting data
    and coordinating personnel. Rapidly deployable systems should be
    available to quickly increase capacity in crisis areas.
                                 medical tools
        Among the pathogens we know about, flu is the most likely to cause
    a big epidemic. But we could also encounter one we have never seen
    before. In 2003, for example, no scientist had seen SARS. That year it
    infected some 8,000 people and killed 800.
        Making sure that prophylactics and treatments are available for key
    personnel (police, health workers, pilots, etc.) and volunteers could
    make a gigantic difference in stopping an epidemic and limiting the
    damage it does. The good news is that there is a lot of scientific work
    that can be done that is not specific to a particular pathogen and
    enables faster response to a wide variety of infectious agents. It
    should be possible to have general capabilities to make diagnostic
    tests as well as drugs, and vaccine platforms that could be adapted for
    use against various pathogens. Today, with the possible exception of
    flu, we do not have nearly enough capacity to do this.
        One problem is a lack of incentives. Pharmaceutical companies and
    others in the private sector face an opportunity cost in shifting
    resources (including their researchers) away from more commercially
    viable projects to work on drugs or vaccines for epidemics that may not
    happen. Their work represents a kind of insurance policy against the
    next epidemic, and there may need to be an international system for
    funding it that factors in these opportunity costs.
        There are three key areas of medical tools that will be important
    for the next epidemic: diagnostic tests, therapeutics, and vaccines.
                                diagnostic tests
        When a new epidemic breaks out, one of the most urgent tasks is to
    obtain and analyze biological samples--including blood, saliva, nasal
    swab, and stool--to determine what is causing the disease. Those
    samples start the process of figuring out how to make diagnostic tests,
    drugs, and vaccines. The samples will be tested, the pathogens
    sequenced, and all of that data should be immediately published
    digitally for the world's scientists to study. Fairly quickly it should
    be possible to see the signature of the disease and determine whether
    the pathogen is a virus, bacterium, or something else.
        It's extremely important to have an accurate diagnostic test that
    can determine whether someone is infected. The ideal test, which is
    being developed, will be one where you take a sample and get a
    definitive result within 20 minutes. People who are infected can be
    sent to treatment centers so they are isolated from the uninfected. If
    getting results takes more than a day--because the testing capacity is
    overloaded, or the transport of the sample to the testing service is
    slow, or the test process itself takes a lot of time--then holding
    people while you wait to get the answer is very difficult.
        Other than watching for symptoms (which are a clinical diagnostic
    test, albeit a bit late), most of the diagnosis during this Ebola
    epidemic has been done by taking a blood sample and sending it off for
    quantitative polymerase chain reaction (qPCR) analysis. Availability of
    these expensive qPCR machines is limited and centralized, so on average
    it has taken one to three days for test results to come back after a
    sample is collected and sent out. For the next epidemic, we should make
    sure adequate qPCR machine are made available or mobilized in the first
    few weeks (with trained technicians and supplies), while novel
    diagnostic methods are rapidly developed. A number of diagnostic
    companies have technologies that are cheaper, more portable, and faster
    and requires less expertise than qPCR. When you move to a new format,
    though, you have to be sure that the biomarker and your sensitivity to
    that marker are not compromised--otherwise you could miss early disease
    and allow infected people to be identified as uninfected.
        In the future there should be a clear process for taking the
    information about disease signature and then developing and
    manufacturing accurate diagnostic tests very rapidly. A focused effort
    to accelerate this process and establish a rapid approval and
    procurement process would be worthwhile. The science of bio-diagnostics
    is advancing rapidly, so there is a good chance that a proven test
    could be produced at scale within weeks of an outbreak.
             therapeutics: antivirals, antibodies, rna, transfusion
        It is hard to overstate the value of having a drug that reduces the
    duration and degree of infectiousness and saves lives. Infected people
    are more likely to come to a treatment center if doing so will increase
    their odds of surviving, rather than just preventing them from
    infecting others. Survivors from the treatment center would likely be
    immune from getting sick again, so they could go back to the affected
    regions to help inform people about the importance of seeking
    treatment.
        There are drugs that work against viruses that are similar to
    Ebola, and in various test assays, a number of them show an effect
    against Ebola. Unfortunately, they were not tested in Ebola patients
    until after the peak of the epidemic. This was partly because there
    wasn't a clear decision process to approve a novel trial format and to
    provide indemnity against legal liability. The role of the local
    governments relative to the global actors remains unclear, but it is
    not hard to imagine local authorities being inundated with suggested
    therapies, as happened with this epidemic. There should be a clear set
    of guidelines (and testing and regulatory pathways) for figuring out
    whether existing drugs could be re-purposed to help stop a particular
    epidemic. This testing should be carried out as soon as possible--we
    can fill the pipeline now with the best options so they are ready to be
    used in a future outbreak.
        We also need to invest in more research on antiviral drugs and have
    either stockpiles or rapid manufacturing capacity for those that might
    be effective in an epidemic. The search for drugs against HIV, which
    started in the 1980s, has contributed a lot to the field of antiviral
    drugs. The number of antiviral drugs that perform well against HIV is
    quite impressive. Since the next epidemic will probably be caused by a
    virus, general work on broad-spectrum antiviral drugs is a global
    public good that needs more research than is being done.
        There is a special class of therapies that are based on antibodies.
    For example, Zmapp was specifically designed for treating Ebola
    patients. This is another intervention that was given to many of the
    patients who were treated in the United States and Europe, but it was
    not made in sufficient volume quickly enough to help in Africa.
        Because of the small number of treated patients and lack of an
    adequate control group, we don't know which interventions were key to
    the higher survival rates in the United States and Europe. Still, the
    evidence suggests that antibody-based approaches will probably be
    valuable for the next epidemic. We need to improve our ability to
    design an antibody against a new pathogen and make sure that it is
    applied along with new rapid manufacturing techniques and a clear
    regulatory pathway to maximize the chance of success. Manufacturing
    capacity for making antibodies at scale will have to be set aside or
    subject to being commandeered during an epidemic. We should also
    leverage approaches like adeno-associated virus (AAV) vectors, which
    use a harmless virus as a backbone to explore generating robust
    antibody levels.
        Another special class of drugs involves giving patients a set of
    particular RNA-based constructs that enables them to produce specific
    proteins (including antibodies). Although this is a very new area, it
    is promising because it is possible that a safe therapy could be
    designed and put into large-scale manufacture fairly rapidly. More
    basic research as well as the progress of companies like Moderna and
    CureVac could eventually make this approach a key tool for stopping
    epidemics.
        There is one approach that should have been applied for this Ebola
    epidemic, but it wasn't approved and scaled up until it was too late to
    have a large impact. It involves taking the blood of survivors,
    extracting the plasma from it (plasmapheresis), and giving the plasma--
    or the immunologically potent parts of it--to people who have early
    symptoms of disease or who are at high risk of contracting it.
    Depending on the disease, a single survivor should be able to provide
    protection for at least one person every 2 weeks.
        This process is quite effective for a number of diseases. It was
    very effective with smallpox and viral hemorrhagic fevers, including
    treating a patient in the United States who had Lassa fever in 1969. It
    has a reasonable chance of working for Ebola as well. It was used to
    treat 8 patients during an Ebola outbreak in Zaire in 1995, but because
    it wasn't done as an organized trial, we don't know for sure whether it
    worked. Subsequent animal experiments had mixed results.
        The Gates Foundation started working to get plasmapheresis units
    going in early September and quickly found partners with equipment
    ready to take it into the affected countries. Unfortunately, the effort
    was hampered because there was no clear process for approving new
    approaches, or for exporting plasma to other countries to be processed
    and then getting it back to the patients who needed it. By the end of
    2014, only a few patients in West Africa had been treated with
    convalescent plasma, which means the sample size is too small to
    determine whether it was effective. (This treatment was given to some
    of the Ebola patients who were lucky enough to be treated in rich
    countries.)
        For future epidemics, there need to be rules in advance for all
    medical interventions and a clear assignment of responsibility for
    approving studies and treatments, including experimental ones. One of
    the critical elements would be to obtain specimens (e.g., blood) from
    infected individuals to isolate samples of the pathogen and also to
    fish out high-affinity antibodies. Then we should be able to quickly
    leverage the sequence information of the antibodies to test novel
    approaches and determine what might work quickly and be safe. A Global
    Epidemic Drug Approval process could avoid long delays by indemnifying
    companies working on new approaches and enabling decisionmaking around
    ``permission to use'' of investigational medical products.
        For transfusion in particular, there needs to be ample equipment
    easily available, as well as a process for quickly getting donor plasma
    to facilities for processing and then returning the finished product to
    the affected populations. There is a good chance that the plasma
    transfusion could work as a therapeutic and have a dual impact on the
    potential disease as well as empower local populations to engage in the
    outbreak responses.
                                    vaccines
        Three different Ebola vaccine constructs were being developed in
    the summer of 2014, but all were in early stages and had not reached
    Phase 1 safety testing. The normal process for going from Phase 1 to
    full approval for sale and use would have taken at least another 5
    years. Even the accelerated process adopted for the epidemic will
    require more than 9 months. Ironically, by the time of the final phase
    of testing--which measures effectiveness in a large population--there
    will likely be too few people still being exposed to Ebola virus to
    know reliably how effective these vaccines are.
        Because of this early work, we were more prepared for Ebola virus
    than we would be for a new pathogen. If the pathogen hasn't been seen
    before, at least another year of work would probably be needed. And the
    issues of how quickly to move and who should finance the final research
    and the manufacturing are not as clear as they should be.
        With the seasonal flu, we know how to make vaccines against
    specific antigenic forms of the virus, but even the relatively minor
    season-to-season variations are significant enough that we have to
    design a new vaccine each year. When a very different antigenic variant
    like H1N1 (the swine flu of 2009) comes along, there is no clear
    process for getting resources applied to creating a new vaccine. In
    fact, after the swine flu scare--where WHO worked with pharmaceutical
    companies to create and buy a stockpile of vaccines--some people
    criticized WHO for doing too much, a stark contrast with the complaints
    that it did too little on Ebola. Given that flu is the most likely
    single known pathogen to cause a large epidemic and that even the
    seasonal variations likely cause several hundred thousand excess deaths
    each year, it is disappointing that we don't have a vaccine that works
    on all variants of flu. There is work being done toward this goal, but
    with nowhere near the resources that it deserves.
        I have a bias towards vaccine research because of the impact I see
    from vaccines in the Gates Foundation's work on preventing disease.
    Many of the same legal and regulatory barriers that slow down the
    approval of therapeutics also apply to vaccine candidates. We should
    establish clear guidelines to avoid these hurdles during emergencies.
    The ideal would be to fund vaccine research so that a vaccine can be
    designed, tested for safety, and ready for manufacture in large volumes
    in a matter of a few months. There is no guarantee of success, but
    given enough time--probably no more than a decade--and enough
    resources, I think this effort could produce an invaluable contribution
    to both promoting overall health and preventing epidemics.
                      quarantine and communications plans
        During the Ebola epidemic there was a lot of discussion about
    quarantine. Should commercial flights into and out of the affected
    countries be stopped? Should people returning from the affected region
    be forced into quarantine? For this epidemic, given the limited
    infectiousness of Ebola in the early stages of the disease, most of
    these proposals would have been counterproductive. Banning travel from
    affected areas to the United States, for example, would have forced
    people to take an indirect route, making them harder to track once they
    arrived. Forcing people into quarantine would have discouraged
    volunteers from working in the affected countries. Basic monitoring
    procedures were adequate to determine whether patients were developing
    Ebola and get them into isolation before they infected others.
        But when a far more infectious agent comes along, quarantine will
    be one of the few tactics in the early stage of the disease that can
    reduce the spread of contagion. Travel today is so common that an
    infection can spread across the globe far faster now than in 1918, when
    the Spanish flu epidemic swept across the world. During the SARS
    epidemic, China eventually did a good job of curtailing travel and
    public gatherings in affected areas. I doubt every country would have
    handled this aspect as well as China did, because in normal situations
    the system is designed to avoid abridging individual rights to travel
    and assemble freely. I worry that in the early stages of an epidemic,
    democratic countries might be too slow to restrict activities that help
    spread the contagion.
        Part of the process should include a plan for effective public
    communications. There will be lot of panic and thirst for information
    when the epidemic hits. Many people will be tempted to tie up health
    and transport assets when they should not. Well-designed quarantine
    plans need to be part of an overall outreach plan that coordinates all
    the different voices people will hear: governments, U.N. agencies, news
    media, bloggers, etc. The ways that people communicate digitally can be
    used to great advantage, but unless a plan is in place ahead of time,
    they will just spread confusion and panic faster than in the past--
    perhaps at the cost of many lives.
                                  bioterrorism
        I chose to focus this essay on the lessons from a natural epidemic.
    But an epidemic could also be engineered intentionally. As biological
    science and technology advances, it is getting easier to create (or re-
    create) pathogens with only modest effort and technical knowledge. Over
    the next few decades it will be even more feasible to synthesize, mass-
    produce, and disseminate pathogens that are highly infectious and
    largely fatal. (Because Ebola doesn't spread very effectively, it would
    not make a highly effective bioterror weapon.) Everything I have
    described in this essay would also be worthwhile in preparing for
    bioterrorism. Nathan Myhrvold discusses these challenges in his essay
    on strategic bioterrorism, which I highly recommend--although it is
    sobering to read.
                            a global call to action
        The world spends a great deal of money--hundreds of billions of
    dollars a year--getting ready for war. I am not saying this is a
    mistake, but given that an epidemic is more likely to kill millions of
    people than a future war, I believe we should build on these efforts so
    we can be more prepared for a severe epidemic. Some of the
    capabilities, like transport and some personnel, overlap and can play a
    dual purpose if properly planned. Other elements, like research on
    diagnostic tests, vaccines, and treatments, will require specific
    investments.
        A serious epidemic would also raise a lot of questions about global
    governance. What body would bring sovereign nations together and ask
    them to make decisions about limiting travel and allocating scarce
    resources like vaccines or drugs? All of the epidemics we have seen so
    far have shown that we desperately need processes for making tough
    decisions fast.
        One technique that we should borrow from the military is the idea
    of a war game. Once we have taken action on the basics, countries
    should come together every few years to simulate different types of
    epidemics so they can understand what is missing from the response.
        I worry that many people do not think a serious epidemic is a
    problem for them to worry about. They may think that the United Nations
    system, and especially WHO, has it covered. In fact, WHO has not been
    clearly chartered or funded to handle most of the things required in an
    epidemic. Or they may think their government has a plan already in
    place. While the United States, the United Kingdom, and others are
    working on many of the things described in this memo, there are still
    big holes in the world's ability to respond.
        There should be a rigorous study of the cost of building a global
    warning and response system for epidemics, including greater
    investments in research and development, preparing military resources
    for epidemic response, and maintaining a reserve of paid responders who
    go through regular training exercises. There would need to be a plan
    for how much each country would contribute and for coordinating the
    spending so it is used effectively. I think other countries need to
    step up, but they are more likely to do so when they see an overall
    plan and understand their role in it. Rich, technically advanced
    countries should invest far more in the key research and manufacturing
    capacities than they do today. Most of the others can contribute to the
    crucial surveillance work.
        Through the United Nations, some global institution needs to be
    empowered and funded to coordinate a global warning and response
    system--including systems for sharing data, managing personnel, setting
    an R&D agenda, and other key areas. At the request of WHO's Executive
    Board, Director-General Margaret Chan is evaluating the organization's
    response to the recent Ebola outbreak. U.N. Secretary-General Ban Ki-
    moon is commissioning a high-level panel to recommend ways to improve
    international crisis management, with a special focus on health based
    on the lessons learned from the Ebola response. These evaluations would
    be a good place to start a much-needed conversation about how to
    strengthen WHO's capacity and about which pieces it should lead and
    which should be led by others (including the World Bank and G7) in
    close coordination with it. The conversation should include military
    alliances such as NATO, which should make epidemic response a priority
    when they are designing strategies, training troops, and buying
    equipment. The final arrangement should include a reserve corps of
    experts with the broad range of skills needed in an epidemic.
        In my view, an epidemic is one of the few catastrophes that could
    set the world back in a huge way in the next few decades. Severe
    epidemics have struck many times in the past, and they are only more
    likely as the world becomes more closely connected. By building a
    global warning and response system, we can prepare for the next
    epidemic and avoid millions of deaths.
                                recommendations
        The world needs to build a warning and response system for
    outbreaks. This system should:
      --Be coordinated by a global institution that is given enough
            authority and funding to be effective.
      --Enable fast decisionmaking at a global level.
      --Expand investment in research and development and clarify
            regulatory pathways for developing new tools and approaches.
      --Improve early warning and detection systems, including scalable
            everyday systems that can be expanded during an epidemic.
      --Establish a reserve corps of trained personnel and volunteers.
      --Strengthen health systems in low- and middle-income countries.
      --Incorporate preparedness exercises to identify areas for
            improvement.
                                     ______

                    [From the New York Times, Mar. 18, 2015]

                         HOW TO FIGHT THE NEXT EPIDEMIC

       The Ebola Crisis Was Terrible. But Next Time Could Be Much Worse.

                                (By Bill Gates)

        Seattle.--The Ebola epidemic in West Africa has killed more than
    10,000 people. If anything good can come from this continuing tragedy,
    it is that Ebola can awaken the world to a sobering fact: We are simply
    not prepared to deal with a global epidemic.
        Of all the things that could kill more than 10 million people
    around the world in the coming years, by far the most likely is an
    epidemic. But it almost certainly won't be Ebola. As awful as it is,
    Ebola spreads only through physical contact, and by the time patients
    can infect other people, they are already showing symptoms of the
    disease, which makes them relatively easy to identify.
        Other diseases--flu, for example--spread through the air, and
    people can be infectious before they feel sick, which means that one
    person can infect many strangers just by going to a public place. We've
    seen it happen before, with horrific results: In 1918, the Spanish flu
    killed more than 30 million people. Imagine what it could do in today's
    highly mobile world.
        Much of the public discussion about the world's response to Ebola
    has focused on whether the World Health Organization, the Centers for
    Disease Control and Prevention and other groups could have responded
    more effectively. These are worthwhile questions, but they miss the
    larger point. The problem isn't so much that the system didn't work
    well enough. The problem is that we hardly have a system at all.
        To begin with, most poor countries, where a natural epidemic is
    most likely to start, have no systematic disease surveillance in place.
    Even once the Ebola crisis was recognized last year, there were no
    resources to effectively map where cases occurred, or to use people's
    travel patterns to predict where the disease might go next.
        Then, once it became clear that a serious emergency was underway,
    trained personnel should have flooded the affected countries within
    days. Instead it took months. Doctors Without Borders deserves a lot of
    credit for mobilizing volunteers faster than any government did. But we
    should not count on nonprofit groups to mount a global response.
        Even if we signed up lots of experts and volunteers right away,
    it's not clear how we would deploy them quickly into the affected area,
    or how we would transport patients. Few organizations are capable of
    moving thousands of people, some of them infected, to different
    locations on the globe with a week's notice.
        The Ebola epidemic might have been a lot worse if the United
    States, Britain and other governments had not used military resources
    to fly people and equipment into and out of affected areas. But we
    should not assume that the next epidemic will limit itself to countries
    that welcome Western troops.
        Data is another crucial problem. During the Ebola epidemic, the
    database that tracks cases has not always been accurate. This is partly
    because the situation is so chaotic, but also because much of the case
    reporting has been done on paper and then sent to a central location
    for data entry.
        Then there's our failure to invest in effective medical tools like
    diagnostic tests, drugs and vaccines. On average it has taken an
    estimated 1 to 3 days for Ebola test results to come back--an eternity
    when you need to quarantine people until you know whether they're
    infected. Drugs that might help stop Ebola were not tested in patients
    until after the epidemic had peaked, partly because the world has no
    clear process for expediting drug approvals.
        Compare all this to the preparation that nations put into defense.
    Armies have systems for recruiting, training and equipping soldiers.
    NATO has a mobile unit that is ready to deploy quickly. Although the
    system isn't perfect, NATO members do joint exercises where they work
    out logistics like how troops will get food and what language they will
    use to communicate.
        Few if any of these approaches exist for an epidemic response. The
    world does not fund any organization (not even the W.H.O.) to
    coordinate all the activities needed to stop an epidemic. In short, in
    a battle against a severe epidemic, we would be taking a knife to a
    bazooka fight.
        I believe that we can solve this problem, just as we've solved many
    others--with ingenuity and innovation.
        We need a global warning and response system for outbreaks. It
    would start with strengthening poor countries' health systems. For
    example, when you build a clinic to deliver primary healthcare, you're
    also creating part of the infrastructure for fighting epidemics.
    Trained healthcare workers not only deliver vaccines; they can also
    monitor disease patterns, serving as part of the early warning systems
    that will alert the world to potential outbreaks. Some of the personnel
    who were in Nigeria to fight polio were redeployed to work on Ebola--
    and that country was able to contain the disease very quickly.
        We also need to invest in disease surveillance. We need a case
    database that is instantly accessible to the relevant organizations,
    with rules requiring countries to share their information. We need
    lists of trained personnel, from local leaders to global experts,
    prepared to deal with an epidemic immediately. We need trained military
    resources ready to respond, and a list of supplies to be stockpiled or
    commandeered in an emergency.
        Finally, we need to invest far more in research on drugs, vaccines
    and diagnostic tests, and make it possible to accelerate the approval
    of new approaches in times of crisis.
        The United Nations should empower and fund a global institution to
    coordinate these efforts. The United Nations and the W.H.O. are
    studying the lessons of this epidemic; their evaluations would be a
    good starting point for a conversation about how to strengthen the
    W.H.O. and what pieces of the system it should lead.
        I have not seen a rigorous projection for what a system like this
    would cost. But we know the cost of failing to act. According to the
    World Bank, a worldwide flu epidemic would reduce global wealth by $3
    trillion, not to mention the immeasurable misery caused by millions of
    deaths. Preventing such a catastrophe is well worth the world's time
    and attention.

        Bill Gates is co-chairman of the Bill & Melinda Gates Foundation.