The U.S. Global Health Initiative

The Global Health Initiative: The Next Phase of American Leadership in Health Around The World

Thank you. Well, it is such a pleasure to be here again at SAIS, and I want to thank Dean Einhorn for that very warm and thoughtful introduction. But this is such an exceptional educational institution, and I had no idea we had 300 of your alumni, but I see in action every day the results of the work, the research, the study, and preparation that goes on here at SAIS. We are the very proud employer of many SAIS alumni, and I hope that there are more of you who are going to be joining our ranks in the years to come.

In addition to the contributions that Johns Hopkins has made in the fields of diplomacy and international law, I want to add to what Dean Einhorn said about the contributions in health. Hopkins is, of course, home to excellent medical and nursing schools, and home to the Bloomberg School of Public Health. That school’s motto, “Protecting health, saving lives, millions at a time,” captures both the possibility and the responsibility inherent in the pursuit of better health, whether here in our own country or in communities around the world. New breakthroughs and new knowledge about how to fight disease and save lives only add to our responsibility as researchers, teachers, students, government officials, and as a nation. Each of us, I believe, is called to find ways to bring those solutions to the people who need them, wherever they are.

And many contributors to global health are here with us, including representatives from several partner and donor countries, NGOs, the private sector, multilateral institutions, and public-private enterprises. And I want to acknowledge your and their outstanding contributions to saving lives around the globe, often millions at a time.

And that is the mission I’d like to discuss with you today: how the Obama Administration is building upon our country’s long-standing commitment to global health by bringing life-saving prevention, treatment, and care to more people in more places.

This is a signature of American leadership in the world today. It’s also an issue very close to my own heart. I have been privileged to visit many parts of the world on behalf of our country over the last 20 years. And in my travels, I’ve come to know countless people who are living proof of what successful global health programs can do.

I’ve met HIV-positive farmers in Kenya who now have the strength to spend their day in the fields earning a living thanks to antiretroviral drugs; children in Angola who wake up every morning under bed nets and then head off to school eager to learn, unafflicted by malaria; new mothers in Indonesia who proudly show off healthy babies brought into the world with the help of trained midwives; men and women who have grown into adulthood resisting diseases because they had childhood immunizations against polio or measles.

Now, these are but a few of the faces of global health that I have seen; people who are not only alive, but also contributing as parents, workers, and citizens, thanks to the governments, organizations, foundations, and universities like Johns Hopkins who collaborate to bring medical care and education about healthy behavior to more parts of the world.

These are also the faces of America’s commitment. No nation in history has done more to improve global health. We have led the way on some of the greatest health achievements of our time. Smallpox plagued humankind for thousands of years until we helped end it through the World Health Organization’s eradication campaign in the 1960s and 70s. The Expanded Program on Immunization has brought life-saving vaccines to nearly 80 percent of the world’s children, up from less than 5 percent when the program began 36 years ago, and it has done so in large part thanks to U.S. dollars and support. The global distribution of micronutrients, which we helped pioneer, has protected the health of many millions of young children and pregnant women.

And we are the global leader in the fight against neglected tropical diseases, treating 59 million people in the past four years alone. We help prevent and treat malaria for more than 50 million people every year and we provide nearly 60 percent – 60 percent of the world’s donor funding for HIV and AIDS. All told, 40 percent of the total global funding for development assistance for health comes from the United States.

This is clearly not a Democratic or Republican issue; this is a nonpartisan issue that really comes from the heart of America. And our leadership in this field has been possible because of strong support on both sides of the aisle. I commend the Bush Administration for its ground-breaking work in global health, and in particular in two of our country’s flagship programs: the President’s Emergency Plan for AIDS Relief, or PEPFAR, and the President’s Malaria Initiative. I’d like to acknowledge two people who helped make these programs possible: Mark Dybul, the former Global AIDS Coordinator, and Admiral Tim Ziemer, the current head of PMI.

Now, beyond government, American organizations are making extraordinary contributions. From the Bill and Melinda Gates Foundation, which has given billions to revive immunization campaigns and discover new vaccines and other tools to prevent and treat disease, to the Carter Center, which has led the global campaign to eradicate the debilitating guinea worm parasite, to the Clinton Foundation, which has worked with pharmaceutical companies to make AIDS drugs more affordable for millions, and to hundreds of other organizations across America that are finding innovative ways to deliver life-saving and life-improving care to people worldwide.

Churches and faith communities have also led the fight to bring treatment to those in need, including by deploying health volunteers, who sometimes face dangerous circumstances to serve people in places where little or no care exists. Just two weeks ago, medical volunteers from several countries, including the United States, were murdered in Afghanistan as they traveled from village to village to treat eye conditions and run a dental clinic. That was a terrible loss for the families, a terrible loss for the world, and it was a terrible loss for those people who had been and would have benefited from their help.

So stories like these remind us that strengthening global health is not only a deeply held priority for our government, but for many American citizens and our nation as a whole. And it is an important part of our national story, one that isn’t told as often or as thoroughly as it should be.

Today, on behalf of the Obama Administration, I’d like to share with you the next chapter in America’s work in health worldwide. It’s called the Global Health Initiative, GHI for short, and it represents a new approach, informed by new thinking and aimed at a new goal: To save the greatest possible number of lives, both by increasing our existing health programs and by building upon them to help countries develop their own capacity to improve the health of their own people.

Now, before I discuss the specifics of the initiative, let me just take a step back. Some may ask why is a Secretary of State giving a speech about global health; there are a lot of other crises in the world, as I am well aware. Some might accuse me of taking a little break from those crises to – (laughter) – come to SAIS to talk about global health. What exactly does maternal health, or immunizations, or the fight against HIV and AIDS have to do with foreign policy? Well, my answer is everything.

We invest in global health to strengthen fragile or failing states. We have seen the devastating impact of AIDS on countries stripped of their farmers, teachers, soldiers, health workers, and other professionals, as well as the millions of orphaned and vulnerable children left behind, whose needs far exceed what any government agency can provide. The destabilizing impact of AIDS led the Clinton Administration to categorize it not just as a health threat but a national security threat, a position later echoed by then Secretary of State Colin Powell. And the Center for Strategic and International Studies, a think tank focused on national security, launched a Commission on Smart Global Health Policy co-chaired by Helene Gayle of CARE and retired Admiral William J. Fallon, to find new strategies for global health, because we believe that will help us build a safer, more secure world.

We invest in global health to promote social and economic progress, and to support the rise of capable partners who can help us solve regional and global problems. We have seen places where people who suffer from poor health struggle on many levels. Poverty is usually widespread. Infrastructure is usually incomplete. Food production and school enrollments are usually low. People who would otherwise take the lead in driving progress for their families and nations are instead dragged down by disease, deprivation, and lost opportunity.

We invest in global health to protect our nation’s security. To cite one example, the threat posed by the spread of disease in our interconnected world in which thousands of people every day step on a plane in one continent and step off in another. We need a comprehensive, effective global system for tracking health data, monitoring threats, and coordinating responses. The need for such a system was driven home in recent years with the spread of SARS and the H1N1 virus. It is cheaper and more effective to stop an outbreak when it emerges, before it becomes a global threat. But that is very hard to do in places where health and public health services are scant or nonexistent.

We invest in global health as a tool of public diplomacy. For millions of people worldwide, the prevention, treatment or care that the United States makes possible is their main experience of us as a country and a people. And it can be a very powerful one. Giving people a chance at a long and healthy life or helping protect their children from disease conveys as much about our values as any state visit or strategic dialogue ever could.

And we invest in global health as a clear and direct expression of our compassion. Millions die every year simply because they lack access to very simple interventions, like bed nets, or vitamin-fortified food, or oral rehydration therapy. As a nation and a people, we cannot, we must not, accept those senseless deaths. It’s just not in our DNA. That’s why Americans frequently report that they support their tax dollars going to global health programs – not because of what the money can do for us, but because of what it can and does do for others. Few investments are more consistent with all of our values and few are more sound. Global health is a prime example of how investing our resources strategically can have an immediate and lasting impact on people, communities, and countries.

The list of diseases and deficiencies that threaten lives and livelihoods across the world is nearly limitless, but our resources are not. So therefore, we must be strategic and make evidence-based decisions in targeting the most dangerous threats, to ensure that our investments that, after all, come from the American taxpayer, deliver results. And we must also must stay focused on the long-term picture – not only addressing the urgent needs that people have today but building the foundation for better health tomorrow and for the next generation.

This thinking informs every aspect of the Global Health Initiative, which President Obama addressed last year. The United States is investing $63 billion – first, to sustain and strengthen our existing health programs, and second, to build upon those programs and take their work to the next level by collaborating with governments, organizations, civil society groups, and individuals to help broaden the improvements in public health that we can expect.

We’re shifting our focus from solving problems, one at a time, to serving people, by considering more fully the circumstances of their lives and ensuring they can get the care they need most over the course of their lifetimes.

Consider the life of a woman in one of our partner countries.

She lives in a remote village that has been home to her family for generations. Her parents went their whole lives without ever seeing a doctor, but now, thanks to the hard work of the international community, some quality health care is available to her. Within walking distance, there is a clinic supported by PEPFAR, where she first found out that she has HIV and now receives the antiretroviral drugs that keep her healthy. If she makes a longer journey by bicycle or bus, there is another clinic where she can receive prenatal care and where her children can receive immunizations. Sometimes health services come right to her door, in the form of health volunteers bringing bed nets to protect her family from malaria.

But while she can receive care for some health problems, for others she is on her own. Her local clinic is well-stocked with antiretrovirals, but it is empty of antibiotics or contraceptives. If she has trouble giving birth, the nearest facility equipped to perform emergency surgery is hundreds of miles away, so she faces the very real risk of becoming that 1 in 22 women in Sub-Saharan Africa who die in childbirth. And while her home has been sprayed for mosquitoes, she has no access to clean water, so her children may escape malaria only to die from diarrheal disease.

There is no question that this health landscape is much improved from just a few years ago. But its short-comings are significant.

There is too little coordination among all the countries and organizations, including in our own government, that deliver health services, so critical gaps in care are left unaddressed.

There is too little integration. Diseases are often treated in isolation rather than bundled together, forcing people like this woman to travel to multiple clinics to meet their and their children’s basic health needs.

There is too little innovation focused on designing technologies and strategies that can work in resource-poor places and help the people who are hardest to reach.

Step back even further and another problem comes into view: a lack of in-country capacity. In many places, donor countries and outside NGOs have stepped in to deliver critical services that countries didn’t have the money or the expertise to deliver themselves. But while that is absolutely the right response to an emergency, it is a temporary fix, not a long-term solution. Yet in too many places, it has come to serve as a long-term solution.

As a result, this woman’s current access to care is erratic, and her future access to care is uncertain. She is vulnerable to the vicissitudes of funding cycles and development trends in places far from where she lives. She has little control over the quality of care provided to her and her family, while if her elected leaders were more directly and more heavily invested, she and her fellow citizens would have more of a voice in the system.

The fundamental purpose of the Global Health Initiative is to address these problems by tying individual health programs together in an integrated, coordinated, sustainable system of care, with the countries themselves in the lead. We are taking the investments our country has made in PEPFAR, the President’s Malaria Initiative, maternal and child health, family planning, neglected tropical diseases, and other critical health areas – building on the work of agencies across the federal government, such as the Centers for Disease Control – and expanding their reach by improving the overall environment in which health services are delivered. By doing so, our investments can have a bigger impact and patients can gain access to more and better care, and as a result, lead healthier lives.

To illustrate how the Global Health Initiative will work, consider how it will impact one of our most successful global health programs: PEPFAR.

In the past seven years, PEPFAR has provided millions of people with prevention services across Africa, Asia, and the Caribbean. It has also changed the conventional wisdom about treatment. Before PEPFAR, many believed that treating people with HIV in poor countries was impossible, because the drugs were effective only if they were taken according to a precise daily schedule and with sufficient food. For people living in places with food shortages and without health clinics, pharmacies, or health professionals, it seemed like treatment would forever be out of reach.

But the United States could not accept the injustice of allowing millions to die when we did have the drugs to save them. And through PEPFAR, we set up clinics, trained health professionals, and improved shipping and storage. So the experiment worked. Seven years ago, the number of people in Sub-Saharan Africa on antiretrovirals was fewer than 50,000. Today, more than 5 million people in the developing world are safely and effectively using these drugs, and PEPFAR is supporting about half of those people.

Under the Global Health Initiative, we will continue PEPFAR’s success by increasing its funding. In 2008, funding for PEPFAR was $5 billion. For 2011, President Obama has requested more than $5.7 billion, the largest amount any country has ever invested in the fight against global AIDS.

And we are raising our goal for treatment. Through the Global Health Initiative, we seek to directly support treatment for more than 4 million people worldwide—more than double the number of people who received treatment during the first five years of PEPFAR.

We are raising our goal for care, to more than 12 million people, including 5 million orphans and vulnerable children.

And we are raising our goal for prevention. Through the Global Health Initiative, we aim to prevent 12 million new HIV infections. To do that, we are embracing a more comprehensive approach and expanding on what we know works. We are moving beyond A-B-C—abstinence, be faithful, and consistent and correct use of condoms—to an A to Z approach to prevention. Because we need to use every tool we have—the full combination of medical, behavioral, and structural intervention. That includes male circumcision, the prevention of mother-to-child transmission, improvements and the investments of making detection more available and affordable, education, and when needed, legal, policy, or regulatory changes that will make it easier to protect populations.

Despite all the investments the United States has already made and that the world has already made, to stop this epidemic, we know we confront 2.7 million new infections every year. So if we are going to win this war, we need to get better results in prevention. And our strategy under the Global Health Initiative will enable us to do so.

So the immediate impact for PEPFAR is clear. Its funding will increase, its impact will increase, and its prevention strategies will become more comprehensive.

Similarly, we are strengthening our support for the other health programs we fund around the world.

We are increasing our support for the President’s Malaria Initiative, with the goal of reducing the malaria burden by 50 percent for 450 million people.

Against tuberculosis, we intend to save 1.3 million lives by increasing access to treatment.

And we are scaling up our work in family planning and maternal and child health—areas in which the United States can and must lead. Every year, hundreds of thousands of women die from complications related to pregnancy or childbirth, nearly all of them in the developing world, and for every one woman who dies, 20 more suffer debilitating injuries or infections. And every year, millions of children in the developing world die from wholly preventable causes.

Saving the lives of women and children requires a range of care, from improving nutrition to training birth attendants who can help women give birth safely. It also requires increased access to family planning. Family planning represents one of the most cost-effective public health interventions available in the world today. It prevents both maternal and child deaths by helping women space their births and bear children during their healthiest years. And it reduces the deaths of women from unsafe abortions.

The United States was once at the forefront of developing and delivering successful family planning programs. But in recent years, we have fallen behind. With the Global Health Initiative, we are making up for lost time.

All told, we will save millions of additional lives through our increased support to existing U.S. health programs around the world through this initiative.

But what about all the systemic challenges that surround PEPFAR and USAID programs and other U.S.-funded health programs in the field? The constellation of logistical, structural, legal, and political problems that decrease health and make life tenuous for the woman that I described a few minutes ago. As long as they persist, that will limit our or any donor’s impact. Women we save from AIDS will die in childbirth. Children we save from polio will die from rotavirus. And on a broader level—in terms of the scope and quality of medical and public health services available in communities and countries—the future will not look much different than the present.

We need to lay the groundwork now for more progress down the road by tackling some of those systemic problems, and working with our partner countries to uproot the most deep-seated obstacles that impede their own people’s health. That is how we can make our investments yield the most significant returns and save the greatest numbers of lives, today and tomorrow.

So let me explain a few key ways in which we are pursuing this goal.

First, we are working with countries to create and implement strategies for health that they take the lead in designing based on their distinct needs and existing strengths, and we are helping them build their capacity to manage, oversee, coordinate, and operate health programs over the long term.

Now, in practice, this will mean different things in different places. In some countries, our development experts are training community health workers to deliver basic care and answer basic health questions. In others, we are setting up supply chains and establishing drug protocols to ensure that medicine will reach patients efficiently. In still others, we are helping set up health information systems, so health workers can collect and analyze more data—from the number of births and deaths to more complex information, like the number of women who receive prenatal care at a clinic and return later to deliver their babies. Countries need a sustainable system for capturing and understanding data, to continuously monitor and improve their own performance.

Second, we are focusing on the needs and contributions of women and girls, who are still frequently overlooked and underserved by health professionals who don’t notice their suffering or hear their concerns. Our commitment to promoting the health of women and girls is, of course, for their sake, but also for the sake of their families and communities. Because when a woman’s health suffers, her family suffers and then there is a ripple effect throughout a village as well. But when women are healthy, the benefits are similarly broad.

Too often, the social, economic, and cultural factors that restrict their access to health services—such as gender-based violence, child marriage, female genital mutilation, lack of education, lack of access to economic opportunity, and other forms of discrimination—remain unacknowledged and unaddressed. We are linking our health programs to our broader development efforts to address those underlying political, economic, social, and gender problems. And we’re working with governments, civil society groups, and individuals to make sure that the needs of women and girls are recognized as critical not only by us, but by the health ministers, the people at the grassroots who administer care every day, that they are taken into account in the budgets and the planning of finance ministries, prime ministers, and presidents.

Third, we are improving how we measure and evaluate our own impact. This includes shifting our focus from “inputs” to “outcomes and impacts”—that is, determining our success not simply by how many bed nets we distribute, but by how many people actually avoid malaria by using them correctly—a fuller picture that demands that we invest in improving how we ourselves collect, analyze, and share data.

Fourth, we are investing in innovation, with a focus on developing tools that will help diagnose, prevent, and cure disease in the communities where we work, which are often remote and poor in resources. Many of the tools and techniques we use to keep people healthy here in the United States are unsuited to the realities of life in other places. So we need to be innovative about how to reach people effectively. One example is by using cell phones. In several countries, we’re working with public and private partners to help prevent maternal and newborn deaths by sending timely and critical health messages to pregnant women and new mothers via cell phone. The cell phone has penetrated where health clinics have not.

In another exciting example of the impact of innovation, we achieved a significant breakthrough just last month, when scientists in South Africa successfully tested the first microbicide gel to help prevent the transmission of HIV. This proof-of-concept trial was made possible with funding from PEPFAR through USAID and the South African Department of Science and Technology, and it has the potential to be a major breakthrough in the prevention of AIDS, because it is an affordable tool that women can use without needing permission from their partners. Too often, the men decide whether condoms will be used. But with such a gel, women will have the power to protect their own health.

Fifth, we are improving coordination and integration. And that begins with aligning all U.S. Government programs within a country by finding opportunities to bundle services—much like PEPFAR did in Kenya, by linking HIV and AIDS programs with maternal and child health, TB, and family planning.

Coordination starts at the top, here in Washington. The Global Health Initiative brings together experts from across our government. And here today are the three extraordinary heads of agencies—who also happen to be three exceptional doctors—who are leading the day-to-day operations of the initiative: Dr. Raj Shah, the Administrator of the U.S. Agency for International Development; Dr. Eric Goosby, the U.S. Global AIDS Coordinator at PEPFAR; and Dr. Tom Frieden, the Director of the Centers for Disease Control. Their agencies, along with the National Institutes of Health and other agencies from the Departments of Health and Human Services, Defense, the Peace Corps, among others, will work together under the guidance and direction of Deputy Secretary of State Jack Lew who is also here with us today. Now, this is a unique leadership structure and it embeds our commitment to coordination at every level, from the White House down.

Sixth, we are working with existing partners and seeking out new ones. We want to align our efforts with that of other donor countries and multilateral organizations, many of which do outstanding work to improve global health. Let me just mention one in particular: the Global Fund to Fight AIDS, Tuberculosis, and Malaria. This organization has had a transformative impact on the world, not only in the millions of lives it has saved, but by creating a new model for how global community can come together to contribute and to coordinate in the fight against epidemics. The United States was proud to be the Fund’s first donor and its largest donor. We remain the largest donor under President Obama’s request for 2011.

But our most critical collaborations will be with our partner countries, and we are going to be calling on them to bring their full commitment to this effort. Because after all, their contributions will determine whether we succeed with our goal of building integrated, coordinated, sustainable systems of care for more of the world’s people.

We need only look around the world today to see how critical country leadership is. In places where governments invest in their people’s health, where civil society groups are empowered and engaged, where health is recognized as a priority in every sector and at every level of society, health improves and people thrive.

Consider the progress in South Africa with respect to HIV/AIDS. This country has one of the world’s highest burdens of HIV. For too long, some of South Africa’s leaders had a view of the epidemic that denied the link between HIV and AIDS. But that has now changed. Under President Zuma, the South African Government has come forward with a real, renewed commitment to battling the epidemic, with increased funding and strong goals for increasing testing and treatment. The United States has demonstrated our support with additional funding to help South Africa build its capacity to meet those goals and address the epidemic over the long term.

To galvanize country leadership, we are bringing to bear the full weight of American diplomacy. Our diplomats are working closely with their counterparts worldwide to embed a deep commitment to health—not only in the office of the health minister, but the foreign minister, the defense minister, the finance minister, and especially at the top, in the offices of prime ministers and presidents. Too often, we’ve seen health relegated to the sidelines and treated as a lesser priority in terms of how much money is allocated and how much attention is devoted. In fact, we’ve seen that the United States and other donors come in with money and countries actually take money away from health thinking that we’re going to make up the difference. The United States is willing to invest our money, our time, and our expertise to improve health in countries. But we are now asking their governments to demonstrate a similar commitment, in terms of human resources, serious pledges to build capacity, and where feasible, financial support.

We expect these countries to step up. And their people expect the same.

Now, this will not be easy. The changes we are working to achieve through the Global Health Initiative are broad and deep, and there are many obstacles standing in the way. But if we succeed, we will have transformed how health is delivered and received across the world.

Now, we have already come so far as a nation and as a global community in saving and improving lives. And we are grateful to all who brought us to this point, particularly the heroic health workers, and the visionary leaders, the determined scientists and researchers, and committed activists. Thanks to them, we are able—and I would argue, we are obligated—to go even further; to save more lives, to take on more difficult tasks, to commit ourselves to the patient, persistent work of building the foundation for a healthier future.

This is a challenge worthy of us, as a nation and as a people. And we are rising to meet it, as we have done many times in the past. Together, we can give millions of people the chance at healthy lives, and create a healthier, more stable, more peaceful world.

Coming to SAIS to talk about this is truly a privilege because this is a place that will be providing the leaders we need in the future to realize this vision, to ask the hard questions about just because this is the way we’ve always done it before and we’ve had some success, is this the way we should continue. To challenge the Congress whose own structure often creates stovepipes that prevent our own government from working together. To do the difficult, but essential work of convincing countries’ leaders that investing in their own people’s health is not just a worthy goal, but critical to the future of security, peace, and prosperity they claim to be seeking.

So we’re aware of all the pitfalls and all the obstacles, internal and external. But we cannot sit idly by. And we have to do all that we can in our power in this time to make a difference. And that’s what I know you came to SAIS in order to find your own way forward in achieving. And we welcome your participation and we invite you to be part of helping to solve some of the world’s greatest challenges now and in the future.

Thank you all very much.