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

             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) 
    Present: Senators Graham, Blunt, Boozman, Moran, Daines, 
Leahy, Coons, Merkley, and Murphy.


            FREE AFRICA
            AT NATO, 2009-2013, AND CO-CHAIR, U.S. GLOBAL LEADERSHIP 

    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.


    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 
    So thank you all. We look forward to hearing your 
    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.


    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 

    [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 

    Senator Graham. Thank you.
    Mr. 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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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 
    [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 
    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 
    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 
    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 
    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 
    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 
    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 
    Mr. Affleck. Absolutely. You protect our ability to make 
those investments. You make people confident about making 
    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.


    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.


    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.


    Mr. Megrue, I was struck by your testimony as well as being 
a voice for the voiceless, these babies that are now being born 
    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.


    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 


    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 
    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 
    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.


    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 
    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-
    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 
    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 


    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 
    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 
    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.


    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 
    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-
    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 
    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 
    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 
    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 
    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.
    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 
    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.
    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 
    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 
    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.]


    [Clerk's note: The following material was submitted by Bill 
Gates and the Bill & Melinda Gates Foundation to be included in 
the hearing record.]

        [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 
    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 
    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 
    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 
    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 
    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.
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.
    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.
    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 
    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.
    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 

                [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.