[Senate Hearing 114-143]
[From the U.S. Government Publishing Office]
STATE, FOREIGN OPERATIONS, AND RELATED
PROGRAMS APPROPRIATIONS FOR FISCAL
YEAR 2016
----------
THURSDAY, MARCH 26, 2015
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:05 a.m., in room SD-192, Dirksen
Senate Office Building, Hon. Lindsey Graham (chairman)
presiding.
Present: Senators Graham, Blunt, Boozman, Moran, Daines,
Leahy, Coons, Merkley, and Murphy.
DIPLOMACY, DEVELOPMENT, AND NATIONAL SECURITY
STATEMENTS OF:
BILL GATES, CO-CHAIR, THE BILL & MELINDA GATES FOUNDATION
BEN AFFLECK, ACTOR, FILMMAKER, AND FOUNDER OF EASTERN CONGO
INITIATIVE
JOHN MEGRUE, CHAIRMAN, APAX PARTNERS U.S. AND CHAIRMAN OF BORN
FREE AFRICA
ADMIRAL JAMES STAVRIDIS, USN, RETIRED, SUPREME ALLIED COMMANDER
AT NATO, 2009-2013, AND CO-CHAIR, U.S. GLOBAL LEADERSHIP
COALITION NATIONAL SECURITY ADVISORY COUNCIL
SCOTT FORD, CHIEF EXECUTIVE OFFICER, WESTROCK GROUP, LLC, AND
FORMER CHIEF EXECUTIVE OFFICER, ALLTEL CORPORATION
OPENING STATEMENT OF SENATOR LINDSEY GRAHAM
Senator Graham. The subcommittee will come to order.
Our hearing today is on Diplomacy, Development, and
National Security, and we have an incredible panel of great
Americans in their own way. Balancing the schedules of these
gentlemen had to be very difficult, and each and every one of
you made a sacrifice to be here. You had other places you could
go and probably needed to go, but the fact you would come here
and share your testimony, your experiences, your thoughts and
opinions about the 150 account means a great deal to Senator
Leahy and myself.
As to Senator Leahy, we have been partners here for several
years on this account. I have thoroughly enjoyed working with
him and Tim Rieser, and this is one area of the Government that
we are trying to make sure actually works. Our relationship has
grown over time, and we are both committed to making sure that
America stays involved in the world in a productive fashion.
Our panel today consists of Mr. Bill Gates, Co-chairman of
the Bill & Melinda Gates Foundation; founder of Microsoft. Ben
Affleck, an actor, filmmaker, and founder of the Eastern Congo
Initiative, which I visited, and you are doing great work in a
very troubled area of the world. John Megrue is Chairman of the
Apax Partners U.S. and Chairman of Born Free Africa and has
been working with the United Nations particularly dealing with
the mother-to-child AIDS transmissions. Thank you very much,
John. Admiral Stavridis is the former North Atlantic Treaty
Organization (NATO) Commander, is now the Dean at the Fletcher
School of Law and Diplomacy at Tufts University. He wore the
uniform for many years, many decades, and I really look forward
to your view as a military commander about this account. And
Scott Ford is the Chief Executive Officer of Westrock Group and
former Chief Executive Officer of Alltel. And I have had the
pleasure to see what Scott has been able to do in Rwanda
regarding the coffee market.
So all of you are welcome, and I will let the first
statement be by Senator Leahy, if he would like.
STATEMENT OF SENATOR PATRICK J. LEAHY
Senator Leahy. Well, thank you, Mr. Chairman. I think what
is probably the most important is that we hear from the people
who are here.
We talk about diplomacy, development, and national
security. That is really relevant, probably any time since
World War II. We know that there are limits to what our
military can do. And, Admiral, I am delighted you are here. We
discussed this before. We have this huge economic and military
power, but we ought to be showing the rest of the world some of
the best parts of us. I talked with Mr. Gates earlier. When
Senator Graham and I told our colleagues that they ought to
pony up on money on infectious diseases, a country of 320
million Americans ought to be able to at least match what Bill
and Melinda Gates were doing.
But also we know that we have some problems with
development, with funding large contractors and non-
governmental organizations (NGO's) that might make a lot of
money for the ones putting it together, but I am worried that
we do not see what we want to see.
And I think that with the cuts in the House and Senate
budget, we are going to have difficulties. I think we have to
look at what actually makes life better for the people we are
dealing with, but also for our own country. I like going into a
small country and we find that one of our programs is actually
about the only medical team that has ever been there, or the
areas where we worked on land mines, or the school that now has
books. Instead of one book, they have a book for everybody.
These are the things that show what is best in America; a lot
more than some of these huge things.
But I have worked with Senator Graham over the years. Part
of the time, he has been chairman; part of the time, I have
been chairman. We try to make this as non-partisan a bill as
possible, and we will continue to do that. He is a good friend.
He understands this program as well as any Member of the
Senate, either party that I serve with.
Senator Graham. Thank you, Mr. Chairman.
Very briefly, contrary to popular opinion, the foreign
assistance account is 1 percent of the Federal budget. You can
eliminate every penny we spend and not even move the debt
needle 1 inch. So to those who constantly demagogue foreign aid
as being the root of our financial problems, please stop
because you do not know what the hell you are talking about.
This account is designed to show who we are as a Nation. It
is designed to enhance our national security. It is designed to
deal with enemies of mankind such as radical Islam, AIDS,
malaria, and a lot of other disease, poverty. It is designed to
build people up so that we can live in peace with them, they
can have a better life, and make the world a safer place. It is
designed to have an American presence that is nonlethal. You
cannot protect America by just dropping bombs on people.
This account in many ways is the best line of defense in
terms of Africa. We do not have a large military presence in
Africa, but in a bipartisan fashion, we have had developmental
programs fighting AIDS and malaria, trying to resolve conflicts
in Africa. And this account has been the front line.
The return on investment on behalf of the American taxpayer
from this account--I will match it with any place in the
budget. I have never seen what a small amount of money can do
in a positive way better than here. It is $50-something billion
and that is a lot of money, but in the budget it is a rounding
error. The amount of money we have appropriated each and every
year is leveraged by the private sector, and each one of you
come from the private sector. In partnership with your
Government, non-governmental organizations, faith-based
organizations, the Gates Foundation, you just name it--we have
created partnerships that every American I think should be
proud of.
And the day that we stop doing what this account
represents, our best days are behind us. We will have chosen a
path that no generation of Americans have ever chosen before,
one of indifference, one of isolationism, one of we are not
really responsible or the leading voice in the world. We are.
And this account represents that philosophy. It is a good
investment on behalf of the taxpayer. What you have received in
rates of return you cannot measure: an entire generation of
young African children being saved from the scourge of AIDS,
turning the corner on malaria. In the Congo, what Mr. Affleck
has done in cooperation with NGO's and the government is to
take hell on earth and make it a bit better. And to Mr. Ford,
what you have proven the private sector can do is just
astounding.
So thank you all. We look forward to hearing your
testimony.
As we speak today, there will be a vote on the floor of the
United States Senate where a Member of the Senate is chosen to
reduce this account by 50 percent and give that money to the
military. Here is what I would say on behalf of the military.
They do not want this money. They want this account to survive
and thrive.
General Mattis told me probably the best explanation of how
this account plays in the world as it is. He said, Senator, if
you do away with the 150 account, if we withdraw from the world
and these programs go away, you better buy me more ammo. I
could not say it better myself.
So since Republicans are in charge, we are going to start
from the right with Mr. Gates.
SUMMARY STATEMENT OF BILL GATES
Mr. Gates. Good morning, Mr. Chairman, Senator Leahy, and
other members of the subcommittee. Thank you for the
opportunity to talk with you about the importance of U.S.
foreign assistance.
Melinda and I, in writing our annual letter for the
foundation, talked about what great things can happen if the
United States and other countries maintain the generosity that
they have had through this account. Over the next 15 years,
there are some amazing things that can be achieved.
If we go back to 1960, we had a very dire situation. One
child in five died before their fifth birthday. Twenty-five
years ago, by 1990, that rate was down to 1 in 10, and since
then it has been cut in half again to 1 in 20. With the right
investments over the next 15 years, we will be able to cut it
in half again to 1 in 40. That is a faster improvement than we
have ever seen in the past.
And there are many U.S. programs that are absolutely
central to this decline in child mortality and to other gains
in health and development worldwide.
One specific program that makes a huge difference is the
Global Alliance for Vaccines and Immunization (GAVI), the
vaccine alliance. This public-private partnership creates a
market for companies to develop vaccines that protect children
in poor countries against the most common causes of death and
severe illness. As an American, I am proud that the United
States Government is one of GAVI's biggest donors. Since its
inception in the year 2000, GAVI has helped immunize close to
half a billion children and prevented over 7 million deaths. I
can assure you that the parents of those children would be glad
to vouch for the simple fact that vaccines are safe, vaccines
are effective, vaccines save lives.
Another great example of this is the fight against polio.
The number of countries where that disease is endemic has gone
from 125 in 1988 to just three today.
In this year's annual letter, Melinda and I predict that
Africa will be self-sufficient in food production within 15
years. Here too we are seeing great progress, much of it made
possible by U.S. assistance. The U.S. has a major impact in
improving agricultural productivity in poor countries through
USAID and USDA support for agricultural research in partnership
with our land grant universities.
In my written testimony, I discuss a number of U.S.
programs that are delivering high returns on investment and
having a positive impact for the global poor.
But there is another area where foreign assistance will
make a huge difference not only for the people of the world's
poorest nations but for the people of this Nation as well.
As you know, I tend to be optimistic about what the future
holds, but there are a small number of potentially catastrophic
events that could set back the progress of the past two
decades. The most plausible and most frightening of these
threats is a large epidemic. As I note in my recent New England
Journal of Medicine and New York Times articles, I am talking
about something bigger than the Ebola outbreak we have seen in
West Africa. Ebola is not a disease that spreads very easily.
What concerns me most is the prospect of an even more lethal
disease which is also highly contagious. We have seen outbreaks
like this in the past such as the flu pandemic of 1918 and 1919
which had a worldwide death toll of 30 million to 50 million.
Could an epidemic of this scale happen again? Yes, it could,
and in today's far more urbanized and interconnected world, it
would spread far more easily than a century ago.
I have come to Congress on other occasions to ask for the
sustainment of U.S. foreign assistance. I have grounded this
appeal in our shared moral interest in preventing needless
deaths and suffering and also in our economic and security
self-interest. With Ebola and the very real prospect of an even
more infectious disease, the case is now even clearer. I am
asking you to support foreign assistance programs not only as a
highly effective way to help other countries become more self-
sufficient, but also as a necessary means of protecting this
country from a future epidemic.
The sensible place to begin is with investments in basic
health services in those parts of the world that are most
susceptible to outbreaks of infectious disease. Whether we are
talking about preventing the next epidemic or building upon the
enormous global health gains of the past two decades, the time
to act is now. The need for foreign assistance remains strong,
and recent events demonstrate its urgency.
Thank you for inviting me to join you today. I look forward
to your questions.
[The statements follow:]
Prepared Statement of Bill Gates
Mr. Chairman, Senator Leahy, members of the subcommittee--thank you
for this opportunity to talk with you about an important subject: the
role of U.S. development assistance in helping people in the world's
poorest nations attain greater self-sufficiency.
In January, my wife Melinda and I put out our annual letter. In it,
we wrote about ``our big bet for the future''--that the lives of people
in poor countries will improve faster in the next 15 years than at any
other time in history.
In my brief time before you today, I'll make three basic points:
--First, that this ``big bet''--while ambitious--is indeed
attainable, based on the extraordinary progress that we've seen
in recent years.
--Second, that achieving further gains against extreme poverty and
disease in the world's poorest countries would have significant
benefits for the American people.
--And third, that these gains require sustained U.S. commitment to
overseas development assistance. Together with the leadership
and commitment of the countries in which we work, we can make
historic progress--right now--against extreme poverty and
disease.
I'll now touch on each of these points in turn.
First, the progress that the world has made against disease and extreme
poverty is truly extraordinary. It should leave no doubt that we now
have an opportunity for historic advances in the well-being of
humanity--particularly in poor countries.
The most important single measurement of progress in global health
is the child-mortality rate--and its trajectory has been astonishing to
watch.
Worldwide, in 1960 about one child in five died before his or her
fifth birthday.
By 1990--25 years ago--that rate had been cut in half, to 1 in 10.
Since then, it's been cut in half again, to 1 in 20.
We now have the tools to halve this rate yet again, to 1 in 40, and
to do it even faster--within 15 years.
What accounts for this?
One very important factor is the investment by governments around
the world in their own nations' health and development. But that's not
the only factor at work here.
Global economic growth; changes in trade policy; and the spread of
new technologies have all contributed to fundamental improvements in
human health and well-being.
But there's another indispensable factor: overseas development
assistance, notably from the United States.
Working with other national governments and donor partners, U.S.
Government investments have contributed to these amazing declines in
child mortality--and to other gains in health and development
worldwide.
I'll mention just a few specific examples of U.S.-supported
programs that have made an enormous difference.
One of these is Gavi, the Vaccine Alliance. This is a public-
private partnership that pools the demand for vaccines among the
world's poorest nations. It then provides long-term financing through a
number of sources--including from the recipient nations themselves--to
meet that demand.
This creates a viable market for pharmaceutical and biotech
companies to develop vaccines, and increases healthy competition among
them. That, in turn, helps drive down prices for vaccines that protect
young children from the most common causes of death and severe
illness--including diarrhea, pneumonia, and measles.
It's a brilliant model, and a very effective one. Since its
inception in 2000, Gavi has helped immunize close to half a billion
children and prevented 7 million deaths.
I'm proud that our foundation is a contributor to Gavi--and, as an
American, I'm proud that this country is one of Gavi's biggest donor
nations.
At the Gavi replenishment conference in January, the organization
met its target amount of $7.5 billion. The U.S. made a generous pledge
of $1 billion to Gavi over 4 years, including fiscal year 2015.
The new replenishment round will allow Gavi to immunize another 300
million children and save the lives of 5 million to 6 million children.
And I can assure you, members of the subcommittee, that the parents
of those children would be glad to vouch for a simple fact: Vaccines
are safe; vaccines are effective; vaccines save lives.
Speaking of the life-saving power of vaccines, another great
example of progress and partnership has been the worldwide campaign
against polio. Here too, the policy choices of the U.S. Government have
been decisive.
The United States has been a strong supporter of the Global Polio
Eradication Initiative (GPEI)--the Centers for Disease Control and
Prevention was one of the original partners, along with Rotary
International, the WHO, and UNICEF.
Since 1985, the U.S. has provided more than $2 billion to GPEI. At
the time of the initial U.S. investment, eradicating polio seemed like
a fantasy--the disease was endemic in 125 countries around the world
and paralyzed about 350,000 people each year, mainly young children.
Less than three decades later, polio is endemic in only three
countries--Pakistan, Afghanistan, and Nigeria. Actually, we may soon be
down to two, since Nigeria had only a handful of cases in 2014 and may
be on the verge of eliminating the disease there. Worldwide, the number
of polio cases last year was less than 400.
The good news of the past couple decades even extends to some of
the most lethal infectious diseases, such as HIV/AIDS and malaria.
Since 2000, among children under five worldwide, deaths from AIDS
have declined by 50 percent, while deaths from malaria have gone down
80 percent.
For the world population as a whole, the global incidence of HIV
has gone down by 20 percent since its peak in the mid-1990s, and the
mortality rate for malaria has declined by 42 percent since 2000.
These significant gains would not have been possible without major
programs supported entirely or in part by the Government of the United
States: the President's Malaria Initiative, or PMI; the United States
President's Emergency Plan for AIDS Relief, or PEPFAR; and the Global
Fund to fight AIDS, Tuberculosis and Malaria--to which the U.S. is the
top donor.
In addition to historic gains against disease, we are seeing
progress in maternal, newborn, and child health. Investing in women and
children yields broad economic and social benefits that help build
prosperous communities and nations.
The U.S. has been a leader in the campaign to end preventable child
and maternal deaths--and worldwide, more women survive pregnancy and
childbirth than ever before.
As Melinda and I discuss in our annual letter, we believe that even
faster progress is possible--and necessary--over the next 15 years.
In this year's annual letter, Melinda and I also predict that
Africa will be self-sufficient in food production within 15 years.
This would be an enormously significant milestone. Experience shows
that the path for countries to escape poverty is almost always through
agricultural development--as it was for the United States itself.
Agriculture is also closely linked to nutrition and health. Every
year, undernutrition contributes to 3.1 million child deaths--45
percent of the worldwide total. It also costs low- and middle-income
countries up to 8 percent of their economic growth potential.
Since 1990, the world has seen a 37 percent drop in stunting as a
result of better nutrition. The U.S. helped improve nutrition levels
for more than 12.5 million children in developing countries last year.
The U.S. has a major impact in improving agricultural productivity
in poor nations through USAID and USDA support for agricultural
research, in partnership with our land-grant universities.
This research typically generates at least a 20:1 return on
investment. In developing countries, the returns are even greater.
And according to the World Bank, every dollar invested in
agriculture is twice as effective at reducing poverty as investments in
non-agricultural sectors.
Given that 70 percent of all people living in extreme poverty are
in rural areas, and most are engaged in farming, the renewed U.S.
commitment to agricultural development represents a very sensible,
cost-effective approach to reducing global poverty.
In 2013 alone, the Feed the Future initiative helped nearly 7
million farmers and food producers adopt new technologies and
management practices. It also supported nearly 91,000 female farmers in
homestead gardening--improving access to nutrient-dense foods;
increasing income for women and children; and helping families become
economically self-sufficient.
This brings me to the second of my three points: While the lives of
people in poor countries will improve more than anyone else's over the
next decade and a half, that improvement will have very positive
consequences for the people of the United States.
One reason for this is that the American people value the qualities
of self-sufficiency and independence--for ourselves and for other
people around the world. We want people in poorer countries to have the
tools to improve their own circumstances in a way that's sustainable
and lasting for them.
We don't want to see poor nations stay poor, or to remain dependent
on outside aid. We want them to be able to stand on their own two
feet--and that's exactly what the people of those countries want for
themselves.
When overseas development assistance is done right--as with the
programs I've cited today--this is exactly what happens.
We have seen this pattern play out across much of the world.
Several countries that were once major aid recipients--South Korea,
Brazil, Malaysia, Morocco, Botswana, to name a few--are now self-
sufficient, and some have even become donor countries themselves.
Several have become U.S. allies and partners, as well as export
markets for our farmers and manufacturers: Nigeria is the third-largest
U.S. wheat market; Angola is the fourth-largest broiler-meat market;
and Ghana ranks as one of the top 10 rice markets.
In short, it's in the interests of the American people to see more
and more countries complete this development cycle--to make the
transition from aid recipients to full participants in the
international system.
U.S. health and development assistance programs have been vitally
important in helping countries around the world make that transition.
This process is gaining momentum in many low-income nations today--
particularly in Sub-Saharan Africa.
But there's another major reason why progress on health and
economic development in the world's poorest countries is in the
interest of the American people.
As you know, I tend to be very optimistic about what the future
holds. But there are a small number of potentially catastrophic events
that could seriously set back all the progress of the past few decades.
The most plausible--and most frightening--of these threats is a large-
scale epidemic.
I discuss this prospect in my recent New England Journal of
Medicine and New York Times articles; I'll talk about it briefly here
today.
By a ``large-scale epidemic,'' I'm talking about something much
bigger than the terrible Ebola outbreak we've seen in West Africa,
which has taken more than 10,000 lives.
Ebola, for all its horrors, is not a disease that spreads very
easily. What concerns me most is the prospect of a highly lethal
disease that is also highly contagious.
We have seen such outbreaks in the past, such as during the
influenza pandemic of 1918 and 1919, which had a worldwide death toll
generally estimated between 30 million and 50 million.
That included about 675,000 deaths here in the United States--at a
time when the national population was about one-third as large as it is
today. The outbreak was so severe in this country that over the course
of a single year, life expectancy in the U.S. fell by about 12 years.
Could an epidemic of this scale happen again? Yes, it could--and in
today's far more urbanized and interconnected world, it could spread
from continent to continent, and from community to community, far more
easily than it could a century ago.
Members of the subcommittee, I've come to Congress on other
occasions to ask for the sustainment of U.S. overseas development
assistance.
I have grounded this appeal not only in our shared moral interest
in preventing needless death and suffering, but also in our economic
and security interests. All these dimensions remain strong interests of
mine, and I know they are strong interests of yours, as well.
The Ebola tragedy has made our national interest in this effort
clearer than ever before. I am asking you to support our assistance
programs both as a highly effective means of helping other countries
become more self-sufficient, and as a necessary means of protecting
this country from a future epidemic.
Such an epidemic might start far away, but could spread to the U.S.
on a considerably larger scale, and with much greater speed, than any
current form of Ebola.
It's impossible to predict the human toll or the economic
consequences that would result. According to the World Bank, a
worldwide flu epidemic would reduce global wealth by $3 trillion, not
to mention the immeasurable suffering that would accompany widespread
illness and loss of life.
The wise course is to invest manageable amounts now to prevent
future outbreaks--rather than trying to contend with the unpredictable
and potentially enormous costs of a trans-continental epidemic.
The sensible place to begin is with investments in basic health
services in those parts of the world that are most susceptible to
outbreaks of infectious disease.
As we have seen with the Ebola epidemic, the world's poorest
countries remain acutely vulnerable to health crises that can render
them unable to support their own people or build their own economies.
This epidemic is also a reminder that infectious diseases don't
respect national borders. In the interconnected world of the 21st
century, a non-functional health system anywhere can create problems
everywhere.
It is imperative that we learn the right lessons from the Ebola
emergency. Perhaps the most urgent of those lessons is the paramount
importance of bringing health systems up to a level of at least basic
adequacy in as many places as possible.
The process begins, of course, with the recipient nations
themselves--which must invest in the health of their own people, in
partnership with external donors.
This had already happened in enough areas of Nigeria, Senegal, and
Mali to prevent Ebola from spreading farther in those countries--and
thank goodness for that, since any expansion of the outbreak to large
urban areas like Lagos or Bamako could have immensely increased both
the death toll and the complexity of this epidemic.
To its great credit, the United States has played a leading role in
responding to the West African Ebola outbreak. Our challenge now is to
maintain the effort and the investment required to ensure we're better
prepared for future epidemics.
This includes investment in a range of vital systems: primary
healthcare; disease monitoring; and data collection--as well as such
basic medical tools as vaccines, therapeutics, diagnostics, and
transfusion processes.
But in some ways, the main problem with U.S. epidemic preparedness
is not our level of investment--though that will also need to improve--
but our lack of optimal coordination across agencies.
Within the U.S. Government, there are multiple agencies engaged in
epidemic response at some level--either directly, or indirectly through
the development of guidelines or technical expertise.
These include the Centers for Disease Control and Prevention; the
National Institutes of Health (NIH); the Food and Drug Administration;
the Defense Threat Reduction Agency (DTRA) and the Defense Advanced
Research Projects Agency (DARPA) at the Department of Defense; the
Department of Health and Human Services Office of the Assistant
Secretary for Preparedness and Response (ASPR); and several others.
Consider the Government's response to the Ebola epidemic: Just
within the area of research and development, we had the development of
ZMapp, which was funded by the Biomedical Advanced Research and
Development Authority within ASPR; a lead vaccine candidate funded by
NIH; a diagnostic test funded by DTRA; and additional technological
approaches funded by DARPA.
Such diversity of agencies engaged in a shared challenge is by no
means necessarily a problem. It can even be a strength. But
particularly when it comes to R&D, we need better coordination and
transparency. That includes a greater awareness of what is being funded
and studied across agencies, so that we may avoid unnecessary
duplication of effort; derive maximum leverage from what's already
being done; and advance the state of research as much as possible.
There's one more reason why improvements in cross-agency
coordination--and, where needed, additional investments--make enormous
sense: They will be worth it even if a large-scale epidemic never
happens.
That's because the measures that will enable us to respond
effectively to a major disease outbreak are the same ones that will
equip us to help other countries:
--limit the spread of infectious disease;
--reduce child mortality;
--protect the health of expectant and delivering mothers;
--and otherwise contribute to the increasing self-sufficiency of
their own people.
In other words, these are investments and policies that are proven
to pay off for the American taxpayer--no matter what happens.
I'll conclude with my third point: The progress we've made in recent
years would not have been possible without development assistance from
the United States. The progress we need to make in years to come won't
be possible without it, either.
Whether we're talking about preventing the next epidemic or
building upon the enormous global-health gains of the past two decades,
the time to act is now.
As I've noted, this means increased investment from developing
countries as they assume greater responsibility for their own health
and development.
This also means the U.S. should at least maintain global-health
investments at the fiscal year 2015 level--and, if possible, increase
them.
Even though the progress we've seen is quite impressive, much
remains to be done.
While child mortality is declining, it remains too high in too many
places. Nearly 22 million children worldwide remain under-immunized
each year, and more than 6 million die before the age of 5--with about
1.5 million of these deaths resulting from vaccine-preventable diseases
like diarrhea and pneumonia. To address this, it is vital that the U.S.
fully fund its recent Gavi pledge.
Despite some gains in maternal and child health, progress on
newborn health has lagged, and far too many women still die in
childbirth. Cost-effective and proven solutions are available to treat
or prevent the causes of most newborn deaths.
These include such relatively simple and affordable measures as
umbilical cord care; exclusive breastfeeding; and access to skilled
birth attendants. Our ability to end these preventable deaths will
depend on an even stronger commitment of U.S. funding for maternal and
child-health programs.
Toward this end, we also need to ensure that women are fully
supported in achieving healthy timing and spacing of pregnancies. U.S.
investment in women's access to contraceptives and information not only
contributes to better maternal, newborn, and child health--it also
helps girls stay in school, and expands economic opportunities for
women throughout their lives.
As I mentioned earlier, we may be on the threshold of a polio-free
Africa--and of the eradication of polio itself. That's due in no small
part to the initiative and generosity of the United States.
But this progress is hard-won, and the final eradication phase is
the most difficult of all. But once we achieve eradication, we can turn
those resources and that expertise toward other global-health
challenges. Now is not the time to let up--we need to eradicate polio
now, once and for all.
The Global Fund to Fight AIDS, Tuberculosis and Malaria is crucial
to building health systems in poor countries. I urge you to maintain
strong U.S. support for this highly effective organization.
Continued American leadership on the Global Fund now will set the
pace for the upcoming 2017-2019 replenishment, and will help ensure
strong support from other donors.
In addition, it is vital that the U.S. provide robust funding for
PEPFAR and PMI--and maintain its current level of support for bilateral
tuberculosis and neglected infectious disease programs. I am hopeful
that new data will allow PEPFAR to support recipient-country efforts to
focus resources on areas of greatest need in the campaign against HIV.
It's also especially important that we eliminate malaria now in
certain areas, such as the Mekong River delta of Southeast Asia, to
prevent the spread of drug-resistant strains of the disease.
We need to bolster funding for research and development through the
various USAID global-health budget lines. USAID plays an essential
leadership role on R&D, in concert with other U.S. Government programs
funded by the Labor-HHS bill--including through the National Institutes
of Health; the Centers for Disease Control and Prevention; and the Food
and Drug Administration.
The U.S. Government is also uniquely qualified to make vital
investments in agricultural development. I urge continued strong
support for the Feed the Future program--as well as for land-grant
university research programs and the Millennium Challenge Corporation.
The Global Agriculture and Food Security Program has helped to
ensure that developing countries have sound investment plans for
agriculture--and that they put their own resources against those plans.
This program exemplifies a rising trend in global development and
health: an emphasis on deriving leverage from the contributions of
other donors--and from the domestic resources of the recipient nations
themselves.
This makes development assistance an even better investment for the
Congress, and for the American taxpayer. The need for such investment
remains strong, and recent events demonstrate its urgency.
Thank you for inviting me to join you today. I look forward to your
questions.
[Clerk's note: The 2015 Gates Annual Letter and articles
from the New England Journal of Medicine and the New York Times
are included as an appendix at the end of the hearing
transcript.]
Senator Graham. Thank you.
Mr. Affleck.
SUMMARY STATEMENT OF BEN AFFLECK
Mr. Affleck. Thank you very much. It is an honor to sit
here in this room and speak before you great Senators. Thank
you both very much for having me here. I am humbled by this
esteemed panel. Thanks for having me follow the greatest and
most important philanthropist in the history of the world.
I am sure I am going to come off great.
But, no, truly, it is an honor to sit next to Mr. Gates who
has done such extraordinary things in technology and in
philanthropy and I understand on your way in doing so in
bridge.
Chairman Graham, Ranking Member Leahy, distinguished
members of the subcommittee, I want to thank you deeply for
inviting me to testify here today. My name is Ben Affleck. I am
the founder of Eastern Congo Initiative. We are a grant-making
and advocacy organization working with and for the people of
the Democratic Republic of Congo.
I want to offer a special thanks to the chairman for
holding today's hearings. Senator Graham, like others on the
subcommittee, has proven time and time again to be a genuine
champion for smart, effective U.S. foreign assistance. In
August 2013, amid renewed violence in the region, Chairman
Graham led a delegation to Eastern Congo, bringing five Senate
colleagues along to see firsthand the potential of the region.
This marked the largest ever delegation of U.S. Senators to
visit this war-torn region. So thank you, Mr. Graham, for your
confidence in the people of Congo and for learning more about
what can be done.
And to Senator Leahy, I would be remiss if I did not
acknowledge my co-star in Batman, roles marginally smaller than
mine, but I understand you are quite good. Good morning, sir.
Members of the subcommittee, I am here today to offer a
case study of the difference our Nation's foreign assistance
and diplomacy is making, where small, targeted public and
private investments are transforming communities in need,
advancing our Nation's interests, and creating opportunities
both in the countries we assist and here at home.
You have undoubtedly heard a bit about Congo, about its
challenges and about the worst of its past: two decades of
armed conflict; an estimated 5 million deaths due to violence,
disease, and starvation; 2.7 million people who remain
displaced today; and the appalling levels of sexual violence.
But these statistics tell you nothing about Congo's future
or about the extraordinary and resilient people working every
day to rebuild their nation.
Despite the many challenges, the Congolese people refuse to
be defined by their country's past, and in spite of those who
may question the effectiveness of our foreign assistance, I can
tell you firsthand that U.S. diplomatic and financial
investments in Congo are working.
U.S. foreign assistance accounts for only 1 percent of the
entire Federal budget and vastly less than 1 percent of that 1
percent is allocated to the Democratic Republic of the Congo
(DRC). Yet, from that fraction of a fraction, we are seeing
important, powerful progress. Let me give you an example of
what I mean.
In the late 1970's, Congo was one of coffee's leading
exporters, but because of conflict and diseased crops,
production today is less than 10 percent of what it once was.
Congolese families lost a vital source of income, and the rest
of us lost some of the world's greatest coffee.
Three years ago, Eastern Congo Initiative (ECI) saw an
opportunity to revitalize Congo's coffee sector. In our work,
we had met struggling rural farmers living on less than a few
dollars a day. And we knew that with the right partners we
could help give the skills and resources they needed to
transform their communities. And we were thrilled that the
United States Agency for International Development (USAID)
agreed. Our Government made the bold decision to help us create
a public-private partnership, together with ECI, the Howard G.
Buffett Foundation, and the Catholic Relief Services.
Together in only 2 years, we have trained and supported
4,500 coffee farmers across four cooperatives to dramatically
increase the quality and quantity of their crop and to help
maximize farmer profits. We brought in global trade specialists
to build an ethical supply chain that keeps money in the
pockets of farmers and their families.
But what we have been able to achieve together does not end
there. Prior to ECI's involvement, these coffee farmers had no
access to financing, no line of credit. Imagine trying to start
a business without any capital. You simply cannot, let alone in
an emerging economy like Congo's.
So to close this gap, we brought in experts. We approached
Scott Ford's company, Westrock Finance, which has worked
alongside these cooperatives to dramatically scale their
businesses in environmentally sustainable ways. I should add
that Scott was part of that historic delegation with Mr. Graham
that visited Congo in 2013.
The final puzzle piece was getting this coffee into
American homes. So ECI brought in another investor, which was
Starbucks. In the coming weeks, Starbucks officials will travel
to the eastern region of Congo to begin a partnership with us
to develop Congo as a key source of high-quality coffee.
Starbucks has already purchased 40 tons. It may not be a lot
for Starbucks, but it is a heck of a lot in eastern Congo, I
assure you. It is the entirety of the cooperatives' very first
export, representing millions of cups of coffee that will be
sold in U.S. markets.
Involvement by the world's largest coffee company is a
clear testament to what is possible for Congo. This is not
charity or aid in the traditional sense. It is good business.
From a relatively modest investment, farmers' incomes have more
than tripled, and they can now afford to send their children to
school, put food on the table, and access proper health care.
As a result, the world has a new source of high-quality coffee.
This public-private partnership has transformed the lives
of thousands of families in eastern Democratic Republic of the
Congo (DRC), all made possible because USAID agreed that it
could be done. But we think this is just the beginning of what
is possible.
Next month, ECI will launch an economic development fund
that is focused on expanding our existing work not only in
coffee but in cocoa and other strategic crops. As a result of
our new fund, we will work with at least 10,000 additional
farmers over the next 4 years to build their business capacity,
improve the quality and quantity of their products, and secure
direct access to premium markets.
This work is scalable. This work is replicable. And in just
5 short years, it will have a transformative impact on nearly
100,000 individuals living in eastern Congo.
None of this would have happened without USAID, without
their commitment--a relatively modest commitment, I might say--
and without private sector partners willing to operate in one
of the highest risk environments in the world.
With proper training and strategic investments, agriculture
will become a driving force for Congo's economy, supporting the
more than 60 percent of Congolese--that is 40 million people--
whose families rely on agriculture as their primary source of
income.
Simply put, we believe that a country with enough arable
land to feed a third of the world's population should not
struggle to feed its own people, to send its own kids to
school, or afford basic health care.
Senators, this brings me to my final message. The next 2
years represent a critical turning point for DRC. With local
elections scheduled for later this year and national elections
in 2016, DRC enters an incredibly important window of
opportunity for an unprecedented democratic transition.
Direct and consistent engagement by Secretary Kerry, the
Special Envoy's office, and Ambassador Swan have helped Congo
reach this moment. As you know, your former colleague, Senator
Feingold, served as Special Envoy until just a few weeks ago.
His leadership and the 15 trips he made to DRC during his 18-
month tenure was the very definition of direct and consistent
diplomatic engagement, and we thank him for his service.
U.S. leadership played a vital role in the recent, yet
fragile, progress toward peace and stability. To ensure this
progress does not come undone, we urge you to join ECI and
other groups like Open Society, Humanity United, Human Rights
Watch, and the Enough Project in calling on the administration
to appoint a new Special Envoy without delay.
Senators, if we continue to make smart and effective
financial and diplomatic investments, we will help foster the
next generation of Congolese entrepreneurs and leaders who will
carry their country forward to stand as a model for the region
and the continent.
Thank you, and I look forward to answering your questions.
[The statement follows:]
Prepared Statement of Ben Affleck
Chairman Graham, Ranking Member Leahy, distinguished members of the
subcommittee, thank you for the invitation to testify here today. My
name is Ben Affleck and I am the founder of Eastern Congo Initiative, a
grant-making and advocacy organization working with and for the people
of the Democratic Republic of the Congo (DRC).
I want to offer a special thanks to the Chairman for holding
today's hearing. Senator Graham, like others on this subcommittee, has
proven time and again to be a genuine champion for smart, effective
U.S. foreign assistance. In August 2013 amid renewed violence in the
region, Chairman Graham led a delegation to eastern Congo, bringing
five Senate colleagues along to see firsthand the potential of the
region. This marked the largest ever delegation of U.S. Senators to
visit this war torn region. Thank you Mr. Graham for your confidence in
the people of Congo and for learning more about what can be done.
And to Senator Leahy, I would be remiss if I did not acknowledge
the second biggest Batman fan in the room. Good morning, sir!
Members of the subcommittee, I am here today to offer a case study
of the difference our Nation's foreign assistance and diplomacy is
making--where smart, targeted public and private investments are
transforming communities in need, advancing our Nation's interests and
creating opportunities, both in the countries we assist and here at
home.
You have undoubtedly heard a bit about Congo--about its challenges
and the worst of its past: two decades of armed conflict; the estimated
5 million deaths due to violence, disease, and starvation; the 2.7
million people who remain displaced today; and the appalling levels of
sexual violence.
But these statistics tell you nothing about Congo's future, or
about the extraordinary and resilient people working--everyday--to
rebuild their nation.
Despite the many challenges, the Congolese people refuse to be
defined by their country's past. And, in spite of those who may
question the effectiveness of our foreign assistance, I can tell you
first-hand that U.S. diplomatic and financial investments in Congo are
working.
U.S. foreign assistance accounts for only 1 percent of the entire
Federal budget, and vastly less than 1 percent of that 1 percent is
allotted to DRC. Yet from that fraction of a fraction, we are seeing
important progress.
Let me give you an example of what I mean.
In the late 1970s, Congo was one of Africa's leading coffee
exporters. But because of conflict and diseased crops, production today
is less than 10 percent of what it once was. Congolese families lost a
vital source of income, and the rest of us lost some of the world's
greatest coffee.
Three years ago, ECI saw an opportunity to revitalize Congo's
coffee sector. In our work, we had met struggling rural farmers living
on less than a few dollars a day. And we knew that with the right
partners, we could help give them the skills and resources they needed
to transform their communities.
And we were thrilled that USAID agreed. Our Government made the
bold decision to help us create a public-private partnership bringing
together ECI, the Howard G. Buffett Foundation and Catholic Relief
Services.
Together, in only 2 years, we've trained and supported 4,500 coffee
farmers across four cooperatives to dramatically increase the quality
and quantity of their crops. And to help maximize farmer profits, we
brought in global trade specialists to build an ethical supply chain
that keeps money in the pockets of farmers and their families.
But what we've been able to achieve together doesn't end there.
Prior to ECI's involvement, these coffee farmers had no access to
financing, no line of credit. Imagine trying to start a small business
without any capital. You simply can't, let alone in an emerging economy
like DRC.
So to close this gap, we brought in the experts. We approached
Scott Ford's company, Westrock Finance, which has worked alongside
these cooperatives to dramatically scale their businesses in
environmentally sustainable ways--I should add that Scott was part of
that historic delegation with Mr. Graham that visited Congo in August
2013.
The final puzzle piece was getting this coffee into American homes,
so ECI brought in another investor: Starbucks. In the coming weeks,
Starbucks officials will travel to the eastern region of Congo to begin
a partnership with us to develop Congo as a key source of high-quality
coffee. Starbucks has already purchased 40 tons--the entirety of the
cooperatives' very first export, representing millions of cups of
coffee that will be sold in U.S. markets.
Involvement by the world's largest coffee company is a clear
testament to what's possible for Congo. This isn't charity or aid in
the traditional sense, it's good business. From a relatively modest
investment, farmers' incomes have more than tripled, and they can now
afford to send their children to school, put food on the table and
access proper healthcare. And as a result, the world has a new source
of high quality coffee.
This public-private partnership has transformed the lives of
thousands of families in the eastern part of DRC, all made possible
because USAID agreed it could be done. But we think this is just the
beginning of what's possible.
Next month, ECI will launch an economic development fund focused on
expanding our existing work not only in coffee, but in cocoa and other
strategic crops As a result of our new fund, we will work with at least
10,000 additional farmers over the next 4 years to build their business
capacity, improve the quality and quantity of their products and secure
direct access to premium markets.
This work is scalable. This work is replicable. And in just 5 short
years it will have transformative impact on nearly 100,000 individuals
living in eastern Congo.
None of this would have happened without USAID's commitment and
without private sector partners willing to operate in one of the
highest risk environments in the world.
With proper training and strategic investments, agriculture will
become a driving force for Congo's economy, supporting the more than 60
percent of Congolese--that's 40 million people--whose families rely on
agriculture as their primary source of income.
Simply put, we believe that a country with enough arable land to
feed a third of the world's population should not struggle to feed its
own people, to send its kids to school or access basic healthcare.
Senators, this brings me to my final message. The next 2 years
represent a critical turning point for DRC. With local elections
scheduled for later this year and national elections in 2016, DRC
enters an incredibly important window of opportunity for an
unprecedented democratic transition.
Direct and consistent engagement by Secretary Kerry, the Special
Envoy's office and Ambassador Swan have helped Congo reach this moment.
As you know, your former colleague Senator Feingold served as Special
Envoy until just a few weeks ago. His leadership and the 15 trips he
made to DRC during his 18-month tenure was the very definition of
direct and consistent diplomatic engagement, and we thank him for his
service.
U.S. leadership played a vital role in the recent--yet fragile--
progress toward peace and stability. To ensure this progress does not
come undone, we urge you to join ECI and other groups like Open
Society, Humanity United, Human Rights Watch and the Enough Project, in
calling on the administration to appoint a new Special Envoy--without
delay.
Senators, if we continue to make smart and effective financial and
diplomatic investments, we will help foster the next generation of
Congolese entrepreneurs and leaders who will carry their country
forward, to stand as a model for the region and the continent.
Thank you and I look forward to answering your questions.
Senator Graham. Jennifer and Violet are very proud. Very
well done.
John.
SUMMARY STATEMENT OF JOHN MEGRUE
Mr. Megrue. Good morning and thank you, Chairman Graham and
Ranking Member Leahy and members of the subcommittee, for
allowing me to come today and talk to you about something that
we all are, which we are all very passionate about, which is
foreign aid. I have had a chance to get to know many of you on
congressional delegations (CODEL's) and visiting hospitals and
clinics around Africa, so I understand the kind of pushback you
get here at home at times. But I thought I would share a
business perspective on why I think foreign aid has been so
effective and so important.
By way of introduction, I am a business person. I spent 30
years in private equity buying companies and owning companies
and, with a team, trying to make them bigger, better, more
efficient. But I am here because I have spent more than the
last 10 years working in Africa on issues around health care,
agriculture, education, and specifically the last 3 years, I
started an organization called Born Free, which is fighting the
transmission of HIV from mothers to children.
And in my philanthropy, I have followed three basic rules
or criteria, if you will. One is that I work on things that are
fast; two, that are doable; and three, that have great
leadership that I can partner with.
And in mother-to-child transmission, just looking at each
of those briefly--fast. The statistics around mother-to-child
transmission led by the U.S. foreign aid are really astounding.
In 2003, there were 600,000 babies born HIV-positive. Ninety
percent of those died in the first 5 years of life. Last year,
we were down to 200,000, so a 65 percent decrease in just over
10 years. This year, I think it will be less than 150,000, so a
75 percent decrease. These types of improvements are unheard of
in global health. I know that we can eliminate mother-to-child
transmission in the next few years.
Secondly, I mention that it is the things that are doable.
Mother-to-child transmission is doable for two main reasons.
One is that the science is very clear and it is proven, and
secondly, that it is cheap. Having worked on other issues like
education, agriculture, there are always significant debates
about how to solve problems. But in the case of HIV,
antiretroviral medicine is very clear, and it is now very
cheap. And so when you invest your money, when others invest
their money on the ground, we know what hits the ground
effectively and without any debate about whether we are doing
the right thing.
And the last thing I mentioned is great leadership, and my
experience in business says that is probably the most important
of the everything we go after. And I talk about leadership in
three areas.
First, on the ground in Africa, we work very closely with
government leaders, with health ministers, and community health
care workers all over Africa. And of course, you do not get to
the kind of statistics that I just mentioned, those kinds of
improvements, without those frontline people making it happen.
But also, and perhaps surprisingly, U.S. corporations. I
work with many U.S. multinationals, including Chevron, General
Electric, Johnson & Johnson, Estee Lauder, Mylan, MAC
Cosmetics, and others who are all investing alongside the U.S.
Government in this particular issue. And they are not just
doing it because of corporate and social responsibility. They
are doing it because it is good business. This is going to be
the fastest growing market over the next two decades, and so
they are committed to making these kinds of investments
alongside the U.S. Government.
And last is the U.S. Government and the leadership that it
is providing. I have worked closely with the leaders at USAID
and at the President's Emergency Plan for AIDS Relief (PEPFAR).
I know them well, and I can assure you they are doing a great
job. They are making tough decisions to make sure that our
money is spent efficiently. And for me as a philanthropist and
for many others--I am sure the people at this table--knowing
that that leadership is there keeps us inspired to be able to
partner with the U.S. Government.
And I will share one final thought, and that is that we
have a clear exit strategy in areas like this. This is not
funding that is going to be required from the United States
forever. Three years ago, I was co-hosting a CODEL. We were in
Cape Town South Africa. We brought together some of the largest
business people, philanthropists, the health minister for a
lunch. And at the end of the lunch, one of the leading business
people stood up and said two things. One, they said thank you
to the U.S. Government, and secondly, they said how important
our investment has been in South Africa getting over the hump
and really starting to beat HIV and in particular mother-to-
child transmission. They said, but we will not need your help
forever. We will pick this up.
And so I came back. I looked up the statistics, and sure
enough, in 2003, we were 100 percent of the HIV response. In
2008, we were 50 percent of the HIV response, and now we are
down to about 25 percent of the HIV funding response. And we
are seeing those stories around Africa where these countries
feel an obligation to pick up these investments.
So I know with continued investment, that we will eliminate
mother-to-child transmission. It will be one of the greatest
accomplishments of this generation and I think an incredible
accomplishment for the U.S. Government and our foreign aid to
be the leader in that.
But I would say going into the budgets today, now is not
the time to blink. This is not the time to slow down when you
are really winning a battle like this, and I would like you to
know there are people like myself and other panelists here that
are there on the ground, very active, making sure that our
money is well spent.
So thank you for giving me a chance to talk, and I look
forward to answering any questions.
[The statement follows:]
Prepared Statement of John Megrue
Good morning and thank you Chairman Graham, Ranking Member Leahy,
and members of the subcommittee for the opportunity to be with you here
today on Capitol Hill to discuss these critical important issues. I am
also honored to be part of this distinguished panel of witnesses.
Because of America's unwavering, bi-partisan leadership, we are
incredibly close to eliminating mother to child transmission (MTCT) of
HIV/AIDS throughout the world. As an American, a humanitarian, and a
financial investor, I strongly believe that we must sustain the cost-
effective investments we have made in PEPFAR to achieve this important,
and once unimaginable goal.
We have seen unprecedented progress in the fight against HIV/AIDS.
We have gone from zero to nearly 10 million people on Antiretroviral
Treatment (ARV) each year. We have saved more than 4 million lives, and
prevented over 1 million HIV infections in children. Because of this
progress, we have the historic opportunity to witness a generation born
free of HIV. Momentum is building to reach this target. My
organization, Born Free Africa (BFA), is committed to our goal of
ending mother to child transmission by December 31, 2015.
My philanthropy has been guided by three simple business
principles. I have chosen to invest my time, money, and resources in
areas that meet three criteria: they need to be fast, doable, and have
great leadership. It is with this private sector perspective, or this
lens, that my views on our foreign aid investments are shaped. I can
therefore comfortably speak on the effectiveness of our investment in
the areas and these diseases where I work and about the efficiencies,
the payback rates, the challenges, the return on investment, and
scalability.
First is fast: the area where I focus, ensuring that babies are
born HIV free, is one of the great success stories in global health
history. Twelve years ago there were 600,000 HIV positive babies born
per year. Four years ago the number was down to 440,000, down 25
percent. Last year it less than 200,000, down 65 percent, and this year
I believe it will be well below 150,000, down 75 percent from its peak.
The speed of success in dropping these numbers is unprecedented. I have
no doubt that we can virtually eliminate mother to child transmission
of HIV in the next few years.
Second is doable: the science is clear and the interventions are
cheap. On many other critical issues like education reform, water and
sanitation, agriculture, and energy, there are debates about the right
way to solve the problem, or even about what the problem is to begin
with. The science of antiretroviral medicine to fight HIV/AIDS is clear
and proven. A pill costs less than 30 cents per day for a pregnant
woman living with HIV to take during the prescribed period. Given this,
my investment, and the investment by the U.S. Government, hits the
ground with full effect, with no debate about science or methodology,
and without overwhelming cost.
Third, and finally, great leadership: smart investments require
sound leadership, and HIV programs in Africa are lucky to have strong
leaders from all sides of the partnership. We rely on leaders in sub-
Saharan African countries and Ministers of Health who are the core
drivers of the success we are seeing in mother to child transmission.
We also rely on leadership and funding that U.S. corporations provide.
I work with U.S. companies including Chevron, Johnson & Johnson, Estee
Lauder, Mylan, General Electric, and many others that invest both their
time and money to fight these diseases. They are doing it not only
because of an obligation to corporate social responsibility, and not
only to improve local government relations. They invest in these issues
because these countries are their fastest growing end markets. This is
where they see their greatest growth coming from over the next two
decades, and they know that investing in healthcare initiatives there
will ensure that the markets are strong for the future and for their
bottom lines. Lastly, and most importantly, we rely on leadership from
the U.S. Government and its agencies, including PEPFAR and USAID. Both
of these organizations have incredible leadership--teams who are
adeptly refining their strategies, using data to drive their decisions,
and making smart, forward-thinking judgment calls in the face of a
changing landscape. These are exactly the kind of people we want
running our investments. The U.S. Government is the largest bilateral
funder of foreign assistance for health, we guide and influence the
funding from the rest of the developed world, and we provide
infrastructure and assistance far beyond our financial resources. As a
businessman, a private philanthropist, and a co-funder of these issues,
U.S. Government leadership has been critical to my interest and to our
success.
Based on these principles, I started Born Free Africa because I
realized that the private sector has a critical role to play in
contributing to eliminating mother to child transmission of HIV. In
2001, over half a million children were infected with HIV, and 90
percent of these cases were transmitted from their mothers. When I
first heard these figures, I was floored. With simple, once daily
treatment, 98 percent of children can be born HIV free. I decided to
use my experience from the private sector to identify gaps in the
response to MTCT and accelerate its elimination. And so BFA was
launched.
BFA is a group of private sector leaders who lend our business
acumen, skills, and resources to accelerate the pace towards a
generation born HIV-free in the African countries most affected by this
dreadful disease. BFA leverages our corporate experience to partner
with African governments and business communities to recruit, develop
and empower local management talent who then work within their own
governments to amplify and expand the work of the partners,
governments, donors and policy makers to eliminate mother to child
transmission of HIV. Infusing business sensibility and injecting
corporate talent into African Ministries of Health helps accelerate
progress toward no child being born with HIV. Rather than duplicate or
fragment, we seek to leverage on-going efforts. Our only agenda is
contributing to elimination, and we work hard to fill gaps thereby
maximizing the work of those around us, and having the greatest
possible effect on outcomes.
Allow me to provide an example of how BFA operates. Nigeria
accounts for over 25 percent of the number of children newly infected
with HIV among the 21 high-burden countries that have been prioritized
for MTCT programs. From 2007 to 2010, there was only a 2 percent annual
decrease in the number of children newly infected with HIV. Given this,
BFA decided to work with the Nigerian Government to accelerate
progress. We created a core group of private funders who came together
to pool their resources and invest catalytically in Nigeria's scale up
of PMTCT and its journey toward elimination by leveraging small
investments against Nigeria's more than $500 million annual response to
HIV.
Together, our partners, including Chevron, the MAC AIDS Fund,
Johnson & Johnson, the Elton John AIDS Foundation, the Children's
Investment Fund Foundation, and Mylan, all saw the value of investing
in Nigeria and in collaborating to support a team within the Federal
Ministry of Health to eliminate mother to child transmission of HIV. We
support 12 local Nigerians who work within the Ministry of Health,
where they act as behind the scenes advisors, doers, and leaders in
support of the existing government teams. These individuals utilize
best practices from the private sector, including data-driven planning
and effective performance management, to promote the ongoing scale up
of PMTCT services at the primary care level. After a renewed focus,
increased attention, and smarter implementation, there has been a 10
percent decline in MTCT from 2010-2013. Additionally, in 2013, Nigeria
tripled the number of clinics offering PMTCT services, and from 2013 to
mid-2014, the country saw a 100 percent increase in coverage of
pregnant women living with HIV initiating treatment.
Let me be clear that the progress we are all making simply would
not be possible without PEPFAR, and the enormous and historic support
of the United States Government and then American people. In my view,
PEPFAR is the cornerstone of what the world has been able to achieve in
the last decade. Put another way, PEPFAR spurned myriad partnerships
among donor and endemic countries, and brought billions of dollars of
new money to the fight. Sequestration with a flat cut to PEPFAR's
budget would stop this progress in its tracks. We can deploy the best
trained business minds, with the most committed and knowledgeable
scientists, doctors and nurses, and the savviest technocrats, but
without PEPFAR, and without your sustained leadership and the
commitment, eliminating MTCT would be nothing more than a dream.
As an investor, I put my own money into BFA because I know that I
can leverage the enormous investments made by the United States, and
because I know it works. Like with any smart business investment, we
have the data to prove it. In the last 5 years, there has been more
than a 40 percent decrease in the number of new infections among
children. But our work is not finished. In 2013, fewer than 200,000
children were infected with HIV passed down from their mothers. This
remains unacceptable.
In an age of seemingly infinite disagrees, we can all agree that no
child, anywhere, should be born with HIV. We have the tools and
knowledge to block this transmission. The only thing stopping us is a
lack of resources to ensure more access. We cannot back down from this
fight now, not when we are so close to achieving elimination of one of
HIV's most devastating byproducts. I am confident that with continued
investment, eliminating mother to child transmission of HIV will be one
of the greatest accomplishments of our generation.
Thank you, Mr. Chairman.
Senator Graham. Thank you.
Admiral.
SUMMARY STATEMENT OF ADMIRAL JAMES STAVRIDIS
Mr. Stavridis. Terrific to be with everybody this morning.
I want to begin by thanking the Chairman and the Ranking Member
for asking me to testify and waiving the height and the hair
requirements, looking at my other vastly better looking
colleagues here today.
I think the last time I saw Mr. Affleck was on the deck of
an aircraft carrier in the Arabian Gulf, and he was out there
doing a United Service Organization (USO) thing with Robin
Williams, and I remember that day very well and thank you for
coming out and seeing us and your support to our military, sir.
I am here because I am a member of the U.S. Global
Leadership Advisory Council for National Security, and a group
of about 160 senior retired military officers are part of that.
And I wanted to kind of pick up where some of my colleagues
have left off, which is to say from a military perspective how
important this kind of work is. We have a very strong and
capable military. Thank you to the Congress for that.
But we cannot create security in this 21st century simply
with hard power. We need the tools of soft power which are what
my co-panelists are talking about, and they are really
diplomacy and development in a nutshell. And I would say, to
summarize, we are very good at launching missiles today. We
could improve at how we launch ideas. And diplomacy and
development allow us to do that. So cutting this kind of work I
think is a mistake at this time.
I will give you some practical examples. Senator Leahy and
I, when I was the Commander of U.S. Southern Command before my
time at NATO, worked together on Colombia. This is an area
that, if you go back 15 years, looked a lot like Syria does
today, a complete humanitarian disaster, millions of people
displaced, high levels of violence. As Ben was describing in
the Congo, it was an absolute disaster. We created something
called Plan Colombia, which had a military component, but more
importantly, it funded development and diplomacy, human rights,
all of the soft power parts fitted together with the hard
power. Today, Colombia is a nation that has not only improved
vastly but is in a position to continue forward as an absolute
linchpin strategically for the United States in the South
American context.
In my time as a NATO Commander, I witnessed the same sort
of effect in the Balkans. If we think back to the Balkans, 10
to 15 years ago, again it looked a lot like Syria does today,
8,000 men and boys killed in a single day at Srebrenica,
extraordinary levels of violence, rape, torture. Yet, today in
the Balkans, when they want to solve a dispute, they do not
reach for a rifle. They reach for a telephone to call the
European Union, to call the United States. Why? Because we were
able to use some hard power but combine it with the soft power
tools of diplomacy and development, which are the long game.
I will give you a third example and it is current. It is
what we are doing today in Afghanistan where Senator Graham has
served as a reservist coming on active duty in Afghanistan
working on the judicial process there. This is soft power. Do
we need hard power in Afghanistan? Absolutely, unfortunately.
But the long game is diplomacy and development. You need both
those things. When you bring hard and soft power together, you
create smart power. That is what I would advocate for, and to
try and do defense without diplomacy and development, I will
simply repeat the quote that Senator Graham gave us earlier, as
my very good friend, Jim Mattis, will tell you, if you scrimp
on the development and the diplomacy, you are going to end up
buying more ammunition. And as Secretary Gates, who was
interagency before interagency was cool, would tell you, we
cannot kill our way to victory in these situations. We need
hard power, but we need these tools, development and diplomacy,
as well.
I look forward to your questions, Senator.
[The statement follows:]
Prepared Statement of Admiral James Stavridis
Chairman Graham, Ranking Member Leahy, members of the subcommittee:
I am delighted to join you today as we reflect on America's leadership
role in the world, and the responsibility that leadership requires.
This subcommittee, under your guidance, will determine the resources
needed to protect our Nation and advance our values. Your decisions
will help set the course for American security and prosperity.
Today, I want to salute this subcommittee and your leadership. You
have been steadfast over these years of turmoil and threat in providing
a steady hand at the wheel of U.S. foreign operations. More
importantly, you have established a bi-partisan atmosphere of respect
and problem solving that is rare in this rancorous town, and should
give some hope to the American people.
Mr. Chairman, I have come today to offer my military analysis, my
firm belief that security, prosperity and peace are not simply an
outgrowth of kinetic action and the tools of war. We need a balanced
approach, what has been called a smart power model, which combines all
the tools of statecraft, to include diplomacy and development,
alongside defense. Moreover, we need to enhance our understanding in
global affairs. As we say at The Fletcher School, we need to ``know the
world''. Finding our way to a balance between hard power and soft power
is smart power--the key to our security in this turbulent 21st century.
My message to you today is direct. Now is the time to double down
on smart power.
I am part of a group of over 160 retired 3 and 4 star general
officers who have planned for war, fought wars, and sought a path to
peace. We know from hard experience, from command responsibility, that
war alone, the military instrument alone, does not bring security. We
all serve on the U.S. Global Leadership Coalition's National Security
Advisory Council, which I co-chair, with my good friend, Marine General
Tony Zinni. We support the USGLC, a broad based network of 400
businesses and non-governmental organizations (NGO's), national
security and foreign policy experts, and business, faith based, and
community leaders in all 50 states who support what I have referred to
as a ``smart power'' approach of elevating development and diplomacy
alongside defense in order to build a better, safer, world.
Mr. Chairman, I speak as part of the large coalition of military
officers and veterans who embrace not just the notion of a balance
between defense, diplomacy and development, but an enhancement, a new
vigor in the concept of smart power that will help us meet the
challenges ahead.
In my 37 years in military service to this great Nation, and now as
the Dean at the Fletcher School of Law and Diplomacy at Tufts
University, I have had the unique opportunity to see both the global
battlefield and the global marketplace of ideas. There is no doubt in
my military mind that we face new, unconventional security threats that
will continue to test our ability to out-think our opponents and
confront brutal ideologies.
But they are not the sum of my concerns. I also see serious threats
to global health and economic prosperity. Narcotic trafficking and
criminal gangs undercut democracy and development in Central and South
America and their violence washes up on our shores as well, sadly
accompanied by human trafficking and even human slavery. Extreme
poverty still claims lives and dashes hope around the world. Indeed,
the world is burdened by these assaults on dignity and justice. Civil
wars and insurgencies, lawlessness and crime infect parts of Asia and
Africa, the Pacific nations as well as the Atlantic. In sum the world
is a dangerous place.
But danger comes with opportunity. I believe that over the long run
we can turn peril into promise, but only if we meet the world's high
expectations for our strength, wisdom and vision. We need to invest in
our ability to exercise global leadership in a wide variety of ways.
For this Nation to excel, we need to understand the interplay of
economics and development, politics and diplomacy, culture and
business, surveillance and security. We need robust funding for what I
consider the new strategic triad of United States national security--
defense, diplomacy and development. There is no doubt in my mind that
our strength, our own security, rests on congressional support for all
the tools of American leadership.
The United States has a very strong and capable military. No one
can match us on the sea, in the air, and in ground maneuver. While
there will continue to be a need for that hard military power, Mr.
Chairman, we simply cannot lead without using other tools as well.
Competitor nations, competing ideas, challenge us with dark and
repressive visions of life. But we must show the world, indeed reassure
the world that:
--When disaster strikes, we are there
--When famine and disease threaten, we are there
--When there is a hope for diplomacy, we are there
--When people search for a better ideas and positive solutions on the
global social networks, we are there.
We are very good at launching missiles--we must improve at
launching ideas.
What is the price tag for a better, safer world? I would argue that
the non-military aspects of our power bring a strong return on our
investment, both in the public as well as the private sector. The funds
we allocate to foreign aid, diplomatic security, humanitarian relief,
education, and the many other international programs can save us from
spending far more to put boots on the ground in troubled regions. It's
exceptionally cost-effective.
By bolstering funding for our presence in the world, we reduce the
burden on our men and women in uniform. As many senior military have
said in one way or another, without funding diplomacy and development,
you ensure that we will end up spending more on hard power.
The programs supported by this committee advance the values and
interests of this country. I saw this day after day in every one of my
senior military leadership assignments. I saw the value of public-
private partnerships. The foundations and charities represented on this
panel demonstrate unique commitment, compassion, and innovation. They
strive to solve many of the world's enduring problems. They are on the
ground, working hand in hand to improve lives. Whether it is in health,
education, job creation, or local governance, these activities improve
lives.
Their work and commitment is matched by the outstanding work done
in our Nation's `headquarters'' for diplomacy and development. These
headquarters--centers of excellence, if you will--are key to U.S.
security and prosperity.
The State Department, the Agency for International Development, the
Millennium Challenge Corporation, Peace Corps, and many others, are
national assets to achieve our foreign policy and national security
goals.
The dedicated men and women in these agencies and departments, the
NGO's working alongside these professionals, all comprise a great
resource for our country. In the course of my career I relied on these
experts constantly to provide economic development and effective
diplomacy, whether in Southern Command implementing Plan Columbia to
combat narcotics trafficking or as the Supreme Allied Commander of NATO
in Afghanistan fighting against the Taliban.
These are steady and slow efforts, requiring patience and
persistence. But there are results. Colombia, a nation once synonymous
crime and violence is now experiencing an economic and tourism boom.
Afghanistan experienced its first peaceful transfer of power, and new
opportunities for economic development, especially in the mineral and
natural resources area, are reducing dependence on poppy farming. There
is no question that the civilian side of our international presence is
crucial to our success. I honor the men and women civilians who live
and serve overseas just as I honor those who serve in uniform. We share
a commitment to this great country and a peaceful world.
The United States leads the world, not just in our military
strength, but in the private sector, both business and NGO outreach. I
support those programs where professionals can go back and forth
between public and private activities, where those with a great depth
of knowledge can contribute to the policy process and program
development. There is an abiding value to experience, expertise, and
steady involvement in a region or sector, in the military and diplomacy
and development work. I hope those in public service in these areas can
lengthen their tours in country, enhance their regional concentrations,
to match the standards of commitment shown on today's panel.
I want to know that the expert on Bosnia or Afghanistan or Kenya
has followed events there for years, remembers the head of state as a
young professional, senses mood and political dynamics. As a military
leader, I relied on our diplomatic experts who anticipated policy
opportunities, who knew that the leader of the opposition worked with
us a decade ago, and now is in a position to provide positive
contributions. I want to know that a development project, tried years
ago can now work better with micro financing or in partnership with the
private sector. I value experience.
Under the outstanding leadership of Raj Shah, outgoing
administrator of USAID, we are ``bending the curve of development'' to
pull nations out of poverty, open opportunities, and search for local
solutions matched by technology and innovation in healthcare, infant
survival, agricultural production, and environmental protection. In
this regard, we are reviving the idea of resilience, optimism, and
problem solving.
These vibrant efforts can be seen in the Partnership for Growth
program in El Salvador, Tanzania, Ghana, and the Philippines. Mr.
Chairman, just last week, I saw an article noting the dramatic decline
in corruption in the Philippines, reflecting both the development
objectives of these programs with the technology of social media to
crack down on corrosive corrupt business and government practices. This
is resilience and problem solving. More importantly, as a country
strengthens in its governance, as prosperity grows and stability takes
root, America finds itself with new partners, new allies, in addressing
global threats. I first saw the proven record of smart power in South
Korea, a country which rose out of war torn poverty to a first world
success. It was that combination of development assistance and strong
diplomatic connection that turned a problem into promise. And this
success enhanced American security.
Mr. Chairman, the programs funded by this subcommittee leverage
American concern into American security.
I can attest to this connection personally. When I had to decide
about military deployments in harm's way, I knew that in so many cases,
the professionals at State, USAID and the NGO community ``had our
warriors' back'' and supported our understanding of complex
humanitarian crises. They cared for refugee and displaced children
through three bone chilling Syrian winters. They connected aspiring
computer scientists in Burma to U.S. high tech firms to speed an open
society. They tended the sick, nourished the hungry, educated youth,
and confronted injustice. These kinds of professionals are a gift to
this Nation and we need to tap their knowledge and experience
throughout the national security community.
On the diplomacy front, U.S. State Department experts represent our
Nation bravely in over 180 nations around the world--often at high
personal risk, as we have seen most recently following the horrific
attack on Ambassador Mark Lippert in South Korea (a former member of
this subcommittee's staff). Our diplomats are working tirelessly in the
midst of high tension scenarios from Iran to Ukraine to East Asia.
Strategic diplomacy and effective development can avert war, reconcile
aggrieved groups, and alleviate humanitarian tragedy. As a military
professional, I have always known that the use of hard power must be
the last resort, and that effective diplomacy can help reduce the
chances that we need to reach for the combat instrument.
But to be effective, we need a coordinated effort, between State
and USAID, and all the other agencies of the U.S. Government engaged in
the international world--Department of Justice, Homeland Security,
Agriculture, Drug Enforcement Administration, on and on--all have a
vital role to play.
My own experiences in Latin America as Commander of Southern
Command, in the Balkans as the Commander of U.S. European Command, and
in Afghanistan as the NATO Supreme Allied Commander all reflect the
need for strong interagency and private-public partners.
Our approach must be international, interagency, and private-
public--all undergirded by effective strategic communications. If we do
that well, we achieve smart power.
Mr. Chairman, all of these efforts, our international, interagency,
and private-public partnerships, are a vital investment for this
Nation, an investment that must constantly be refreshed. The support
this subcommittee provides is the seed money--the venture capital, if
you will--for U.S. leadership in the world.
Mr. Chairman, just as we invest in technology or invention to
achieve future wealth and advancement, we need to invest in these
professionals and their programs, in diplomacy and development and
other international, interagency, and private-public partnerships to
achieve prosperity and security.
But these investments require political will and talking straight
to the American people. Polls show that the American people have no
idea how little this country actually allocates to International
Affairs. In fact, they think we spend 20 to 25 times the amount we
actually do--which leads to unfounded calls to cut these programs.
With a mere 1 percent of the entire U.S. Federal budget, the
International Affairs Budget supports all of America's civilian tools
of diplomacy and development.
Mr. Chairman, the United States is active around the world--in
Europe, Asia, Latin America, the Caribbean, and Africa. No other
country can compare. We set the standard for others to follow.
Americans, in both public and private efforts, helped tackle Ebola,
almost eradicated measles and polio, brought food and shelter after
disaster, and brought encouragement to those searching for a way ahead.
We have been leaders in all these areas--humanitarian, development and
active diplomacy. Our diplomatic and development communities create the
conditions for effective political and military coalitions. Because of
our team approach, we have strong bilateral and multilateral ties which
bring stability, peace and prosperity to the world.
Let me close by commenting on one region in particular which
threatens this stability, prosperity and peace: the Middle East. And in
this regard, I urge you, from my vantage point as a military commander
and now as a dean in higher education that now is a time, as I said
earlier, to double down on smart power. We need to bring the talent of
this great nation, the development experts, the scholars, the diplomats
together to enhance our understanding of this specific challenge. We
shouldn't be scaling back funding. We need to scale up funding.
Our goal should be state-of-the-art diplomacy and development. To
do this, we need to support smart research, smart new diplomatic and
cultural initiatives, working with our allies, to confront the ideology
of those drawn to the fight. We need a sophisticated grounding on this
ideology, a world view so different than our own, so that our efforts,
in diplomacy, development and defense, can be successful. We need hard
power in the short term of course to face the spread of the Islamic
State and support our allies. But we also need counterterrorist
financing and effective intelligence. And for the long term, we need to
support educational reform, intellectual development and opportunity.
Combining hard and soft power over time: that is smart power.
Chairman Graham, Ranking Member Leahy, members of the subcommittee,
these are serious times. We need to be creative and innovative, we need
to be wise and knowledgeable. This Congress has the power to plot our
course to continued global leadership by robustly funding diplomacy and
development, and thus enabling smart power. I look forward to working
with this committee in any way I can to support this vital effort.
Senator Graham. We have Senator Boozman from Arkansas, and
Scott is from Arkansas. So I think you may want to say
something about our next witness.
Senator Boozman. Well, very much so. And I apologize. After
Scott testifies, I have got to run to a Veterans Affairs
hearing talking about over-prescribing opioids. So there are
all kinds of important things that are going on.
But I do want to thank all of you for being here. I am very
familiar with the work that you have done. You are great
examples of people that are using your time, your resources for
those that simply have no constituency at all in the sense of
representation.
Scott, it is a real honor to have you here. Scott is the
guy that just felt called to jump out and do something for his
fellow man and, as a result, through his efforts and hard work,
I think has raised the gross domestic product (GDP) of Rwanda
about 1 percent by giving them a worldwide ability to sell
their coffee at the international market. So again, we
appreciate your example, appreciate all you have done, as the
other witnesses.
Thank you, Mr. Chairman.
Senator Graham. Mr. Ford.
SUMMARY STATEMENT OF SCOTT FORD
Mr. Ford. Senator Graham, Senator Leahy, Senator Boozman
from the great State of Arkansas, thank you very much. Nice to
be here with you.
We could play a bit of a game here. One of these is not
like the other. I am just from the private sector. I did not
even know a lot of this was going on when I stumbled into the
coffee business in Rwanda a few years ago, but I have learned
the important powers of how the private sector and the public
sector, even from the United States, can meet in places like
East Africa and radically change people's lives. And I think
that accrues to our collective--both continent's collective
benefit.
I was the CEO of a company called Alltel Corporation until
we sold it to Verizon in 2009.
I had been doing charity work in Rwanda for several years
before that, and I had spent some time, considerable time, with
the President of Rwanda, Paul Kagame. I discovered in some of
those discussions that he and I--we are a bit of an outlier in
this regard. We had a common philosophy around the role of the
state and what it can and cannot do and the role of business
and what it can and cannot do.
I will sum it up to say this. The crux of our conversations
centered around a shared belief that the state, through its
attendant bureaucracies, can from the top down bring safety and
security, political freedom, even religious freedom. But it is
materially limited in its inability to bring economic freedom.
It is the final fruit of the tree, if you will. It is economic
freedom that is actually only created in the private sector
when people that have learned how to organize and manage a for-
profit business, then mentor other people in that process.
Paradoxically, the group that benefits the most from a free
market private enterprise system is not the richest of the
rich. They are everywhere in the world. It is actually the
poorest of the poor. President Kagame challenged me, if I ever
got an opportunity to come back to Rwanda, to invest in the
business that in his words said help the poorest of the poor
taste the benefits of the free market system, he says, because
once they do, they will not settle for a government that will
not give it to them.
So I went back. Alltel sold in 2009, and I went back,
frankly, not sure that I could find anything to do in Rwanda.
But I thought, well, I will honor the request and I will go
look and I will at least be able to report that I looked.
I got to Rwanda and I found out that there--I looked at a
whole host of things too long to go through here, but I ran
into the fact that 20 percent of the people in Rwanda make
their income, their cash income, from the coffee business and
that there were just two exporters that dominated the coffee
trade. I then figured out that they were not paying the highest
price for the coffee to the farmers that they could have and
that there was room for a third party to come in and pay more
to the farmers and still make a profit because I have to make a
profit or I do not get to sustain the work.
So we started looking through how could we go into the
coffee business. We really did not know much about it. We just
bought an old, abandoned, bankrupt mill at auction. We
revitalized it and we hung a shingle out and we went into
business. In the first 6 months of our operations, we saw the
price that the farmers in Rwanda received increased 30 to 50
percent. That was the power of somebody just setting a
reasonable price in terms of the cost of the product.
In addition, we have invested money on helping them to
improve their yields, helping them to improve the quality. All
of this translates directly into income. We were successful in
Rwanda.
We expanded into Tanzania with Tembo Coffee Company. We
then partnered with Falcon Coffees out of the United Kingdom
and we finance and procure coffee from other parts of East
Africa. I think we are one of the largest specialty exporters
out of Uganda, Ethiopia, and now behind the leadership of the
Eastern Congo Initiative and really closely right behind. It is
kind of like going to--we had the United States ask us would
you go to Congo. And I said not without Batman.
When Batman showed up, we went to eastern Congo, and we
have actually been doing the logistics and financial support of
his project as we try to get that coffee out to market.
I do not know what I was thinking, but we started a coffee
roasting business. It is restaurantcoffee.com because I am
running out of time. Thank you for the ability to make the
plug.
Starting these businesses from scratch in this part of the
world--my wife and my father stood with me, and everybody else
said I was a madman. But we have seen $100 million of
incremental income go into the pockets of the Rwandan farmers
from our being on the ground there over the last 6 years. That
is a 50 percent increase in their standard of living. How do
you impact 20 percent of the United States with a 50 percent
increase in their standard of living? I do not know how to do
it, and I could not have believed it was possible in just the
private enterprise system.
But it was because we got there and there were groups that
were funded by the U.S. Government and by philanthropists like
Mr. Affleck and Mr. Gates, like TechnoServe, the Eastern Congo
Initiative, the German Investment and Development Corp., all of
these groups that are spending money to help the co-ops on the
ground get their act together, get their accounting together,
be able to function as a community under the rule of law. That
is all supported by NGO's that are supported in turn by the
U.S., and we have been building on that to translate the income
differences into the Rwandan farmer.
I will say this as a final moment. I recognize in today's
panel that we are just one company operating in a limited
sphere of influence. I am good with that. But I hope that we
serve as at least an example of what an American private sector
actor can look like when we align with likeminded
organizations. We can produce benefits that the poorest of the
poor can literally taste. And I think that accrues to America's
credit.
If you want to ask questions about that and how that
ripples into policy and things, I would be glad to answer it.
But it is an honor to be here today, and I appreciate the
invitation.
[The statement follows:]
Prepared Statement of Scott Ford
Chairman Graham, Senator Leahy, and members of the subcommittee, my
name is Scott Ford and I thank you for this opportunity to share a
brief history of Westrock Coffee's entrepreneurial activities in East
Africa.
In 2004, after being involved in post-genocidal charity work for a
few years, and while still CEO of Alltel Corporation, I took my three
sons to visit Rwanda. While there, I had the opportunity to spend
considerable time with President Paul Kagame. I discovered we were
like-minded in our view that the free market system of open,
competitive trade is the only system that offers sustainable economic
hope--along with personal dignity--to those most deeply mired in
poverty.
The crux of our conversation centered on our shared belief that the
State--through its attendant bureaucracies and the rule of equally
applied law, can, from the top down, ensure Safety and Security,
Political Freedom, and even Religious Freedom--but that the State,
beyond policy making, is relatively powerless to bring about true and
lasting Economic Freedom. Prosperity, in other words, can only be
created from the ground up, so to speak, by private individuals who,
upon learning how to organize and operate a for-profit business,
support and mentor others in that process. And paradoxically, the group
that experiences the greatest relative benefit of genuine economic
prosperity in a society is actually the poorest portion of the
community.
In light of our common economic views, President Kagame asked me to
join his Presidential Advisory Council and challenged me to someday
return to Rwanda to invest in its future. Five years later, after
Alltel was sold to Verizon, I returned to explore opportunities to
follow through on his request to help build a company that would, in
his words, ``help the poorest of the poor taste the benefits of the
free market system''.
After looking at several business opportunities, I settled on
coffee exporting for a number of reasons but primarily because there
were only two major market participants operating in the coffee export
sector in Rwanda. It was clear; there was room for a third participant
to make a reasonable profit while paying considerably more for coffee
than was being offered to farmers at the time.
Rwanda, it turns out, was an anomaly in terms of typical coffee
industry practices, but knowing nothing more about the coffee industry
than that, we founded Rwanda Trading Company and purchased, at auction,
a bankrupt, abandoned, coffee-processing export mill in the capital
city of Kigali. Our intent was to make a profit and to attain enough
market share that the other two exporters would have to increase the
price they paid to farmers in order to stay competitive with us--
thereby giving every farmer in the country--whether they sold to us or
one of our competitors--an immediate and substantive raise! In our
first 6 months, we saw the price paid to farmers rise between 30
percent and 50 percent compared to the established local market price.
In addition to impacting the price paid to farmers, we continue to
invest to help them improve their yields and quality and make certain
that our mill employees are paid and treated in a manner that is fair
and honorable.
Based on the success of our coffee business in Rwanda, we expanded
our export operations into southern Tanzania as Tembo Coffee Company
and have partnered with Falcon Coffees in the United Kingdom to finance
and procure similarly sourced coffees from other parts of East Africa
including Uganda, Ethiopia, and most recently, behind the leadership of
and in cooperation with the Eastern Congo Initiative, the Democratic
Republic of Congo.
In order to directly connect East African coffee farmers with the
American consumer, we started a coffee roasting operation in Little
Rock, Arkansas, which roasts and packages coffee under the Westrock
Coffee brand and is available through retailers such as Kroger, BI-LO/
Winn-Dixie, Walmart, and online at westrockcoffee.com. We also offer
coffee service to corporations, airlines, restaurants, and hotel
chains.
Starting these businesses from scratch has been risky, but the
impact our efforts have on the employees and farmers we work with is
the reason we continue to expand. Last year, in Rwanda and Tanzania
combined, we employed over 140 people full-time and 1,150 part-time and
financed and procured coffee from over 60,000 individual coffee
farmers.
Collectively, we estimate that the sum total of our coffee
activities in Rwanda alone, over the past 6 years, put upwards of $100
million directly into the pockets of small-holder coffee farmers, and
our experience indicates this income most immediately goes to
educational and nutritional advances for their children.
Additionally, where need and opportunity align, we build community
water facilities and partner with governmental and social impact
organizations like Heifer International, the Eastern Congo Initiative,
TechnoServe, the German Investment and Development Corporation, and
others--many of which are partially funded by the United States
Government and private citizens like Mr. Gates and Mr. Affleck. We also
work with OPIC, through which we purchase political risk and investment
insurance, and with fellow members of the private sector that help
finance the tremendous working capital requirements of these ventures.
Senators, I appreciate your time and the invitation to share our
story. I recognize that we are just one company operating in a limited
sphere of influence, but I hope we serve as an example of how an
American private sector participant--when aligned with like-minded
organizations--can produce benefits that are, quite literally, tasted
by ``the poorest of the poor'' around the globe--I hope and I believe,
to America's credit.
Thank You.
Senator Graham. Thank you all. That was excellent.
So we will have that debate later on, and I will take some
of your words to the Senate.
IMPACT OF SEQUESTRATION
Mr. Gates, you have been doing this quite a while in your
private sector role. If the budget cuts are enacted that we are
talking about under sequestration, scenario A, but if we
actually adopted what is being proposed in the Senate today, a
50 percent reduction, how would that set us back from your
point of view?
Mr. Gates. Well, I am very enthused about the progress that
is being made. And so it would be a tragedy as we see how close
we are on polio eradication that if we do not put out those
resources now, that disease will spread back and the amount of
money that you would have to invest to get back to where we are
would be absolutely gigantic.
If you look at a disease like HIV, through the President's
Emergency Plan for AIDS Relief (PEPFAR) and Global Fund,
millions of lives are being saved, and if you cut those
programs back, there simply will not be enough medicine to keep
people on treatment. The United States has been an incredible
leader there, has done a great job of drawing other governments
in. It is only through our generosity, though, that that other
money is activated. So if we cut back, I think we will see
other funds going away as well. Other governments, as a
percentage of their economy, are often quite a bit more
generous on foreign aid, and even so, because of the size of
the economy, because of the technical expertise we bring, the
U.S. finds itself in a leadership role that I do not think
anyone would be able to step up to. So it would be a huge
setback for childhood health, maternal health, disease
eradication, all these things that we are devoting our lives to
work on.
Senator Graham. Thank you.
SECURITY ENVIRONMENTS
Mr. Affleck, you have been, I think, very involved in the
security environment. All these development programs, whether
it be private sector, whatever, you have to have enough
security so that people from outside the region can come in and
help. What is your evaluation of training the security forces
as an American role? I mean, what benefit do we have not just
on the hard side, soft side, but actually training indigenous
forces? And how important is that to you in terms of your
potential success?
Mr. Affleck. Well, I think one of the greatest issues
facing the Democratic Republic of the Congo (DRC) now
particularly in the east is the lack of a security sector. Not
only that, but in fact there are times where the Congolese Army
(FRDC) preys on the population itself, a sort of philosophy, a
legacy handed down from the Mobutu days. We are not going to
pay you. You guys live off the land, euphemistically. And this
is an area that we are working in, but really this is a top-
down area. It requires leverage from the United States and
local regional actors to say--you know, include trying to end
corruption, trying to get soldiers paid. And those are
difficult things.
But one of the hardest things about that is to train
soldiers properly, and we are uniquely suited to do that and we
have been doing that. And the role of the United Nations
Organization Stabilization Mission in the Democratic Republic
of the Congo (MONUSCO), who has also been doing it, is somewhat
controversial, but it is absolutely something that is required,
particularly in light of what we are talking about, which is
this sort of nascent public-private partnership building
sustainable economic models where people are not just making a
living but they are being set up. Their capacity is being built
so that they can continue to make a living so that they can
contribute to their society, so that you can see the ripple
effect of this virtuous cycle. And that aspect of security is
really important.
You have areas in the north where we are doing work with
coffee collectives that are under threat from the Alliance of
Democratic Forces for the Liberation of Congo (AFDL), which is
an al-Shabaab-associated militia out of Uganda. When you have a
state--and I am not saying anything new here--that in parts is
failing, it is more vulnerable to that kind of extremism. When
you have a state where people are more prosperous, they are
able to resist that more effectively. In speaking to what the
Admiral said, I am certainly no expert, but it makes sense to
me when I hear folks like you and the Admiral say let us spend
money this way before we spend money on bombs.
But this kind of training is something that we can do. It
is relatively inexpensive, and we are the greatest in the
world, without exception, at knowing how to build and train
militaries.
Senator Graham. So the reason I asked that question, for a
small security investment, relatively small, not thousands of
boots on the ground, but sort of in a mentor, training role, we
can enhance everything you are trying to do in the private
sector.
Mr. Affleck. Absolutely. You protect our ability to make
those investments. You make people confident about making
investments.
You know, what Scott is doing--he is being modest. He is
essentially gap financing in places in the coffee industry
where people just are not willing to do it. And that is the
biggest impediment to business. And not only is he doing it,
but he is getting his investors a legitimate return. He is
making it capitalism and demonstrating that it is possible. In
order to do that, you have got to have a window of safety. And
that is one of the things that we are trying to expand in DRC
and with a little bit of money, a little bit of investment from
the United States, we can create enough safety that we can
encourage investment, public-private partnerships, the likes of
which I talked about in my testimony.
Senator Graham. Well, it is sort of a commercial for the
United States Africa Command (AFRICOM) too. I mean, they do go
together here.
IMPACT OF SEQUESTRATION ON HEALTH PROGRAMS
John, if we do the budget cuts under sequestration that is
being proposed or adopt the amendment that is being proposed
today, what does that do to all the success you have had in
mother-to-child AIDS transmission?
Mr. Megrue. Well, not surprisingly, the leadership that the
U.S. has and continues to provide is critical to the success.
And many people follow us. The Department for International
Development (DFID) from the UK, Germany, and most of the
developed world have followed our lead on this. And so when we
are making these kinds of investments in infrastructure, in
medicine, in treatment and training, to pull the rug out to the
magnitude of the kind of numbers that are being proposed today
really brings it to a complete stop. It is not the kind of
thing you can just meter back at these kinds of magnitudes that
are being discussed. It halts it.
In a disease like HIV, what that does is instead of
starting to in the case of mother-to-child, dropping it
dramatically, in the case of HIV overall, which is now
stabilized and starting to drop, you would see an explosion
right away. So from my perspective and the team on the ground,
we are really worried about that kind of move.
Senator Graham. Admiral, I know you are not wearing the
uniform today. Do you think it would be smart to take money out
of this account and give it to the Department of Defense (DOD)?
And do you think DOD really wants the money coming from this
account?
Mr. Stavridis. I think it would be a huge mistake. As I
hope I have articulated, you have to put these tools together
to create real affect in security.
SECURITY TRAINING
I want to underline the indigenous troop and training point
that Ben was making in response to your comment, Mr. Chairman.
And I will put a number on it. To sustain an American forward
in combat in a place like Afghanistan or Iraq is about $1
million a year for an enlisted troop. We can finance, train,
and put effective Afghan troops, for example, in the field, as
we do today, for literally pennies on the dollar compared to
that. So the efficiency of this I think is very, very important
to underline.
And I will also go back to what Mr. Gates and Mr. Megrue
were saying, along with Mr. Affleck, which is the cost here is
minimal. You leverage the private sector. And at the end of the
day, our security is like an iceberg. The tiny tip of it that
sticks up is the high-end capability. The mass of what we can
create is frankly in the private sector.
So I think for those two reasons, taking money away from
development and diplomacy and putting them into defense where
we have strong levels of resources would be a significant
mistake.
Senator Graham. I am a little over my time, but I will ask
one last question.
Scott, would it be possible for you to have done all of the
transformation in terms of the coffee business and creating
more disposable income without the Government infrastructure
that exists today?
Mr. Ford. No. I mean, if you do not have that part of the
apparatus in place, guys like me have nowhere to go.
Senator Graham. Thank you.
Senator Leahy.
Senator Leahy. Thank you, Mr. Chairman.
The chairman has mentioned that efforts that are going to
be made to cut this budget even further. The House and Senate--
the budget numbers were announced that those were cuts,
certainly well below the fiscal year 2015. The House even more
so, and they have talked about even beyond that.
I am thinking, Admiral--you mentioned the Colombia project.
I do remember our time working on that. You may be interested
in knowing I was at lunch with President Santos down there at
one point, and he went out of his way to praise you and the
project. So I mention that for whatever it is worth.
But let us assume that these cuts--we had level funding
from last year. Of that, $50 billion is--of that $50 billion, a
large part of it is used to run the State Department, our
embassies, our consulates, pay our diplomats. A portion is used
to fund ongoing programs we are committed to, treaty
obligations like the United Nations.
ADDITIONAL RESOURCES
Let me ask this question of all of you, and let us say
there was $5 billion in there up for grabs. We spend it anyway
you want. Any suggestions? Mr. Gates, you and I have talked
about this many, many times in my office. Where would you spend
it?
Mr. Gates. Well, there is an amazing number of NGO's that
work on areas of agriculture, areas of health, and I am sure
they would make a very strong case for any increase that would
be available.
The basic health structure in Africa is very weak today,
and as I said, that weakness means that if an epidemic shows
up, we would not see it soon enough to go stop it and it would
spread in the global economy very, very quickly, faster than
the Spanish flu did back in 1918.
Senator Leahy. In fact, you did an op-ed piece just a
couple of days ago in the New York Times. You talked about
that.
Mr. Gates. Right.
We are very much at risk unless the basic health and health
surveillance systems in Africa get improved. The current budget
lets us do that at a certain rate. If there were additional
dollars, we would accelerate improving that basic
infrastructure. And the beauty of that is that although it is
an insurance policy to prevent an epidemic, which would come to
these shores, it is also, year in and year out when there is
not an epidemic, an amazing thing to lift people up and
accelerate the time at which these countries will be self-
sufficient, both big contributors to the economy and able to
educate their own people, and provide health services.
So health and agriculture are pretty basic things, and the
formula for how you get better seeds out there, you get credit
out there, and you build primary health care--a lot has been
learned in a very sort of business-like way of looking at which
countries have done it well and spreading best practices. That
is so much stronger today than 10 years ago or 5 years ago that
extra money could be used very, very effectively.
Senator Leahy. Mr. Affleck, in the Congo--and I have read a
number of the things you have said about it. There you have
seen things that you thought might work and it did not. On the
other hand, you have seen things that have pleasantly surprised
you that worked. Suppose, using your experience, you were told,
okay, we are going to make you the czar of that $5 billion, how
would you spend it?
Mr. Affleck. The first thing I would do is surrender that
title.
Look, we financed a survey because one of the criticisms we
got was, hey, you cannot work there. Hey, it is too dangerous.
Hey, there is nobody on the ground. Our theory was we want to
support community-based organizations. We want to show up and
tell people what to do. I know I am the little guy on this
panel. So I can speak for the little guy and the grassroots
guy, which is to say that when we looked around, we saw a lot
of grassroots organizations. These coffee and cocoa collectives
are a perfect example of that. And we saw with our economic
development fund alone, it is expandable and scalable. All
across this part of the country, you have many, many, many
NGO's, local Congolese-based NGO's, who are doing extraordinary
work who are really wanting only for money. We can submit for
the record the survey that we did, but it is definitively
illustrative of it is not a question of where the money could
go, but of need.
I will say that I take that your real point is around
sequestration, around cutting the budget. And really, there are
two ways to go. As I said, this is a very nascent process--
these public-private partnerships, our ability to bring locals
into this partnership and have them commit to it, have them
believe in it. It is not like you have a line of people ready
to sort of sign up to this exact way of doing things. And we
ask them to change their practices and so on in order to create
a virtuous cycle, in order to have a contagion of success. And
that is what we have seen so far in just 2 or 3 years.
And I can tell you that taking away those checks, all of a
sudden pulling the sheet out from under that will have the
exact opposite effect. There will be a vicious cycle. People
will say, well, you cannot work with them. Well, you cannot sit
down with them. You cannot believe what Americans say. This
kind of process is never going to work. We would rather revert
to traditional aid where we sort of stand around and hope
someone gives us a check.
Senator Leahy. I do not want to put words in your mouth.
Mr. Affleck. You would not be the first.
Senator Leahy. If that happened and you had to try to
replicate it a few years from now, it is going to cost you a
heck of a lot more. Is it not?
Mr. Affleck. All the costs that we spent would be gone, and
then it would be twice as hard and twice as expensive to try to
do it again, to rebuild the infrastructure, to re-gather the
personnel, to try to reassemble what we had built and overcome
a history of mistrust, a history of disappointment, and frankly
people who had gone elsewhere, whether it is to do more or less
agriculture somewhere else, or in the case of eastern Congo,
having joined a militia, having gone to work in an illegal
mine. There are a lot of other places that people could be
working if they are told there is no longer a job for them
farming cocoa or farming coffee.
Senator Leahy. Thank you. My time is just about up. I do
not know if any of the other three witnesses want to take a
stab at this or all three, whatever you wish.
Mr. Megrue. Sure. I would just follow up on what Bill said.
There are so many needs in Africa, but the area that I see the
greatest leverage on our investment is investing in health care
infrastructure and not in physical plant and equipment, but
really in talent. The African health care systems are just
sorely understaffed. And what we have seen is by providing what
is essentially quite inexpensive talent to health ministers,
health commissioners, around very specific issues, whether it
is malaria, tuberculosis, HIV, et cetera, their rate of
improvement is extraordinary. So in states like Rivers State in
Nigeria where we have seen a 300 percent increase in 12 months
of mothers on treatment or Bayelsa State where we have seen 160
percent increase, that is done by inserting some people that
the health commissioners in that case can use to mobilize their
people and train their people in the right way.
Senator Leahy. Admiral.
Mr. Stavridis. Senator, I would say very quickly I would
take a significant chunk of it and do what you see in this
panel, which is using State and AID that have the
bureaucracies, leverage the private-public partnerships. And
you see both at State and at AID small numbers of people who
are expert at doing exactly that.
And then I have to give a shout out within this account for
the Peace Corps which I think is incredibly underfunded and
undervalued. Yet, every year at the Fletcher School where I am
the Dean of the School of International Relations, our largest
cohort walks in the door and they are Peace Corps volunteers.
And I hear their stories, and I know their impact in the world.
It is so wildly disproportional to the tiny amount of resources
they get.
Thank you.
Senator Leahy. Mr. Ford.
Mr. Ford. You do not have to spend it all. You could put it
to work in credit because credit is the lifeblood of commerce,
and credit is what is dried up and missing. The U.S. banks have
withdrawn completely from financing anything like what we do.
The European banks which used to finance it have withdrawn
completely. Our coffee business, all that we have talked about
today, funded by individuals, happens to be from the State of
Arkansas and the State of Texas who just care, and otherwise,
it is the Chinese that have come in. So if you have got access
to that kind of money, credit could use it too.
Senator Leahy. You are preaching to the converted. Thank
you for all that you do.
Senator Graham. Amen.
Senator Daines.
Senator Daines. Thank you, Mr. Chairman.
It is not often up here on Capitol Hill when you get to
have an inspirational morning. But I want to thank you. I want
to thank you each for your passion, your compassion, your
generosity, your kindness, as well as your vision. And I am
grateful for that that this morning.
TECHNOLOGY AND GLOBAL HEALTH
Mr. Gates, I heard rumors you had a background in
technology. I have had great respect and watched what you have
done for our country, as well as now for the world. Before I
came on the Hill, I spent 28 years in the private sector as
part of a cloud computing company we took public before--you
know, people back then thought cloud was something to do with
the weather, and we found it was something different than that.
But I would be curious around your thoughts of how you see
technology affecting global health over the next 15 years. You
have called that the big bet for the future.
Mr. Gates. Well, it is amazing how quickly these
innovations that are initially designed to be used in rich
countries--how quickly they can become very powerful tools in
the poor countries that we are talking about. We are looking at
using cell phones now to track the supply of medicines. It has
been very difficult to run supply chains in these countries,
and so often when you want malaria medicine or HIV medicine or
reproductive health tools, they are just not available. So we
are going in right now together with USAID and others and
looking at this supply chain capability and saying we should
know whenever there is a stock out. And as soon as you have
that kind of information system, you are able to raise the
reliability very, very dramatically.
A lot of the challenges in primary health care have to do
with the workers showing up and the quality of their work, and
by simply tracking their activity, having them take photos when
they come in in the morning to show that they are there, taking
a photo of what is in the clinic, that it is well maintained,
we see a way to very efficiently improve the quality of the
services delivered. And so this digital realm is giving us this
unbelievable gift of patient tracking, supply tracking, labor
quality.
And then, of course, over in the biological realm, the
innovation there of creating new vaccines, new drugs, giving us
the tools that will give us a chance to say that malaria, after
we finish polio, will be the next disease that we will go after
eradication.
So without that help of new technology, many of the goals
that we have just would not be realistic. Because of
breakthroughs, some funded by the National Institutes of Health
(NIH), some funded by foundations like ours, most funded by the
commercial sector where it is simply a reuse of the same cell
phone or Internet technology, that is why we can be so
optimistic about what a little bit of aid money could do to
help these countries.
POLIO
Senator Daines. Mr. Gates, you mentioned polio. As a
Rotarian, I have been excited to be part of that effort, and
what you all did there--we are very, very close now to
eradicating polio in the world.
How can that story of the eradication of polio be a model
for future success when we look at other public health issues
that need to be tackled in order to bring parts of the world
both out of poverty and into economic success and stability?
Mr. Gates. Well, polio has been an amazing campaign, and
Rotary has been the lifeblood of keeping the energy there, even
as it proved to be more difficult than was expected back in
1988. Today we have not had a case of polio in Africa for over
6 months. So the only two countries we have seen cases in in
the last 6 months are Pakistan and Afghanistan. And even there
where it is difficult, the government, the army, the NGO's are
coming together. And so we are very optimistic that in the
years ahead, we will see the end of polio.
There are a lot of lessons about how you orchestrate
people, and it is a commitment of the polio eradication
campaign that we will not just get rid of this disease, but we
will leave behind far stronger health systems. For example, in
the case of Nigeria, as we did polio eradication there, we saw
that the basic structure of the way they budgeted, the way they
managed the supply chain was not handled very well, and now
through polio-funded initiatives, that is being put on a much,
much stronger basis.
And so the success of polio will let us pick other
diseases, including malaria, to go after with the confidence
that we have learned how to do it.
Senator Daines. Thanks, Mr. Gates.
PUBLIC-PRIVATE PARTNERSHIPS
Mr. Megrue, I was struck by your testimony as well as being
a voice for the voiceless, these babies that are now being born
HIV-free.
Regarding the public-private partnership that has been
described--we will be discussing the funding issues today with
a vote-a-rama on the floor of the United States Senate. And
expanding our thinking even beyond the funding side of this,
what other barriers do you see that we could work to remove or
incentives to create to foster more of what you all are doing?
Mr. Megrue. I think there are two pieces of that. Of
course, there is corporate investment and then private,
philanthropic investment. I think the U.S. does have a chance
to accelerate and sort of match funding ideas that they have
experimented both with other governments, as well as with
corporations and large foundations like Mr. Gates, because
there is a big leverage point to have leadership like the Gates
Foundation can provide to make sure not only--which he does
with his investments but that he can do in a highly leveraged
way with the U.S. Government's funding next to him. So we see
that in many countries. We are working right now and moving
into Kenya and Uganda and Angola and other places. But the U.S.
Government's investment in time and energy there has been
central to creating the kind of dialogue that allows us to
leverage what somebody like we can do.
Senator Daines. Thank you.
Mr. Ford, given your background as well in the private
sector and jumping into what you have done, any thoughts on
that as well, other barriers that we could work to remove,
incentives to create to foster what you are doing?
Mr. Ford. It is a bit of a stretch, but the U.S. banking
system, from what I can see--I knew a lot of bankers. We did
the largest leveraged buyout (LBO) that had ever been converted
to a sale in the history of the U.S. in one check. I knew about
every banker in the country. None of them would go with us to
Africa, and they all pointed to the regulations facing them
that caused them to say we do not know how to comply, and so we
do not know what they are and we are withdrawing. And I had
them tell me that face to face one after another after another.
How that factors into what we are talking about here today
is not clear to me, but it is the reason we had to revert to
gap funding by individuals for projects like this.
Senator Daines. Thank you.
Senator Graham. Senator Merkley.
Senator Merkley. Thank you, Mr. Chairman.
GAVI
Mr. Gates, thank you for the work of your foundation. And
you started out your testimony talking about the Global
Alliance for Vaccines and Immunization (GAVI), the vaccine
initiative, and the basic numbers presented in your testimony I
believe translate to about 25 bucks per vaccine and about 1,500
per life saved. I have heard the international vaccination
effort described as the single most cost-effective way to
influence global health. Is that a fair way to put it?
Mr. Gates. Yes, absolutely. There are two things we do by
vaccinating children. One is that we save lives, and as you
said, that comes down to less than a few thousand per life
saved. But also for every life we save, there are about four
children who would have grown up malnourished, that is, their
brain and their body would not have fully developed. And if you
look at the burden on the countries here, it is not just the
level of deaths, it is the level of sickness so that even when
those kids do get a chance to go to school or eventually
participate in the economy, the fact that their health has been
so poor completely holds them back. And so the vaccine
investments would make the top of the list in terms of enabling
them to support themselves.
Senator Merkley. So the U.S. contributed or pledged $1
billion, including 2015, as you mentioned in your testimony.
Was that the amount you hoped for, or should we have done more?
Mr. Gates. We were very pleased that the U.S. made an
increase. In that case, every 5 years, that fund gets
replenished. We are a big contributor to the fund. We got a lot
of other countries to step up in a big way. Actually the UK is
the single biggest contributor to that. We are the second. The
U.S. Government would be third. So there is always room to do
more, but we were pleased with the increase.
Senator Merkley. Thank you. That was diplomatic and well
stated.
DRC
Mr. Affleck, you have been traveling to east Congo since
2007 I believe. How did you get engaged in the challenges of
central Africa?
Mr. Affleck. I originally got--back then, there was a lot
of activity going on around western Sudan, and I got asked to
be part of that. And I really did not know a lot about it, and
I did not want to be a dilettante. So I started doing a lot of
reading and studying and meeting folks. And then I was shocked
to see the degree to which, the scale of which the wars in
central Africa and particularly in Congo, the great war of
Africa, was dwarfing what was going on in Sudan, not to
diminish that obviously. And I figured, A, if I had never heard
of it and, B, if it was as big a tragedy as was being
described, that ought to be a place I should get involved.
And so Whitney Williams and I started this organization,
started traveling there, and we went around to about 11
countries around Congo and really just started looking at it
and thinking without the sort of assumption that, well, I am a
celebrity, I must be able to help, I thought, well, what can I
do. What can be done? And ultimately we decided that we wanted
to help foster a lot of these community-based groups that were
not able to get money from the United States, that were not
able to get the kind of capacity building because they were too
small. And we wanted to be dexterous and we wanted to be
nimble.
And really, once I had been to Congo a few times, there was
no turning back. You see people suffering as much as these
folks are suffering, fighting as hard as they are fighting. And
I thought I would get there and find people just cowering and
on the ground, and instead you find people going to the market,
trying to get a job, trying to take care of their family in the
midst of, as Senator Graham was there, grenades going off and
all that stuff. Life flourishes and people try and people
exhibit kindness and compassion and they want to take care of
their families. And I was so moved by that spirit that I
thought this is the place where I belong, and I want to try to
do whatever I can.
Senator Merkley. Well, I want to celebrate the model of
looking around the world and saying is there something that I
can have an impact on for every American to think about because
we are part of the global community and to take it as seriously
as you have taken it and to look for real solutions.
You said in your testimony something that caught me a
little off guard. I would have said ``really?'' and that was a
country that could feed a third of the world. Could you expand
on that a little?
Mr. Affleck. Yes. Well, it has just got a gigantic amount
of arable land. It has got the world's second biggest
rainforest in the world. I mean, Congo is a massive country. A
lot of it is under-populated. There are huge jungles, the
hydroponics there could power all of southern Africa. And it is
also extremely wealthy in copper, tin, tantalum, coltan,
charcoal, lumber, gorillas. I mean, it has every conceivable
natural resource. In fact, that may be one of the great
tragedies of it. There were six or seven countries there during
the war trying to grab at what they could, diamonds. It has
incredible potential.
And it suffered from King Leopold and the Belgians and
Mobutu, down to the Rwandan genocide that sort of spilled over
into Congo. So it has had a lot of bad luck, but it has got a
tremendous amount of hope. And the people are great people.
And now is the time. You know, they are taking these steps
into democracy, and they are occasionally taking to the streets
to demand that the democratic changes are transparent. It is an
exciting time, but it requires our engagement, our continued
engagement, a new envoy, continued engagement from the
Secretary to support these commitments that both folks in the
private sector, and Raj Shah I know left a couple of weeks ago,
whatever it was, but his commitment to USAID there and all over
the world is important. And I think it is morally important
that we maintain the continuity of those commitments.
Senator Merkley. Well, thank you for your hugely
substantive engagement, and I am pleased that USAID has paid
attention. I appreciate that Russ Feingold brought his
expertise to bear from his Senate experience and the whole
combination, many people coming together to make a difference.
An election is coming up in a few months?
Mr. Affleck. There are elections, but again, this is why it
requires engagement. It is a little complicated. The president
initially attached elections to a census, sort of got it
through the lower house, and then once it went to the upper
house, people objected to it. So he retracted. They are having
this de courtage--my French is not great--which basically means
they are going to carve up the existing provinces into fewer
provinces, a process of decentralization, which is
fundamentally popular in a country that big. However, people
are suspicious that because they are not really ready for de
courtage, it is a way of postponing presidential elections.
The long and the short of it is diplomacy does not cost a
nickel, and we need to be engaged diplomatically. There is a
lot of suspicion in many African countries of some of the
former colonial powers. There is nothing but a lot of respect
and admiration for the United States and our people, and we
ought avail ourselves of that diplomatically.
Senator Merkley. It is tremendous. Thank you.
And my time is out, but for the balance of the panel, each
of you are doing really important, valuable work. So often
international aid is framed as, well, why should we be helping
overseas when there are so many challenges here at home? And
that is a question worth asking, but let us look at it also the
other way. Given the gravity of issues around the world, should
the U.S. as a leader in the world not be engaged? And does it
not contribute to the relationships and the partnerships that
help address world security issues as well? And you mentioned,
Admiral, about the soft power side. So while we are doing
really positive things for quality of life, we are also doing
things that are valuable to the United States. Thank you for
all of your work.
Senator Graham. Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman.
Thank you. Your work really is truly inspirational and
hopefully we will have, in part, a shaming affect on the United
States Congress as we engage in a debate that will make your
work harder.
SECURITY IN DRC
Mr. Affleck, I wanted to continue talking about the work
that you have done. A few months ago, a story came out that the
World Food Program had run out of money to serve Syrian
refugees, the consequence of which was pretty clear. These were
individuals who had no choice but to feed themselves and their
family. And so if they were not getting that sustenance from a
legitimate source like the World Food Program, then it was
groups like ISIS itself where they were going to be forced to
turn to for a paycheck and for a square meal for them and for
their family. And so as we were battling ISIS, we were making
decisions to underfund humanitarian resources that had the
effect of driving people to the very organizations that we are
trying to eliminate in the region.
And I imagine this plays out in the Congo where you have
choices to be made. You have militias from the Lord's
Resistance Army to M-23 that are offering help to these people
in the form of small paychecks and sustenance, and if they do
not have legitimate sources of income, I imagine that that just
drives recruitment into a lot of these illegitimate sources and
just creates more of the kind of problem that we are trying to
solve.
So I would just love to hear you talk a little bit more
about how this plays into the security dynamic inside Congo.
Mr. Affleck. In countries like this, you see a clear
correlation between increased security and increased economic
development, as you pointed out. It is really not debatable.
And you know, like Hezbollah in southern Lebanon, when they
step in and fill those roles, it creates problems. As I was
talking about the Alliance of Democratic Forces for the
Liberation of Congo (AFDL), they essentially are present in
areas where our coffee manufacturers and our cocoa farmers
rather are present.
Now, if this all goes away, if the funding is removed, if
we are not there, it creates a very different environment.
Either people have to flee or they have to join up with whether
it is them or the Democratic Forces for the Liberation of
Rwanda (FDLR), as you said, the M-23 or the many, many Mai Mai
militias, oftentimes people are forced to join militias just to
protect what meager things they have. And if they just have a
job, if they just have a purpose, they will stick with it,
frankly, under really, really difficult circumstances. And it
is when people run out of options, that they either go work for
slave labor in some mine and be exploited or engage in all the
kinds of activity that we collectively understand as either
abhorrent or virtually sort of slave labor. And it is really,
really important that we support the civil society that is
burgeoning in these countries and support the economic growth
so that people have a place to go.
I think you make a very good point. And Congo, as it
becomes better developed, will no doubt become more peaceful.
Senator Murphy. Admiral Stavridis, one of the challenges
that we have is figuring out who to fund. We have an interest
in making sure that the money goes immediately to the best
purposes, which often means funding really well organized
nonprofits, but in the end, we have an interest in good
governance. And so there are reasons to run the money through
local governmental institutions.
FUNDING MECHANISMS
I know the answer is different in each place, but as we
look at some of the most dangerous places in the world, parts
of Africa that we are talking about today or the Middle East,
what is your recommendation and guidance as to the source of
this funding?
Mr. Stavridis. Thanks, Senator. I think you hit the nail on
the head in that it is different in each of these different
venues. But as a general proposition, using an agency like AID,
Millennium Challenge, or State as a vetting kind of authority
can be very helpful.
Secondly, depending on the individual state--and most
recently, for example, Afghanistan. We have had a lot of
controversy about whether this aid should flow through Kabul or
go directly out into the field. There are even micro-climates,
if you will, wherein you can be confident in Mazar-e-Sharif in
the north, relatively confident in Herat in the west, but you
ought to be a little more concerned as you get down toward
Urozgan province or into Kandahar. So the point is there is no
substitute for local knowledge, local expertise. You should
kind of turn first I think in this case to the U.S. Government
as a vetting authority.
And I want to close by saying I am very encouraged by some
of the reforms that Raj Shah put in place at AID to improve the
capability in this particular, very important aspect of things.
Thank you.
Senator Murphy. I just want to close with a question to
you, Mr. Gates. You are, obviously, a technology expert, as
Senator Daines noted, but you also know something about
marketing. And we are in a position today, as we have noted,
where most Americans think we are spending about 23 percent of
the budget on foreign aid. And the reality is even worse than
it first appears. Yes, we are spending only 1 percent, but if
you go back to the peak of foreign aid, the Marshall Plan, at
that point, we were spending .3 percent of GDP on foreign aid,
a program that I think everyone agrees has a good deal to do
with the world order that we are living in today. We have got a
94 percent decline in foreign aid spending as a percentage of
GDP since 1950. And yet, people still believe that it is a much
bigger share of the budget than it is.
PUBLIC PERCEPTION OF FOREIGN AID
What is your quick recommendation as to how we change
people's perception? What are the two or three most salient
points from a marketing perspective to make people understand,
to make our constituents understand that we have got to be
dramatically increasing the share of the Federal budget or at
least a portion of the Federal budget that we are spending on
well-run programs?
Mr. Gates. As you say, most people grossly overestimate
what portion of the budget is going to these things. And if you
ask them, hey, what portion should go, they will say 2 or 3
percent, and of course, our response is, great, we would settle
for that in a second. That would be a gigantic increase.
In terms of the share of budget or share of the economy,
the U.S. is relatively low compared to other countries. In
fact, the UK as an example raised their level up to be over
three times what our level is at a time where they had very
substantial deficits. And it was a decision that the relative
impact of the aid dollars was very, very high.
It is unfortunate that the historic picture people have of
aid is clouded somewhat by aid given during the Cold War where
it was more about the bad guy or who was our friend than about
the humanitarian impact. Today, the aid budget is not burdened
by those things, and we are able to go in with the same
business-like thinking that I applied at Microsoft and said,
hey, is this money being spent the best way that it possibly
could.
And the percentage of the USAID budget where our foundation
is doing something in partnership with the U.S. Government is
very, very high. So we get the analytic capabilities of USAID
that are better today than ever, combined with ours and that of
other people. And so there is a lot of learning that is going
on in areas like agricultural and livestock. It is very
exciting the new things. We are finding how to get new seeds
out and how to raise the productivity and how to create self-
sufficiency.
And so if people knew how small it was and how careful we
are to make sure that there is impact, I think we would get
strong support for the modest level that we are hoping to
maintain.
Senator Murphy. Thank you to all of you.
Thank you very much, Mr. Chairman.
Senator Graham. Senator Moran.
Senator Moran. Mr. Chairman, thank you very much.
Mr. Gates, nice to see you again. We have had a
conversation for several years about eradication of polio in my
role and capacity on the Labor, Health and Human Services, and
Education, and Related Agencies Appropriations Subcommittee. It
seems to me we are making significant progress. Thank you to
your foundation for working so closely with Rotary
International.
POLIO
But there have been outbreaks of polio in Kenya, as I
understand, cases that are now being reported. How close are we
and what more is it going to take to finally put this
circumstance to an end?
Mr. Gates. Yes. The first half of 2014 was a concern
because we had cases that had come up in Syria, cases that had
come up in Somalia that spread to Ethiopia and Kenya.
Fortunately, those outbreaks are now under control. And the
country we thought would be the last, Nigeria, has not had a
case since July 24th. And so if we are lucky and if we go
another 6 months without finding a case, then we would be quite
sure Africa may have seen its last case.
And so the focus now in Pakistan and Afghanistan is very
intense, taking some of the same tactics that worked in
Nigeria. And I would say we have a period of relative stability
where the area up in the federally Administered Tribal Areas
(FATA) that the Taliban controlled where kids were not being
vaccinated--because the Pakistani army has gone in there, we
now have access to enough children that we can succeed in
Pakistan. So we are very hopeful.
And the polio budget, which is a combination of some of the
foreign assistance account and the Centers for Disease Control
and Prevention (CDC) budget--that has made a huge difference.
There was an increase there. CDC is an amazing organization, a
great partner. I was down there, spent the day with Tom Frieden
just a few weeks ago talking about Ebola and polio and how we
work together. Very impressive. And the extra resources are
making a difference.
Senator Moran. Well, congratulations on your success and
thank you for your commitment.
EBOLA VIRUS DISEASE
Let me ask just the panelists generally. What has been the
consequence of the effort by the United States and the world
community in regard to Ebola? What are lessons that are
learned? What does it tell us that we ought to know to prevent
circumstances such as this from occurring with this disease or
any other medical health affliction? What can we learn from the
world response to the arrival of Ebola in West Africa?
Mr. Affleck. That is you, Bill.
Senator Moran. My press staff is going to be disappointed
that I did not get an answer from Ben Affleck.
Mr. Affleck. Believe me, you made the right decision.
Mr. Gates. Well, all the things we do to build up
stability, particularly what is called the primary health
system that reaches out even to the poorest, most rural areas,
when you do not have good primary health care, that means an
epidemic can get started without the global awareness to go in
there and intervene at the early stage. And because infectious
diseases are exponentially explosive, the 6 months that we
missed in Guinea because we did not know what was going on,
that is what led to it being such a gigantic outbreak.
We are very lucky in this case that the agent was not more
infectious. We are lucky that finally when it was recognized
last August, that the world, particularly the United States
CDC, has done a phenomenal job here. The U.S. military came in
with the logistical capabilities that were lacking there. That
was invaluable.
But we are likely to see sometime in the next 20 years a
far worse pathogen than Ebola, and by having high-quality
primary health care, good surveillance in Africa where it is
very likely to emerge, we will be able to catch it at the early
stage and not have it become like a 1918 Spanish flu. So it
really underscores the investments we have made and the need to
do even better on the surveillance front.
Mr. Stavridis. May I comment on that, Senator?
Senator Moran. Yes.
Mr. Stavridis. I just want to pick up on what Mr. Gates
said about the--there is a role I think for militaries here.
This is a classic example of soft power. The militaries, in
which we invest so much, have not only hard power warfighting
capability but enormous logistics muscle, manpower, a
capability directly impacting the medical field. So as a kind
of ``point of the spear'' response to get all of the real
professionals in there, I think there is a role for the
military.
I will add that speed is really the key particularly if a
pandemic morphs the way that Mr. Gates is talking about. Think
World War Z. There are examples not only in the real world but
in fiction that would tell us we need to be ready for this. And
I do want to just underline that.
Senator Moran. I appreciate you indicating that because I
think the initial response by many Americans when the idea of a
military was going in to battle Ebola was that is not what we
train military men and women for. That is not their mission.
Why are they being called on to do that?
Mr. Stavridis. A good way to think of that is an on and off
switch. You know, life is not an on and off switch. In other
words, we do not fund this magnificent military just to be in
combat, on, or to sit in a barracks, be a ship tied at the
pier, or an airplane that is on a runway somewhere, off. It is
a rheostat between hard power, which we need at times, but also
to bring this logistics, this expertise, this information, this
intelligence to bear in a crisis like this at speed. We can
dial that rheostat toward the soft power at that moment, and it
is a very effective way, cost-effective way to use our
military.
Senator Moran. I appreciate that answer, and I would use
this opportunity to thank Kansas Guard members who were called
to duty in the fight against Ebola in Africa.
And, Mr. Gates, I would reiterate what you said about CDC.
All Federal agencies are subject to criticism. I am a fan and
supporter of Dr. Frieden and the efforts--Ebola and many other
aspects of what CDC is doing, including prevention here in the
United States and community health center.
Thank you very much to the panel for being here.
Senator Graham. Senator Coons.
Senator Coons. Thank you, Chairman Graham, for calling this
hearing, and I would like to just follow the line of
questioning my good friend, Senator Moran, has been leading.
I had the opportunity to visit Liberia for the third time
in December 2014 and to visit with our troops and missionaries,
nurses, doctors, folks from the uniformed Public Health
Service, many of the troops from the 101st, and to see the work
they were doing on the ground. I also saw the impressive impact
of the collaboration between significant private sector donors,
between continent-wide organizations, and between grassroots
community groups. I would like to explore two different points
on that if I could.
EBOLA VIRUS DISEASE
First, Mr. Gates, as you referenced, we may well face a
pathogen more lethal, more rapid in its spread than Ebola in
the coming decades. In fact, it is likely we will.
We have made some significant progress in vaccines as well,
developing both a field test for Ebola, and making progress in
vaccines for Ebola brings some real hope about this particular
episode hopefully coming to an end within the next few months.
In addition to the importance of having an African CDC for
early warning, how do you see the path forward on vaccine
development and strengthening the capabilities for rapid
characterization and rapid deployment of a vaccine in the face
of a more lethal pathogen?
Mr. Gates. Well, it is amazing to how the little the world
has prepared for a serious epidemic. The U.S. has done more
than any other country, but even there we have not done enough.
The Ebola vaccine--and there was actually an Ebola treatment
called ZMapp--was partially ready, but the time it took, even
using very unusual regulatory approval and trial processes, the
time was too long for it likely to have any impact on this
particular epidemic. And so our state of readiness was not as
strong as it needs to be.
We do need to draw on other countries to also contribute to
these efforts. We do need to take the various agencies of the
U.S. Government who work on this and make sure that we have an
overall strategy. One thing that I have called for is that we
ought to do--in the same way we do war games to simulate
challenges coming at us on the military front, that we ought to
do germ games where we look and see how we would respond. The
last time that was done in the United States, 2001, Dark Winter
looked at a smallpox epidemic, and the resources proved
inadequate in that case. So there is a good foundation. There
is a lot of good science. NIH is the leader in many of these
things. And so the idea that tools could be created quickly--
that is a possibility, but we are not there yet to say that we
are prepared.
Senator Coons. Well, I think there are important lessons
for all of us to learn here, both about the strength of
community health systems, the capabilities of community
responders, and the huge cost we ended up having to invest and
the significant loss of life that could have been avoided. I do
hope we take your advice and work together in a responsible way
to make sure we have those capabilities.
NATURAL RESOURCE EXPLOITATION
Let me talk next, if I could, about natural resource
exploitation. As you know well, Ben, eastern Congo has been a
victim of lots of different ways for illicit exploitation of
natural resources. Wildlife trafficking has caused real crises
in the Congo Basin and other places on the continent, as well
as illegal mining and extractive misuses of natural resources.
And we are increasingly focused in a bipartisan way in Congress
in how that also helps fund and fuel extremism, and both
transnational both criminal and terrorist organizations. So I
would be interested, Mr. Affleck, to hear what you have seen in
eastern Congo about this.
And, Admiral Stavridis, if you would talk about how this
intersection between issues that are typically the concerns of
conservationists and wildlife advocates have now really been
put on the radar for national security issues.
Mr. Affleck. Well, first of all, Senator, I want to say
thank you very much for all the work you have done. You are
just one of these great unsung heroes on these issues--or maybe
partly sung. I do not know how ``sung'' you are, but you are a
hero.
Senator Coons. I sing off key, so not well sung.
Mr. Affleck. But thank you very much.
I can just speak to what I have seen and experienced, which
is, as you point out, there are a tremendous amounts of
resources there, you know, gold, tin, tantalum. It goes on and
on. And almost all of them are dominated either by militia
groups or by a sort of quasi-mafia military organization. Then
really, that also has the same effect of empowering people who
are not doing great things and have a pernicious effect on the
country itself.
I talked about the Alliance of Democratic Forces (ADF) in
the north. There is the Democratic Forces for the Liberation of
Rwanda (FDLR), which is the former Armed Forces of Rwanda (ex-
FAR), the people who committed the genocide essentially in
Rwanda and the organization that they founded and maintained
inside Congo, which they are now sort of taking on half-
heartedly.
But, you know, what happens is when these industries are
unregulated, they are controlled essentially by low level
mobsters who then have allegiance to higher level
organizations. And you have a country that has consistently
been on the top 10 list of failed states. And so you have a
security sector situation that is wide open to be exploited and
manipulated.
I think there are two things to do. One is to try, as best
we can, to help them regulate these industries, which is going
to meet with a ton of resistance. And two is to try to really
examine--look at these groups, see where the money is going,
see what they do. One of them is an extremist Muslim group.
Others are just as violent and hideous but subscribing to
different religions. The truth is it is there. It is happening,
and none of these extremist organizations, none of these
militias survive, even though the cost of an AK-47 there is 40
bucks. None of them survive without these resources.
I do not know if you saw the movie Virunga, which is quite
good, that park which is fighting for its life, quite
literally. One of the things that is undermining them is there
is a charcoal trade, which is illicit and makes a lot of money,
things like timber that you would not expect. But all the
resources that are there are being swallowed up by these
illegal organizations who pay tariffs to the various powers
that be. And it is one of the things bedeviling this country
and preventing it from achieving real progress.
Senator Coons. Absolutely. Thank you for your leadership on
combating this and making it better known.
Admiral Stavridis, how are we doing at bringing together
our military expertise and resources and the fight against
illicit wildlife trafficking, illegal mining, and how does that
destabilize vital allies in the region?
Mr. Stavridis. We focus insufficiently on this as a
security problem. As Mr. Affleck correctly points out, it is
the corruption and the financing that comes out of it that then
undermines these fragile democracies, creates ungoverned space,
and leads directly to security challenges which are global.
And, of course, it is not just in the Congo. It is in Latin
America and the Caribbean. It is in Afghanistan. It is in the
Caucasus. It is very concerning. And we tend, as always, to
look first to the hard power solution, but this is a case where
many of the soft power things we are talking about, creating
jobs, education, opportunity, you play the long game and you
have a better chance of creating security.
I will close by saying another aspect of this is the routes
that come out of it. So if you are moving natural resources
that you have stolen or you are moving cocaine or opium, these
routes create the opportunity to move weapons, extremists, and
at the really dark end of the spectrum, weapons of mass
destruction. So that is another shrimp on the barbie of concern
I will throw out there.
Thank you.
Senator Coons. Mr. Chairman, would I be overstaying my
welcome if I asked a last question?
Senator Graham. Not at all.
MOBILE BANKING
Senator Coons. If I might, to anyone on the panel who
chooses to respond, mobile telephone technology has transformed
the possibilities of connection to the modern economy through
mobile banking, real-time knowledge about everything from
incidence of violence to grassroots political movements.
Campaign incidents in Kenya, for example, were first documented
using an open-source platform that Ushahidi built. Some real-
time knowledge about the spread of Ebola and being able to do
tracking was significantly facilitated through cell phones,
which have now penetrated 70-80 percent of many of African
countries.
How do you think we might partner with African nations to
both unlock the potential of access to resources for the
empowerment of small holder farmers and women's cooperatives
through mobile banking? And how might we strengthen the ability
of citizens to engage in the fight against corruption, against
wildlife trafficking, against extremism through the platform of
mobile communications? Any member of the panel who chooses to
answer.
Mr. Affleck. Is this a technology question?
Senator Coons. Yes, sir. That does suggest a first answer.
Mr. Gates. It is very exciting what we are going to be able
to do over the next decade. I would say we are just at the very
start of that. In the case of Ebola, we were not able to track
movements as well as we would have liked to. Having in place
the ability to look at the data and make sure that we were not
violating people's privacy--that was not set up. I think now
that we have, in a delayed way, looked at that data, what we
would have known better--that is a great impetus to move
forward.
In terms of the Congo, the technology that is even more
basic but is very critical is the satellite photography. The
U.S. military, of course, has funded the creation of those
technologies. Now, in civilian hands, people like Digital Globe
are able to show us, knowing the population of DRC, knowing
where the farming is taking place. We are doing a lot of
funding people to do surveys like that because we have
medicines for things like sleeping sickness, and figuring out
where are the people and how do we get it out logistically,
which is incredibly difficult in the DRC. It is only because of
these digital satellite platforms and over time the increased
penetration of cell phones. We think even in tough countries
like that we will be able to get in and do great things.
As people are able to do digital transactions on the cell
phones, things like remittances, getting back with lower fees,
countries being able to understand their economy in a much
better way, taking government payments that has always been
inefficient and actually fairly corrupt before it gets out to
the recipient that can be done to the woman's cell phone, that
can make a huge difference.
So there is a ton of pilot programs involved in this. Many
of them are involved in what you said, preventing corruption,
by actually documenting what is going on when it goes on. If
you ever have to go back and say, oh, did this seminar take
place or what this payment made, the paperwork when it really
did and the paperwork when it really did not, it is not easy to
distinguish. But if you get photos taken while things are
taking place, it is very possible to make it almost impossible
for the money to go astray. So there is a lot of promise.
Senator Coons. Well, thank you. I appreciate the answer.
Mr. Stavridis. Can I add? Just a practical example of what
Mr. Gates just said is in Afghanistan where we pay 352,000
Afghan troops, but we have moved that to a mobile system. A,
they do not have to go back to their village to take their
tattered stack of currency, and B, it is documented. The
corruption piece washes out.
And another technology that I think is interesting here is
unmanned aerial vehicles, drones, which have a bad rep for a
lot of reasons. But here is a place where they can be used very
effectively to do the kinds of surveillance that Mr. Gates is
talking about in Africa and in other areas to look at crops, to
look at tracking, to look at who is trying to go after the
black rhino, et cetera.
Thanks.
Senator Coons. I think there is huge potential for us to
make a difference.
Mr. Chairman, I will allow Mr. Affleck a last----
Mr. Affleck. Just briefly, as Mr. Gates said earlier,
existing cell phone technology is extremely potent from what I
have seen. It is just a question of training and exploiting
what is already there. And it makes a big difference. And one
of the steps that we have seen in Congo that has been proposed
and I think will be incredibly helpful is to use cell phones
for banking ultimately so that if you are a soldier, the money
actually gets to you because it is transferred directly to you.
The way it works now is you make literally no money. I mean,
you should see the FRDC's barracks. They are like tent cities.
This is your national army? You know what I mean? Guys stealing
pots and pans, and that is why you have these rapes and that is
why you have this impunity. And this is not evil people. They
want to be soldiers. They are put in this position. But if the
pay did not have to go through seven officers who all took
their cut and the guy before the soldiers who took the final
cut, you would revolutionize the way that the armed forces work
there, and they would go from being a really protective force
to one that is a pernicious force. That is just one that I know
of, but Mr. Gates said there are many, many more.
Senator Coons. Well, thank you. I would like to thank the
whole panel for your contributions and for your testimony
today.
Mr. Chairman, I want to specifically thank you for your
real leadership over many years in making sure that our
investments in foreign assistance contribute to our national
security, and appreciate your calling this hearing today.
Senator Graham. I thank the whole subcommittee. We have got
a hard stop at noon, but Senator Blunt is here. So he will be
our last inquisitor.
Senator Blunt. Well, Chairman, thank you.
We had the Secretary of Labor at our hearing who was not
nearly as popular as your panel, I am sure.
I will have some questions for the record.
Let me just say that for the work that this panel
represents, the great private sector partnerships that are
going on out there with what we do in areas like PEPFAR, the
mother-to-child AIDS transmission successes are incredible. The
ag research successes are incredible. What is happening in the
Congo. And this really brings a level of attention to your
leadership and the work we are doing here and also the
importance of finding successes that we can talk about where we
started a program, we worked with local partners, and at some
point, we were able to walk away and leave that program with
somebody else. It is the kind of thing that creates an
understanding and an appreciation for the importance of what
this subcommittee does. And the partnerships here are
incredibly important in encouraging our role to make a
difference around the world.
So, thank you, Chairman, and I will have some questions for
the record.
Senator Graham. Well, thank you, Senator Blunt. You have
been on every trip I have ever put together. This is a great
subcommittee, Republicans and Democrats.
Senator Blunt. I would like that struck from the record, if
you do not mind.
Senator Graham. And we have gone to great places like the
Congo, places I think most people appreciate you going because
it means a lot to us.
In 2 hours, we are going to vote to cut this account in
half. So this is a perfect day for you to be here. You made a
compelling case. Scott, we need some financing we do not have
today. I think I have learned a lot from the hearing. You have
made a compelling case that we are inside the 10-yard line on a
lot of these problems, mother-to-child AIDS transmission. The
Congo may be turning a corner. Bill, polio. We got all this
stuff on the run. And in 2 hours, the Congress, the Senate is
going to have the chance to cut this account by 50 percent.
Only in America. Only in Washington.
So in about 30 seconds apiece, tell me why that would be a
good idea or a bad idea. Scott.
Mr. Ford. The footprint that America has in Africa, which
is the only place I have got any direct experience, and the
goodwill that we have inured there through the public and
private sector engaging with the Rwandan leadership, with the
Congolese leadership, and Uganda and Tanzania--to withdraw
right before we win the game is to throw a pass when you are on
the 1-yard line.
Mr. Affleck. I thought that was a good play.
Senator Graham. I am sure you just made yourself a big hit
in Seattle.
Admiral.
Mr. Stavridis. I would say that we ought to look hard at
what is efficient here, and the tiny cost of this account, as
it is represented in the President's budget, is pennies on the
dollar. It is like preventative medicine, which we have talked
about a lot today. Do you want to spend money on massive
treatment once the disease has taken place? That is hard power.
Or would you rather have a program that is preventative, that
looks at health on a day-to-day basis? That is soft power. It
is much less expensive. You need both. There are times when you
have to have hard power, but that balance between hard power
and soft power, that is smart power. Let us be smart and not
cut the development and diplomacy tools. They are absolutely
necessary.
Thanks.
Mr. Megrue. Thank you, Senator.
One of the most basic business tenets that we learn early
in our career is do not withdraw or blink when you are past the
tipping point of success. And we are past the tipping point of
success with this account in so many ways. We have heard today
national security and others.
And Senator Murphy asked earlier, how do we explain this to
the American public. And I think part of it is explaining some
of these incredible successes, whether it is polio or what we
have been able to accomplish in malaria or mother-to-child
transmission or so many others. And I think it is getting that
message out there that will cause people to step back and
realize that making a cut like you are talking about or
proposing a cut like you are talking about--this is the wrong
time to do it. And that the local governments will be picking
this funding up on their own, as they have been.
Mr. Affleck. I think it would be politics at its worst, as
you said, Chairman, demagoguery, and really, truly
shortsighted.
What I have seen personally are people who now have a job
that did not used to have a job are moving into the
marketplace. It is a model. Even more so than 10,000 farmers,
you would be destroying a model in its earliest, most nascent
phase, that is to say, business and investment is strong and
powerful aid. It gives people a sense of self-confidence and a
sense of meaning in their lives. And it brings goods to the
market, the practice of which has built this country and has
proved to be beneficial to producers, to consumers, and to the
people who live in those communities.
And that model that is now starting to be practiced would
be diminished, and that I think would be a real tragedy because
ultimately that model is not only going to save the American
taxpayer a lot of money, it is going to bring the American
taxpayer--it is going to elevate the economy of the American
taxpayer. It would be a crying shame because we are really on
to something great.
Mr. Gates. Yes. I would go back to something Senator Graham
said at the beginning, which is that the impact per dollar in
this budget, particularly the health and the agriculture pieces
that I know best, is probably more impactful than any money the
U.S. Government spends. Yes, there should be a very high bar
for spending money outside the United States in terms of the
benefits to the people back here and to the impact that money
has. But if you cut, say, $3 billion from this budget, we are
saving lives for $1,500 per life saved and even better benefits
for the survivors. So that is over 2 million children a year
that would die for lack of those resources.
Something like $3 billion a year--and the cut being
proposed is way larger than that--that matches all the money
that our foundation spends in this area. We get a lot of
visibility, but people should understand the U.S. Government,
through its broad set of programs that we are partnered with,
is about 10 times in its total foreign aid budget all the money
we spend. And that is the basic underpinning of why we are
seeing the great progress we are seeing on things like polio,
and it is the foundation for making sure that a mass epidemic
is caught at an early stage.
Mr. Affleck. Can I just say one more thing, Chairman,
briefly? I think there is the sense that, well, if we do this,
this is what we are doing, and these are not our priorities.
In our family, my wife does extraordinary work with early
childhood education in the United States in the Appalachians in
West Virginia, in Kentucky, and the central valley of
California. It is something she cares deeply about, and she is
extremely effective at it. And we are all very, very proud of
her and impressed. I do work in the Congo.
We see that as a microcosm of what this Government can be.
We can do both. We can do all of these things. We can apply our
values to our relatives, to our neighbors, be they outside our
national borders or be they within. I believe that is what
America is.
Senator Graham. Well, thank you all. It is probably the
best hearing I have attended in a long time. Each of you in
your own way represent the best of our country, and I think
this account represents the best of America. And in 2 hours, we
are going to go fight for it. Thank you.
SUBCOMMITTEE RECESS
The hearing is adjourned.
[Whereupon, at 11:58 a.m., Thursday, March 26, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]
APPENDIX
[Clerk's note: The following material was submitted by Bill
Gates and the Bill & Melinda Gates Foundation to be included in
the hearing record.]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[From the New England Journal of Medicine, Apr. 9, 2015]
The Next Epidemic--Lessons From Ebola
(By Bill Gates)
The ongoing Ebola epidemic in Guinea, Sierra Leone, and Liberia is
a huge tragedy. The impact on the 22 million people who live in those
countries goes far beyond the Ebola deaths. The health systems and the
economies of the three countries have been largely shut down during the
outbreak. The world has a lot of work to do to make sure the case rate
drops to zero--in the week leading up to March 1, 2015, there were 132
new confirmed cases reported. It will also need to make sure a good
healthcare system is built and enough food and other basics are
available. Without catch-up vaccination for the children who have not
gotten vaccines during the epidemic, for example, the increase in
measles deaths alone could outnumber the deaths from Ebola.
The only good news from this epidemic is that it can serve as a
wake-up call to help us prepare for a future epidemic that spreads more
effectively than Ebola does. There is a significant chance that a
substantially more infectious epidemic will come along over the next 20
years; after all, we saw several of them throughout the 20th century,
including the Spanish flu of 1918-1919, which killed at least 30
million people, and the ongoing HIV pandemic. In fact, of all the
things that could surprise people in a negative way by killing more
than 10 million people, by far the most likely is an epidemic, from
either natural causes or bioterrorism.
Ebola is far from the most infectious disease we know about. During
the epidemic, almost all of the secondary infections have taken place
after the patient was very sick. Most people are infected while taking
care of a patient at home or in a hospital, or by touching the body of
someone who died from Ebola. This means there has been very little
spread to strangers other than healthcare workers and those providing
emergency transportation. This factor has helped keep the number of
cases below 0.5 percent of the general population, and it allowed a few
tactics--such as persuading infected people to get isolated and
treated--to slow the epidemic.
By contrast, other disease agents (measles and flu, for example)
are far more infectious because they can spread through the air, rather
than by direct contact. People may not even be aware that they are
infected or infectious. These agents make it possible to infect lots of
strangers in the marketplace or on a plane, so the number of cases can
get large very quickly. And successive waves of infections can come
just days apart, leaving little time to mount an effective response.
When I heard that the Ebola epidemic had reached urban areas, I had
a dreadful feeling that we might not be able to keep it from spreading
to many more countries with weak health systems. It was only when I got
a chance to start looking at the case data with colleagues at the
Institute for Disease Modeling that I saw the relatively confined
pattern of the infections and began to think the geographic spread
could be controlled.
I am concerned that as the intensity of the problem fades from the
world's attention, we will miss the opportunity to learn from the Ebola
epidemic and be better prepared for the next one. Even if the system we
have today worked perfectly, it would not contain a more infectious
disease.
It's useful to compare our preparations for epidemics with our
preparations for war. Defense budgets and investment in new weapons
dwarf investments in epidemic preparation. NATO has a mobile unit that
is ready to deploy quickly. Although it's not a perfect system, they do
joint exercises where they work out basic logistics like how fuel and
food will be provided, what language they will speak, what radio
frequencies will be used. When soldiers sign up to serve, they know
what the risks are and who will take care of them if they're injured or
killed.
Few if any of these things exist for an epidemic response. The
world does not fund any organization to do the broad set of coordinated
activities that are needed for the next epidemic. The last serious
simulation of an epidemic in the United States, the Dark Winter
exercise, took place in 2001. The International Health Regulations
(IHR), adopted by the United Nations after the SARS outbreak of 2002-
2003, were intended to improve the world's ability to prevent and
contain outbreaks. But few countries have met their commitments under
the IHR. Nor have most countries established an Emergency Operations
Center that can be activated within 2 hours of identifying an outbreak,
a commitment made under the 2014 Global Health Security Agenda.
Because there was so little preparation, the world lost a lot of
time trying to answer fairly basic questions about how to deal with
Ebola. In the next epidemic, these delays could cause a global
disaster.
The problem does not lie solely with any single institution--it is
a global failure. The world needs a global warning and response system
for outbreaks. (WHO has a group with a similar name--the Global
Outbreak Alert & Response Network--but it is severely understaffed and
underfunded.)
In this essay, I describe what I think that system might look like,
based on lessons learned from the Ebola response. Many details will
need to be worked out. I have not seen a rigorous projection for what a
complete system like the one I describe would cost, but the World Bank
has made some projections that give a sense of the cost of inaction.
For example, it has estimated that a worldwide flu epidemic would
reduce global wealth by $3 trillion. It has also projected that Guinea,
Sierra Leone, and Liberia will lose 12 percent of their GDP this year
because of Ebola; if a global epidemic were as costly, the worldwide
impact would be more than $7 trillion, not to mention the immeasurable
misery caused by millions of deaths.
The key point is that the world is not nearly as prepared for a
massive epidemic as it needs to be. While Melinda and I remain
committed to our work on improving the health of the poorest, I hope
this paper--in spite of whatever shortcomings it has--helps spark
conversation and action to prepare for an epidemic that could have
global consequences.
public health and primary healthcare systems
There is a critical need to reinforce basic public health systems.
These are fundamental systems that include primary healthcare
facilities, laboratories, surveillance, critical care facilities, etc.
As many commentators have pointed out, Ebola has spread much faster and
more widely in countries whose health systems, and especially primary
care systems, were severely weakened by years of conflict and neglect.
Countries with stronger health systems have been able to respond more
quickly.
Strengthening primary healthcare systems provides a double benefit.
One, it improves our ability to prevent, detect, and respond to
epidemics. The other benefit is to health more broadly. Primary
healthcare facilities are where women go to seek preventive services
like family planning and vaccinations for their children, and to get
treatment for a sick child. Without a functioning health system--
including adequate numbers of trained health workers, good supply
chains, disease surveillance, information systems, and policies that
enable access by the poor--it is very hard for a country to end the
cycle of disease and poverty.
Good health is so fundamental to well-being and development that
even if there were no chance of another epidemic ever occurring,
healthcare systems would be a worthwhile--and life-saving--investment.
The fact that they also bolsters our ability to deal with the next
epidemic is all the more reason to invest in them.
disease surveillance
There is no systematic disease-surveillance process in place today
in most poor countries, which is where a natural epidemic seems most
likely to break out. The Zaire strain of Ebola had not previously been
seen in West Africa, so the region wasn't as prepared as central
Africa, where it has shown up more than 20 times over the past several
decades. Although Medecins Sans Frontieres (MSF) reported a rise in
Ebola cases in Guinea last spring, there weren't adequate resources on
standby to go into the area and do the requisite sampling to determine
how widespread the outbreak was. Even once the crisis was recognized,
there weren't resources to effectively map where cases were occurring
and in what quantity.
We need to invest in better disease surveillance and laboratory
testing capacity, for normal situations and for epidemics. Routine
disease surveillance systems should be set up so they can detect early
signs of an outbreak beyond their sentinel sites and be efficiently and
quickly scaled up during epidemics. They should be tied in to the
national public health laboratories to enable robust monitoring and
response as part of a country's healthcare system. The data derived
from the testing needs to be made public right away. A lot of the
laboratories in developing countries have been financed by the polio
eradication campaign, so there should be a plan for what capacities we
need once that campaign is over.
personnel
Once it became clear that a serious emergency was under way,
recruitment of local clinicians and the flow of trained personnel into
the affected countries should have been very high. It wasn't. There was
no comprehensive plan for what was needed. No training centers were
standing by. The United States, Cuba, China, and other countries
stepped forward with volunteers, but few of them were trained in what
treating Ebola patients effectively would entail. All of this happened
over 2 to 3 months, when it needed to happen within days. It is
fortunate that MSF was able to mobilize volunteers faster than any of
the governments.
We need trained personnel ready to deal with an epidemic quickly.
One approach is to think of them in three tiers: (1) an incident
manager for each Emergency Operations Center (EOC), in charge of
coordinating efforts by the medical care providers, military,
volunteers, and others at the country level; (2) experts in
epidemiology, surveillance, outbreak response, social anthropology, and
other areas who can provide surge capacity for the response; and (3)
respected community leaders who can lead the local engagement efforts
and community workers who can implement programs and give accurate
information to the public in local dialects.
There should be updated lists of people at all levels--especially
the first two--documenting their availability and capabilities. There
should be standby training centers and a plan to quickly recruit
community leaders as soon as the EOC is activated. There should be an
explicit understanding about how to compensate and insure the
volunteers, and information about what is expected of them so they can
decide very rapidly whether to sign up. Countries should commit to
manage a pool of volunteers and send a certain number of people with
various skills and equipment within a week of an emergency, with plans
for evacuating them if they are exposed. We should also leverage the
talent at schools of public health around the world. The earliest
people to go in should be surveillance experts, logistics experts, and
clinical staff. Finally, countries should have plans in place for
supporting volunteers when they come back. In this epidemic, returning
health workers have lost their jobs and experienced discrimination,
which may have made others reluctant to sign up.
transportation and equipment
When an epidemic strikes, transportation will be a critical
problem. Roads and airports in affected areas will be overwhelmed by
swarms of people trying to get out. Volunteers will be more likely to
sign up if they know they will be able to get out when their duty is
done or if they get sick.
There are very few organizations in the world that can move
thousands of people to different locations on the globe with a week's
notice--especially given that, in an epidemic, some of the transport
needs onboard isolation so that passengers can't infect each other or
the crew. The United Nations has to borrow transportation equipment to
support its military missions. The World Food Programme can move people
and food during a famine but has nowhere near enough capacity for an
epidemic.
The Ebola epidemic might have been a lot worse if the U.S. and U.K.
Governments had not used military resources to help build health
centers, manage logistics, and fly people in and out of the affected
countries. The militaries also provided command and control capacity to
help organize the different groups working on Ebola. It is fortunate
that they were not too busy with other emergencies to help out, and
that the Ebola epidemic is happening in countries that are open to
working with them. We should not assume that this will always be the
case.
The world should identify trained military resources that will be
available for epidemics. In a severe case, almost every middle-income
and rich-world military would have to come together with their
resources. Countries might hesitate to deploy resources abroad that
might be needed at home, which could create a paradox where the world
allows an epidemic to spread from the primary sites and reach lots of
countries.
Transportation is not the only critical resource. Severe epidemics
also require tents, protective suits, bleach, portable power sources,
portable air conditioning, medical supplies, and more. We should have a
list of supplies needed to stop an epidemic that reaches 10 million
people, which would be 100 times what we experienced in the Ebola
epidemic. Because face masks, protection suits, medical tents, and
other medical supplies could see extreme demand, there should be an
analysis of which items need to be stockpiled or subject to being
commandeered so we don't run out. Militaries and agencies that deal
with humanitarian crises stockpile items like these for natural
disasters and refugee crises, and they should get support for expanding
their supplies to what is needed for epidemics.
I have experience with one item that--although it wasn't critical--
shows how unclear the decisionmaking process is. By early September, it
was apparent that health workers in protective suits would get so hot
that it was difficult for them to care for their patients. I asked a
group of people who work for me on technology for keeping vaccines cold
to refocus on keeping the medical workers cool. Within days, they had
found existing commercial and military technology that could help. But
there was no unified mechanism for getting this equipment to the
treatment centers. The team had to create new distribution channels by
working directly with local treatment centers and organizations like
Partners in Health and MSF. I am not saying this was a critical issue,
but it illustrates how there was no coordinated process for getting new
equipment designed and distributed to the people who need it.
data systems
Given all of the actors involved in an epidemic and the importance
of allocating resources quickly and efficiently, it is critically
important to have good data about what's going on. Unfortunately during
the Ebola epidemic, the case database has not always been accurate or
up to date. Some of this is because of the chaos of the situation, but
it is also because there isn't good technology and training available
or clear rules about making the data accessible.
Today the default is that countries must sign off on making data
about their citizens available, but because that process is unclear, it
happens slowly or not at all. For future epidemics it should be
possible to have a system to digitally enter information like suspected
cases, locations, survivors, etc. into a database that is instantly
accessible to organizations engaged in the response and the agencies
coordinating their work. The rationale for not waiting for each country
to release the information is clear: An accessible database would be a
critical global public good. The groups that work on the Ebola data--
including WHO, the CDC, and others--could write up a specification or
revise the International Health Regulations for what we need next time.
Based on what we've learned with Ebola and polio, I think some
combination of foundations and technology companies can find the
resources to make sure a robust system, including the training
materials and back-end systems, comes together within the year.
Experts will also need computer models to predict what might happen
and which interventions should be prioritized. The ideal is to have
multiple strong modeling groups who can focus full-time attention on an
outbreak. They should have access to satellite photography and analysis
so they can understand how people are moving in the region. And with
appropriate privacy safeguards in place, cell phone records can help
modelers understand population counts, social connections, and
movement.
If the data systems are going to work, we also need to improve
Internet and cell phone connectivity. During the Ebola crisis, there
has been a lot of discussion about enhancing the Internet and cell
phone networks in the affected areas, but there was far too little
progress. As a result, much of the case reporting has been done on
paper and then sent to a central location for data entry. We should be
able to use cell phone systems to get messages out to everyone and to
poll people about what they are seeing. Key centers should have high-
bandwidth Internet capacity via satellite, and wi-fi capacity should be
added in key areas so that digital tools can help with reporting data
and coordinating personnel. Rapidly deployable systems should be
available to quickly increase capacity in crisis areas.
medical tools
Among the pathogens we know about, flu is the most likely to cause
a big epidemic. But we could also encounter one we have never seen
before. In 2003, for example, no scientist had seen SARS. That year it
infected some 8,000 people and killed 800.
Making sure that prophylactics and treatments are available for key
personnel (police, health workers, pilots, etc.) and volunteers could
make a gigantic difference in stopping an epidemic and limiting the
damage it does. The good news is that there is a lot of scientific work
that can be done that is not specific to a particular pathogen and
enables faster response to a wide variety of infectious agents. It
should be possible to have general capabilities to make diagnostic
tests as well as drugs, and vaccine platforms that could be adapted for
use against various pathogens. Today, with the possible exception of
flu, we do not have nearly enough capacity to do this.
One problem is a lack of incentives. Pharmaceutical companies and
others in the private sector face an opportunity cost in shifting
resources (including their researchers) away from more commercially
viable projects to work on drugs or vaccines for epidemics that may not
happen. Their work represents a kind of insurance policy against the
next epidemic, and there may need to be an international system for
funding it that factors in these opportunity costs.
There are three key areas of medical tools that will be important
for the next epidemic: diagnostic tests, therapeutics, and vaccines.
diagnostic tests
When a new epidemic breaks out, one of the most urgent tasks is to
obtain and analyze biological samples--including blood, saliva, nasal
swab, and stool--to determine what is causing the disease. Those
samples start the process of figuring out how to make diagnostic tests,
drugs, and vaccines. The samples will be tested, the pathogens
sequenced, and all of that data should be immediately published
digitally for the world's scientists to study. Fairly quickly it should
be possible to see the signature of the disease and determine whether
the pathogen is a virus, bacterium, or something else.
It's extremely important to have an accurate diagnostic test that
can determine whether someone is infected. The ideal test, which is
being developed, will be one where you take a sample and get a
definitive result within 20 minutes. People who are infected can be
sent to treatment centers so they are isolated from the uninfected. If
getting results takes more than a day--because the testing capacity is
overloaded, or the transport of the sample to the testing service is
slow, or the test process itself takes a lot of time--then holding
people while you wait to get the answer is very difficult.
Other than watching for symptoms (which are a clinical diagnostic
test, albeit a bit late), most of the diagnosis during this Ebola
epidemic has been done by taking a blood sample and sending it off for
quantitative polymerase chain reaction (qPCR) analysis. Availability of
these expensive qPCR machines is limited and centralized, so on average
it has taken one to three days for test results to come back after a
sample is collected and sent out. For the next epidemic, we should make
sure adequate qPCR machine are made available or mobilized in the first
few weeks (with trained technicians and supplies), while novel
diagnostic methods are rapidly developed. A number of diagnostic
companies have technologies that are cheaper, more portable, and faster
and requires less expertise than qPCR. When you move to a new format,
though, you have to be sure that the biomarker and your sensitivity to
that marker are not compromised--otherwise you could miss early disease
and allow infected people to be identified as uninfected.
In the future there should be a clear process for taking the
information about disease signature and then developing and
manufacturing accurate diagnostic tests very rapidly. A focused effort
to accelerate this process and establish a rapid approval and
procurement process would be worthwhile. The science of bio-diagnostics
is advancing rapidly, so there is a good chance that a proven test
could be produced at scale within weeks of an outbreak.
therapeutics: antivirals, antibodies, rna, transfusion
It is hard to overstate the value of having a drug that reduces the
duration and degree of infectiousness and saves lives. Infected people
are more likely to come to a treatment center if doing so will increase
their odds of surviving, rather than just preventing them from
infecting others. Survivors from the treatment center would likely be
immune from getting sick again, so they could go back to the affected
regions to help inform people about the importance of seeking
treatment.
There are drugs that work against viruses that are similar to
Ebola, and in various test assays, a number of them show an effect
against Ebola. Unfortunately, they were not tested in Ebola patients
until after the peak of the epidemic. This was partly because there
wasn't a clear decision process to approve a novel trial format and to
provide indemnity against legal liability. The role of the local
governments relative to the global actors remains unclear, but it is
not hard to imagine local authorities being inundated with suggested
therapies, as happened with this epidemic. There should be a clear set
of guidelines (and testing and regulatory pathways) for figuring out
whether existing drugs could be re-purposed to help stop a particular
epidemic. This testing should be carried out as soon as possible--we
can fill the pipeline now with the best options so they are ready to be
used in a future outbreak.
We also need to invest in more research on antiviral drugs and have
either stockpiles or rapid manufacturing capacity for those that might
be effective in an epidemic. The search for drugs against HIV, which
started in the 1980s, has contributed a lot to the field of antiviral
drugs. The number of antiviral drugs that perform well against HIV is
quite impressive. Since the next epidemic will probably be caused by a
virus, general work on broad-spectrum antiviral drugs is a global
public good that needs more research than is being done.
There is a special class of therapies that are based on antibodies.
For example, Zmapp was specifically designed for treating Ebola
patients. This is another intervention that was given to many of the
patients who were treated in the United States and Europe, but it was
not made in sufficient volume quickly enough to help in Africa.
Because of the small number of treated patients and lack of an
adequate control group, we don't know which interventions were key to
the higher survival rates in the United States and Europe. Still, the
evidence suggests that antibody-based approaches will probably be
valuable for the next epidemic. We need to improve our ability to
design an antibody against a new pathogen and make sure that it is
applied along with new rapid manufacturing techniques and a clear
regulatory pathway to maximize the chance of success. Manufacturing
capacity for making antibodies at scale will have to be set aside or
subject to being commandeered during an epidemic. We should also
leverage approaches like adeno-associated virus (AAV) vectors, which
use a harmless virus as a backbone to explore generating robust
antibody levels.
Another special class of drugs involves giving patients a set of
particular RNA-based constructs that enables them to produce specific
proteins (including antibodies). Although this is a very new area, it
is promising because it is possible that a safe therapy could be
designed and put into large-scale manufacture fairly rapidly. More
basic research as well as the progress of companies like Moderna and
CureVac could eventually make this approach a key tool for stopping
epidemics.
There is one approach that should have been applied for this Ebola
epidemic, but it wasn't approved and scaled up until it was too late to
have a large impact. It involves taking the blood of survivors,
extracting the plasma from it (plasmapheresis), and giving the plasma--
or the immunologically potent parts of it--to people who have early
symptoms of disease or who are at high risk of contracting it.
Depending on the disease, a single survivor should be able to provide
protection for at least one person every 2 weeks.
This process is quite effective for a number of diseases. It was
very effective with smallpox and viral hemorrhagic fevers, including
treating a patient in the United States who had Lassa fever in 1969. It
has a reasonable chance of working for Ebola as well. It was used to
treat 8 patients during an Ebola outbreak in Zaire in 1995, but because
it wasn't done as an organized trial, we don't know for sure whether it
worked. Subsequent animal experiments had mixed results.
The Gates Foundation started working to get plasmapheresis units
going in early September and quickly found partners with equipment
ready to take it into the affected countries. Unfortunately, the effort
was hampered because there was no clear process for approving new
approaches, or for exporting plasma to other countries to be processed
and then getting it back to the patients who needed it. By the end of
2014, only a few patients in West Africa had been treated with
convalescent plasma, which means the sample size is too small to
determine whether it was effective. (This treatment was given to some
of the Ebola patients who were lucky enough to be treated in rich
countries.)
For future epidemics, there need to be rules in advance for all
medical interventions and a clear assignment of responsibility for
approving studies and treatments, including experimental ones. One of
the critical elements would be to obtain specimens (e.g., blood) from
infected individuals to isolate samples of the pathogen and also to
fish out high-affinity antibodies. Then we should be able to quickly
leverage the sequence information of the antibodies to test novel
approaches and determine what might work quickly and be safe. A Global
Epidemic Drug Approval process could avoid long delays by indemnifying
companies working on new approaches and enabling decisionmaking around
``permission to use'' of investigational medical products.
For transfusion in particular, there needs to be ample equipment
easily available, as well as a process for quickly getting donor plasma
to facilities for processing and then returning the finished product to
the affected populations. There is a good chance that the plasma
transfusion could work as a therapeutic and have a dual impact on the
potential disease as well as empower local populations to engage in the
outbreak responses.
vaccines
Three different Ebola vaccine constructs were being developed in
the summer of 2014, but all were in early stages and had not reached
Phase 1 safety testing. The normal process for going from Phase 1 to
full approval for sale and use would have taken at least another 5
years. Even the accelerated process adopted for the epidemic will
require more than 9 months. Ironically, by the time of the final phase
of testing--which measures effectiveness in a large population--there
will likely be too few people still being exposed to Ebola virus to
know reliably how effective these vaccines are.
Because of this early work, we were more prepared for Ebola virus
than we would be for a new pathogen. If the pathogen hasn't been seen
before, at least another year of work would probably be needed. And the
issues of how quickly to move and who should finance the final research
and the manufacturing are not as clear as they should be.
With the seasonal flu, we know how to make vaccines against
specific antigenic forms of the virus, but even the relatively minor
season-to-season variations are significant enough that we have to
design a new vaccine each year. When a very different antigenic variant
like H1N1 (the swine flu of 2009) comes along, there is no clear
process for getting resources applied to creating a new vaccine. In
fact, after the swine flu scare--where WHO worked with pharmaceutical
companies to create and buy a stockpile of vaccines--some people
criticized WHO for doing too much, a stark contrast with the complaints
that it did too little on Ebola. Given that flu is the most likely
single known pathogen to cause a large epidemic and that even the
seasonal variations likely cause several hundred thousand excess deaths
each year, it is disappointing that we don't have a vaccine that works
on all variants of flu. There is work being done toward this goal, but
with nowhere near the resources that it deserves.
I have a bias towards vaccine research because of the impact I see
from vaccines in the Gates Foundation's work on preventing disease.
Many of the same legal and regulatory barriers that slow down the
approval of therapeutics also apply to vaccine candidates. We should
establish clear guidelines to avoid these hurdles during emergencies.
The ideal would be to fund vaccine research so that a vaccine can be
designed, tested for safety, and ready for manufacture in large volumes
in a matter of a few months. There is no guarantee of success, but
given enough time--probably no more than a decade--and enough
resources, I think this effort could produce an invaluable contribution
to both promoting overall health and preventing epidemics.
quarantine and communications plans
During the Ebola epidemic there was a lot of discussion about
quarantine. Should commercial flights into and out of the affected
countries be stopped? Should people returning from the affected region
be forced into quarantine? For this epidemic, given the limited
infectiousness of Ebola in the early stages of the disease, most of
these proposals would have been counterproductive. Banning travel from
affected areas to the United States, for example, would have forced
people to take an indirect route, making them harder to track once they
arrived. Forcing people into quarantine would have discouraged
volunteers from working in the affected countries. Basic monitoring
procedures were adequate to determine whether patients were developing
Ebola and get them into isolation before they infected others.
But when a far more infectious agent comes along, quarantine will
be one of the few tactics in the early stage of the disease that can
reduce the spread of contagion. Travel today is so common that an
infection can spread across the globe far faster now than in 1918, when
the Spanish flu epidemic swept across the world. During the SARS
epidemic, China eventually did a good job of curtailing travel and
public gatherings in affected areas. I doubt every country would have
handled this aspect as well as China did, because in normal situations
the system is designed to avoid abridging individual rights to travel
and assemble freely. I worry that in the early stages of an epidemic,
democratic countries might be too slow to restrict activities that help
spread the contagion.
Part of the process should include a plan for effective public
communications. There will be lot of panic and thirst for information
when the epidemic hits. Many people will be tempted to tie up health
and transport assets when they should not. Well-designed quarantine
plans need to be part of an overall outreach plan that coordinates all
the different voices people will hear: governments, U.N. agencies, news
media, bloggers, etc. The ways that people communicate digitally can be
used to great advantage, but unless a plan is in place ahead of time,
they will just spread confusion and panic faster than in the past--
perhaps at the cost of many lives.
bioterrorism
I chose to focus this essay on the lessons from a natural epidemic.
But an epidemic could also be engineered intentionally. As biological
science and technology advances, it is getting easier to create (or re-
create) pathogens with only modest effort and technical knowledge. Over
the next few decades it will be even more feasible to synthesize, mass-
produce, and disseminate pathogens that are highly infectious and
largely fatal. (Because Ebola doesn't spread very effectively, it would
not make a highly effective bioterror weapon.) Everything I have
described in this essay would also be worthwhile in preparing for
bioterrorism. Nathan Myhrvold discusses these challenges in his essay
on strategic bioterrorism, which I highly recommend--although it is
sobering to read.
a global call to action
The world spends a great deal of money--hundreds of billions of
dollars a year--getting ready for war. I am not saying this is a
mistake, but given that an epidemic is more likely to kill millions of
people than a future war, I believe we should build on these efforts so
we can be more prepared for a severe epidemic. Some of the
capabilities, like transport and some personnel, overlap and can play a
dual purpose if properly planned. Other elements, like research on
diagnostic tests, vaccines, and treatments, will require specific
investments.
A serious epidemic would also raise a lot of questions about global
governance. What body would bring sovereign nations together and ask
them to make decisions about limiting travel and allocating scarce
resources like vaccines or drugs? All of the epidemics we have seen so
far have shown that we desperately need processes for making tough
decisions fast.
One technique that we should borrow from the military is the idea
of a war game. Once we have taken action on the basics, countries
should come together every few years to simulate different types of
epidemics so they can understand what is missing from the response.
I worry that many people do not think a serious epidemic is a
problem for them to worry about. They may think that the United Nations
system, and especially WHO, has it covered. In fact, WHO has not been
clearly chartered or funded to handle most of the things required in an
epidemic. Or they may think their government has a plan already in
place. While the United States, the United Kingdom, and others are
working on many of the things described in this memo, there are still
big holes in the world's ability to respond.
There should be a rigorous study of the cost of building a global
warning and response system for epidemics, including greater
investments in research and development, preparing military resources
for epidemic response, and maintaining a reserve of paid responders who
go through regular training exercises. There would need to be a plan
for how much each country would contribute and for coordinating the
spending so it is used effectively. I think other countries need to
step up, but they are more likely to do so when they see an overall
plan and understand their role in it. Rich, technically advanced
countries should invest far more in the key research and manufacturing
capacities than they do today. Most of the others can contribute to the
crucial surveillance work.
Through the United Nations, some global institution needs to be
empowered and funded to coordinate a global warning and response
system--including systems for sharing data, managing personnel, setting
an R&D agenda, and other key areas. At the request of WHO's Executive
Board, Director-General Margaret Chan is evaluating the organization's
response to the recent Ebola outbreak. U.N. Secretary-General Ban Ki-
moon is commissioning a high-level panel to recommend ways to improve
international crisis management, with a special focus on health based
on the lessons learned from the Ebola response. These evaluations would
be a good place to start a much-needed conversation about how to
strengthen WHO's capacity and about which pieces it should lead and
which should be led by others (including the World Bank and G7) in
close coordination with it. The conversation should include military
alliances such as NATO, which should make epidemic response a priority
when they are designing strategies, training troops, and buying
equipment. The final arrangement should include a reserve corps of
experts with the broad range of skills needed in an epidemic.
In my view, an epidemic is one of the few catastrophes that could
set the world back in a huge way in the next few decades. Severe
epidemics have struck many times in the past, and they are only more
likely as the world becomes more closely connected. By building a
global warning and response system, we can prepare for the next
epidemic and avoid millions of deaths.
recommendations
The world needs to build a warning and response system for
outbreaks. This system should:
--Be coordinated by a global institution that is given enough
authority and funding to be effective.
--Enable fast decisionmaking at a global level.
--Expand investment in research and development and clarify
regulatory pathways for developing new tools and approaches.
--Improve early warning and detection systems, including scalable
everyday systems that can be expanded during an epidemic.
--Establish a reserve corps of trained personnel and volunteers.
--Strengthen health systems in low- and middle-income countries.
--Incorporate preparedness exercises to identify areas for
improvement.
______
[From the New York Times, Mar. 18, 2015]
HOW TO FIGHT THE NEXT EPIDEMIC
The Ebola Crisis Was Terrible. But Next Time Could Be Much Worse.
(By Bill Gates)
Seattle.--The Ebola epidemic in West Africa has killed more than
10,000 people. If anything good can come from this continuing tragedy,
it is that Ebola can awaken the world to a sobering fact: We are simply
not prepared to deal with a global epidemic.
Of all the things that could kill more than 10 million people
around the world in the coming years, by far the most likely is an
epidemic. But it almost certainly won't be Ebola. As awful as it is,
Ebola spreads only through physical contact, and by the time patients
can infect other people, they are already showing symptoms of the
disease, which makes them relatively easy to identify.
Other diseases--flu, for example--spread through the air, and
people can be infectious before they feel sick, which means that one
person can infect many strangers just by going to a public place. We've
seen it happen before, with horrific results: In 1918, the Spanish flu
killed more than 30 million people. Imagine what it could do in today's
highly mobile world.
Much of the public discussion about the world's response to Ebola
has focused on whether the World Health Organization, the Centers for
Disease Control and Prevention and other groups could have responded
more effectively. These are worthwhile questions, but they miss the
larger point. The problem isn't so much that the system didn't work
well enough. The problem is that we hardly have a system at all.
To begin with, most poor countries, where a natural epidemic is
most likely to start, have no systematic disease surveillance in place.
Even once the Ebola crisis was recognized last year, there were no
resources to effectively map where cases occurred, or to use people's
travel patterns to predict where the disease might go next.
Then, once it became clear that a serious emergency was underway,
trained personnel should have flooded the affected countries within
days. Instead it took months. Doctors Without Borders deserves a lot of
credit for mobilizing volunteers faster than any government did. But we
should not count on nonprofit groups to mount a global response.
Even if we signed up lots of experts and volunteers right away,
it's not clear how we would deploy them quickly into the affected area,
or how we would transport patients. Few organizations are capable of
moving thousands of people, some of them infected, to different
locations on the globe with a week's notice.
The Ebola epidemic might have been a lot worse if the United
States, Britain and other governments had not used military resources
to fly people and equipment into and out of affected areas. But we
should not assume that the next epidemic will limit itself to countries
that welcome Western troops.
Data is another crucial problem. During the Ebola epidemic, the
database that tracks cases has not always been accurate. This is partly
because the situation is so chaotic, but also because much of the case
reporting has been done on paper and then sent to a central location
for data entry.
Then there's our failure to invest in effective medical tools like
diagnostic tests, drugs and vaccines. On average it has taken an
estimated 1 to 3 days for Ebola test results to come back--an eternity
when you need to quarantine people until you know whether they're
infected. Drugs that might help stop Ebola were not tested in patients
until after the epidemic had peaked, partly because the world has no
clear process for expediting drug approvals.
Compare all this to the preparation that nations put into defense.
Armies have systems for recruiting, training and equipping soldiers.
NATO has a mobile unit that is ready to deploy quickly. Although the
system isn't perfect, NATO members do joint exercises where they work
out logistics like how troops will get food and what language they will
use to communicate.
Few if any of these approaches exist for an epidemic response. The
world does not fund any organization (not even the W.H.O.) to
coordinate all the activities needed to stop an epidemic. In short, in
a battle against a severe epidemic, we would be taking a knife to a
bazooka fight.
I believe that we can solve this problem, just as we've solved many
others--with ingenuity and innovation.
We need a global warning and response system for outbreaks. It
would start with strengthening poor countries' health systems. For
example, when you build a clinic to deliver primary healthcare, you're
also creating part of the infrastructure for fighting epidemics.
Trained healthcare workers not only deliver vaccines; they can also
monitor disease patterns, serving as part of the early warning systems
that will alert the world to potential outbreaks. Some of the personnel
who were in Nigeria to fight polio were redeployed to work on Ebola--
and that country was able to contain the disease very quickly.
We also need to invest in disease surveillance. We need a case
database that is instantly accessible to the relevant organizations,
with rules requiring countries to share their information. We need
lists of trained personnel, from local leaders to global experts,
prepared to deal with an epidemic immediately. We need trained military
resources ready to respond, and a list of supplies to be stockpiled or
commandeered in an emergency.
Finally, we need to invest far more in research on drugs, vaccines
and diagnostic tests, and make it possible to accelerate the approval
of new approaches in times of crisis.
The United Nations should empower and fund a global institution to
coordinate these efforts. The United Nations and the W.H.O. are
studying the lessons of this epidemic; their evaluations would be a
good starting point for a conversation about how to strengthen the
W.H.O. and what pieces of the system it should lead.
I have not seen a rigorous projection for what a system like this
would cost. But we know the cost of failing to act. According to the
World Bank, a worldwide flu epidemic would reduce global wealth by $3
trillion, not to mention the immeasurable misery caused by millions of
deaths. Preventing such a catastrophe is well worth the world's time
and attention.
Bill Gates is co-chairman of the Bill & Melinda Gates Foundation.