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

Hillary Rodham Clinton
Secretary of State
School of Advanced International Studies
Washington, DC
August 16, 2010

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.

DEAN EINHORN: Thank you, Secretary. Thank you, Secretary Clinton, for that comprehensive and compelling description. Let me say there’s no one in this audience today or, I dare say, in the audience of the media out there that thinks they heard a speech for a day. This is a speech that people will be studying and that young leaders will be learning about for years to come, and we’re privileged.

Secretary Clinton has agreed, most graciously, to accept questions from our community here today. And so let me return this program back to her and thank – many thanks again.

SECRETARY CLINTON: Thank you, Dean. Well, I would be happy. I don’t know what the arrangements are. Shall I just call on people?

MODERATOR: Whatever you would like. I can call on people for you.

SECRETARY CLINTON: Why don’t you go ahead and call on people.

MODERATOR: Okay. Okay, so when I call on you, if you could please stand up, give your name and your affiliation, and be brief and only ask one question. (Laughter.) If you want, we’re going to let Harley (ph) have the first question since he’s departing us and you’re stealing him away. So –

QUESTION: It will be a pleasure to come and join both you and Raj Shah over at State and USAID. I thank you for a terrific speech. I tremendously appreciate the attention that the Secretary of State can bring to global health issues. I think everyone in the field really appreciates that. You said that global health has everything to do with foreign policy and I completely agree with you. I wonder if you could talk a little bit about how you think about the different contributions diplomacy and development have to global health, and then more specifically how you implement that when the U.S. is engaged in places where we have both humanitarian and strategic interests.

SECRETARY CLINTON: Well, I would start by making the point that I think the United States has both strategic and humanitarian interest across the world – not just in the headline places that we are so well aware of right now, but in so many other places. I like to think about every day considering what the headlines are, but then equally importantly, what are the trend lines – what are the problems that the United States and the world will deal with in a year, five years, ten, twenty years, if we don’t begin thinking about them and even more acting on them now.

And health is such a clear example of that. We have, as I pointed out in the speech, so many intersecting goals when it comes to being the leader in global health. Of course it has to do with foreign policy. Of course is has to do with national security. Of course it has to do with the health of our own people. It has to do with the values of America. It has to do with how we present ourselves in the world and what we’re seen as really committed to.

So when it comes to how we begin to better integrate and coordinate this, diplomacy is a key role. I mean, from the very beginning of my time as Secretary of State, I’ve talked about elevating diplomacy and development alongside defense – the three Ds of smart power, if you will. Because as I look at the real world in which we live, they are not separate, they are all connected. We see, perhaps, the military taking a lead in some places like Afghanistan, but our diplomats and our development experts are in there every single day doing what we can to improve governance, to improve health and education, to improve agriculture, and it is viewed now as a necessary cooperative integration of American power.

What we’re trying to do is take a look at every program and policy that we have across the government, and more effectively design and execute those to deliver on that promise of integrated networked power. This fall, we’ll be releasing the first ever Quadrennial Diplomacy and Development Review; the Defense Department has done one for many years. And having watched the effectiveness, both for the Defense Department and for Congress and the public, of putting together a statement of mission and goals and strategies and tactics, we’re doing the same. And this Global Health Initiative really gives life to what we’re trying to put forward as our new approach to this integrated approach.

Now, there are many sort of real world examples. When you think about a country like Nigeria, we have PEPFAR, CDC, and USAID all operating in Nigeria. Yet, we had a polio outbreak in northern Nigeria a few years ago. So we had our aid program and our development experts on the ground doing extraordinary work, but we didn’t anticipate and quickly respond to what became a series of rumors about how the polio vaccine was a design to sterilize Muslim children. And no matter how hard our development experts or our doctors or our nurses or anybody from one of our agencies worked, that problem undid much of the efforts that we were engaged in.

So we also have launched a kind of diplomatic effort to go along with, to support, undergird, our development and health efforts. So when Deputy Secretary Jack Lew was with Dr. Eric Goosby in northern Nigeria recently – in Kano, right? Right? He went to see the sort of chief of the area, the emir, and was pleased that the emir vaccinated with the polio oral vaccine his own grandchild. That spoke louder than any lecture we could give, any argument we could make. So we can’t do one without the other. We have to have a coordinated effort.

And what has happened too often is that people work so hard. I mean, I’ve never seen harder working people than the people I’ve seen from USAID or PEPFAR or CDC, or our other government efforts. They work so hard to save lives, improve lives, change governments – all the things that they do on a daily basis. But very often, in the countries in which they serve, they don’t work together. I’ve had members of Congress tell me repeatedly who are interested in our development work that they go to the embassy in a country in Latin America or Africa or Asia, and they ask to meet everybody working in development, so all the different agencies’ leaders and workers come together, but that’s the only time they’ve been together. We have to end that. I mean, we have the smartest, most able dedicated people working in development and health in the world in the United States Government. But if they don’t work together, they cannot possibly leverage what they’re doing to get anywhere near to the goals that we set.

So this is just a passion of mine because I want to see our development efforts be viewed as the best in the world across the board, led by USAID, which I want to see returned to become the premier development agency in the world and working with all of the other agencies, departments that do health. We cannot afford in a time of limited financial resources to have everybody doing their own thing. If we’re going to have a clinic then that clinic needs to do not only HIV/AIDS, but family planning and polio vaccine and other matters.

If we’re going to have a country team in a country working together, they don’t all need their own SUVs. (Laughter.) I mean, we have got to get smart about how we spend our money, because we don’t have limitless resources. And I feel a particular obligation, as I have said on numerous times in the past 18 or so months, at a time when American unemployment is recorded at slightly less than 10 percent, and we know structural unemployment is worse. And we’re asking hardworking, maybe unemployed Americans to keep paying their taxes and some of that money will go to fund our development and diplomacy efforts worldwide. I have to be able to look them in the eye and tell them they’re getting their money’s worth. And we just can’t keep doing what we’ve been doing and be able to tell them that. We have to get smarter, more agile. And I’ve seen wonderful efforts by Raj and Eric and Tom and others in their own agencies to really bring that idea forth, and now we’re going to try to do it across government, which, as those of you who are checking in for your first year here at SAIS, is not easy. (Laughter.)

So any ideas you’ve got, send them our way, because we are committed to making these changes for the long term.

MODERATOR: Any students over here? This young woman with the brown hair, yes. If you can wait for a microphone. Please remember to give your name.

QUESTION: My name is Monica Sanor (ph). I’m a second year student at SAIS. Thank you so much, Secretary Clinton, for coming here and speaking to us. It’s quite an honor for all of us and I’m glad to speak on behalf of my class when I say that.

As a current intern at USAID, and I’m, of course, the message – I’m not speaking on behalf of the U.S. Government here – (laughter) – just my personal --

SECRETARY CLINTON: Might as well. (Laughter.)

QUESTION: How – Rwanda just underwent elections we’re calling free and fair. A lot of other Sub-Saharan countries are undergoing their own elections or upcoming elections. How do you reconcile that key facet of leadership, especially in Africa and where a lot of our global health funding is going, and the impact that has on whether or not a program goes forward, has that support, and maybe future recommendations for working with African leadership?

SECRETARY CLINTON: Great question and at the core of so much of the work that we do and the analysis that we undertake every day. That’s why I mentioned South Africa. Leadership matters. It matters enormously. For years, the South African leadership, unfortunately, was in denial or was refusing to accept the facts about HIV/AIDS, and the epidemic exploded in South Africa, which now has the highest percentage of HIV-infected people anywhere in the world.

President Zuma has changed that. Dr. Goosby and I were in South Africa last year just this month, and we saw firsthand on the ground what a difference it makes when a president says we’re going to start treating people, we’re going to work with our generic drug manufacturers to produce more drugs, we’re going to open more clinics, we’re appointing a health minister who is young, dynamic, and very committed. It was stunning and wonderful to see. So leadership matters.

Now, we can go into countries and deal with emergencies and we can even set up parallel systems, which we have done in many places because there was no other way to do it. So we run our own health clinics, we run our own immunization programs, and we save lives and we improve the quality of life. But if there’s no buy-in from the leadership, these are not sustainable.

We have countries not just in Africa but in Asia as well that are becoming quite wealthy in one respect off of natural resources, and yet you see very little of the money going into health. And at some point which is really underlying what the Global Health Initiative is attempting to do, we have to tell countries we cannot help them any more than they are willing to help themselves. Now, maybe their help is just getting the right people appointed to the right jobs because they don’t have any more resources than that, but sometimes it’s allocating their own resources so they’ve got skin in the game, so to speak, and they all of a sudden care about where that money is going. And some of it is working with us on training programs. There are just a myriad of ways that leaders and governments can show their commitment.

But I’ve been in enough countries everywhere in the world to know that leadership is the alpha and the omega as to whether you’re going to have sustainable, effective, health care in any country. So I’m hoping that through this partnership this Global Health Initiative is offering to countries that we will see greater buy-in by leaders. We’re going to try very hard to prevent the diversion of resources out of health, which has been a pattern. Well, if the Americans and the Global Fund are going to come in and do health, we’ll build roads, or – we need roads, so that’s a good substitute, we’ll just take the money out of health.

So our argument has to be no, this has to be a comprehensive approach. Of course, you need a road because you need a road that actually can bring people to the clinic. But you’ve got to – it can’t be one or the other.

We also want to do more work with other donor countries and other NGOs and multilateral institutions. I mean, what we’re trying to do inside the U.S. Government to better coordinate and integrate we would like to see globally. So we are talking with a lot of the donor countries that have programs in the countries that we’re doing the Global Health Initiative, and we’re trying to see how we can maximize the impact of our resources. Ideally, someday I would love to see like a map of the world all lit up and so if the United States is doing a health system in Country X, then the Scandinavian countries take all their resources and go to Country Y, which the United States can’t do and nobody else will do, and we want the Global Fund to be supplementing, not supplanting, the resources that go in. I mean, you can see how this could become the integrated system we hope for, but it’s very difficult.

We’ve also started discussions with China on development. At the last Strategic & Economic Dialogue that I and Secretary Geithner led in Beijing last May, we put development on the agenda. And we talked about the fact that the Chinese are omnipresent in Africa, in Latin America, in Asia. Particularly if we just focus on Africa, there are, we think, millions of Chinese who are working and involved in the contracting and the businesses that are being developed there. And often, the Chinese will offer some kind of development aid in return for a mining contract and what we’re trying to do is to make sure that if they’re going to do it, that it somehow gets integrated. We’ve had conversations about one country where the Chinese are building a road and we’re building a hospital, and we would really like it if the hospital would come to the – the road would come to the hospital. So, there’s all – those discussions are ongoing. To go back to the first question about diplomacy and development, we are trying to look at this holistically and both buttressing and supporting leadership. Trying to get health higher up on national agendas has to be one of our biggest diplomatic efforts, because our development experts can’t really accomplish what they’re trying to if they don’t get the support and the buy-in from the countries.

MODERATOR: I’m hopeful there’s some students in the far back who have questions. Is there anybody in the back who wants to ask a question? Okay, Mike (ph), if you can take a microphone.

QUESTION: Madam Secretary, I’m Sam Christophe (ph). I’m a student here at SAIS. My question is about the relationship between the health initiative and the MDGs. Obviously, health is an important part of the Millennium Development Goals, sorry MDGs – I think three, four, and five or four, five, and six. A number of the targets under the initiative, while they are ambitious, even if they’re achieved, I think it’s by 2014, will still fall well short of the MDGs. I just wonder – I mean, do you see the MDGs as no longer achievable, and I mean, if you do, what sort of outcomes will you be looking for from the summit next month in New York? Thanks.

SECRETARY CLINTON: Well, I certainly do see the MDGs as achievable, but I also see their achievement as taking longer than any of us would have hoped for when they were first adopted back in 2000. I’m looking forward to the summit during the United Nations General Assembly in September. I’ve agreed to participate because what we’re doing is continuing on the path toward the Millennium Development Goals. But we are also taking stock, and we’ve met with the UN officials responsible for the summit and the work on behalf of the MDGs through the various UN organs, to ask that everybody take stock. We all have to ask ourselves where we’ve made progress and why, where we’ve fallen short and why, what can we do to try to fill the gap as we continue on the path toward achieving the goals that were set for it.

I am sensing a much greater openness to accountability, to measurement. It’s not enough just to care a lot and go out and try to do good; that is a sine qua non of making it happen. But you have to be willing to ask yourself how much good am I really doing and am I doing it in a way that’s likely to maximize progress toward the MDGs or other goals that have been set.

So I think we can say that the picture in 2010, 10 years after, is a mixed one. I think we can take some pleasure and pride in the progress that has been made. Child mortality is down, for example. There are some positive milestones that have been reached on the way to the goals. But we have a long way to go, and we hope to use the UN process in September as a forum for bringing a lot of the multilateral organizations and the country donors together to have this very frank discussion.

Raj Shah has started this extraordinary effort in USAID to really maximize use of science and technology in tackling and solving global development challenges, and we’ve got some great ideas. In the United States, we’ll be working to implement them, but we want to spark this kind of effort worldwide. We think that technology can make a big difference in collecting and disseminating information that will help us better educate people about what they can do for themselves. So I think that we see the glass half full, but it’s got a long way to go till it gets to the top. But we are absolutely committed to the MDG process and to the eventual achievement of them.

MODERATOR: Okay. Last question, hopefully from a student. You’re very eager back there. We’ll go ahead and call on you in the green. I know you’ve been patiently waiting.

QUESTION: Thank you. My name is Allison Aslan (ph). I’m an incoming student here at SAIS. And I’m wondering what metrics do you intend to use to measure the success of the Global Health Initiative, specifically with regards to promoting women’s health.

SECRETARY CLINTON: Well, we will be rolling out metrics. Right, guys? (Laughter.) But let me just answer that in a brief non-scientific, non-statistician way. Because that’s one of the other initiatives that both Raj and Eric have undertaken in AID and PEPFAR, and to some extent CDC is like the epicenter of statistical evaluation and reporting and can give the rest of us some real guidance and help about how best to do that.

There are many different indicators on women’s health in – for example. We are focusing on maternal mortality because that is so measurable. We know where we have a better idea of what works and what it will take to have more women deliver babies successfully. There’s all kinds of interventions from the very simplest, like a safe birthing kit, which is a piece of twine and a clean razor blade and a bar of soap and a piece of plastic to put under the women, all the way up to tertiary care for complicated pregnancies. So we will be judging outcomes on how many women safely are able to deliver a healthy baby, and how do we best meet the needs along the way. And that is part of – that is built into our country ownership concept.

We will also be looking at family planning distribution. I believe strongly that better access to family planning is directly related to lowering maternal and child mortality if women are better able to space their children and the births are more likely to be safe and successful. We also would like to see increases in the legal age for marriage, because we know that young girls are more likely at physical risk for pregnancy and delivery. And so this is another way that development and diplomacy work together. We are encouraging countries to pass stronger laws and then enforce those laws against child marriage so you don’t have girls between 10 and 16 trying to deliver babies.

We’re looking at the access to care, which was kind of the example that I gave, because HIV/AIDS now has a woman’s face in Africa. There is an enormous amount of work to be done to prevent the continuing sexual abuse of girls and women by men infected with HIV. Some have the very unfortunate superstition that having sex with a young girl cures you of the disease. So there are lots of educational components about how we try to change behavior and protect girls and women.

So, I mean, those are just some of the examples of how we will on a broad kind of matrix judge ourselves, but also try to get partner countries. I mean, we would really like to see with the MDGs, which sort of set the format, agreed upon measurements. And we do have some, but we don’t have enough. And they’re often honored more in the breach than in the actual implementation. So I think there’s a lot that we can do by just pulling together what we already know and trying to, frankly, publish it in more digestible, understandable forms.

It was fascinating to me that in our last strategic dialogues with Afghanistan, both when I was there last month and then in the recent visit by President Karzai and members of his government, their number one development request was to help on the issue of maternal mortality. Now, when you think about it – and we’ll sort of round all the way back to the first question about foreign policy, diplomacy, and development – there are varying degrees of attitudes within Afghan culture about interventions in health. But there is general agreement about trying to keep women alive as they deliver babies. So working – the Unites States working with other partners in a concerted effort on maternal mortality in Afghanistan gives you an opportunity to connect with segments of the population that may or may not be particularly supportive of anything else that we and others are doing.

So you have to look at how this fits into the overall strategic goals that we have in foreign policy. So that’s why I would end where I started. Now, sometimes with humanitarian emergencies like what we’re seeing in Pakistan, what we saw with the Haiti earthquake, you just act. You just do what’s right because it’s the moral imperative to do so. And the American people are very generous in responding to those disasters.

But once the disaster has receded and the wreckage, the human cost of death and destruction and injury and devastation of infrastructure and farmland is left, then I think we have both a humanitarian and a strategic imperative. And I think that we are at our best when we’re able to produce results where people see us as we see ourselves. The American people see us and I certainly see our country as an incredibly generous nation that really has gone time and time again to the aid of others with whom we don’t have much of a connection. And perhaps the cold real politik wouldn’t dictate that we did so, but we have. And so I want to see us, if we’re going to be investing time, money, blood in our efforts, that we go into it with a very clear view of what we are trying to accomplish and that we take into account the values and the cultures and traditions of others, but we recognize there are certain issues that have to be addressed, leadership being absolutely at the top.

So I’m very optimistic about the Global Health Initiative, about what it can mean in terms of results, but what it can also represent as frankly a new model of how we better present ourselves to the world, how we are more cost effective and efficient in delivering services, and where the United States leads by our values and people can see what that means to them.

Thank you all very much.


PRN: 2010/1116