Discussion: International Health Aid
Should global health become a priority for Americans? Does international aid for health do any good? Critics argue that much well-intentioned foreign aid is being wasted, with debilitating health problems persisting in countries around the world. Should Americans support increases in aid for international health? If so, why?
- Improving public infrastructure and public health
- Misperceptions about health spending, domestic and international
- U.S. spending on health, compared to other nations'
- Grassroots giving: Filling in gaps left by government?
- Beyond foreign aid: Reversing brain drain and retraining health workers
- Foreign aid with strings attached: The gag rule
- Aid money and American intermediaries
- What are the best means of aid distribution?
- Partnerships among aid providers
- Humanitarian, social, and human rights arguments for economic development
- The corruption question
- The case of malaria: What can one person do?
- Domestic and international challenges for improving mental health care
- Final Thoughts
LINDA HARRAR, MODERATOR: Malaria used to be a problem in the United States. I'm assuming the U.S. solved its malaria problems by draining swamps, improving public infrastructure, and perhaps using pesticides that may have dangers of their own. Should more international health aid be directed toward projects that improve public infrastructure, such as preventing stagnant water, eliminating slums, and crowded living conditions?
Dr. ALLAN ROSENFIELD: When malaria was eradicated from places like the southern United States, we were in a temperate climate that was more responsive to the efforts that were undertaken than, say, in the major tropical areas, where the steps taken in the U.S. back 50 years ago would not have accomplished as much in some other places.
Having said that, I think the issues you just raised would be important steps. In addition, although DDT is a bad name with some, the use of DDT within homes is indicated, in my opinion, along with the move towards bed nets, plus the newer medications, the combination drugs that we're now talking about. So I think just what you suggested, plus the approach I just suggested.
DAVID BLOOM, Ph.D.: Let me start the answer by just telling you a little story. I was at the World Health Organization [WHO], and I've been very interested in the contribution that good health makes to economic growth and development. And it occurred to me that I should really be clear on what it takes to promote good health. So since I was at the World Health Organization, I thought: why don't I just ask? There must be a standard response to that question.
So I went into an office, and I was speaking with the folks there, and I asked them, "What is the WHO's view on what makes for good health?" And I was told: "Oh, it's very, very simple: medical interventions. That's what we at the WHO believe: vaccination, drugs, and the like." And I said, "Oh, that's interesting."
And then, for some reason, in the next office I went into, I asked the same question about the WHO's approach to promoting good health, and I got an answer that was equally clear, but very, very different. The answer I got was, "Nonmedical health interventions," so things like improving primary building and strengthening primary health care centers, clinics; training medical personnel; building better health information systems, more effective systems for procuring, storing, developing pharmaceuticals and other medical equipment; safe water, sanitation, family planning, population policy. Again, nonmedical health interventions.
Then after lunch, I went into yet another office and asked the same question, and I was given a completely different answer but with absolute belief and confidence in it. I was told that non-health interventions are the way forward, so better basic education, especially for girls, communications infrastructure, good governance, macroeconomic policy, etc.
I realized at that point that there's a whole taxonomy of interventions, and I think our natural instinct when we think about ways to improve health is to go very, very directly, so to kill the mosquitoes that are causing the malaria or to drain the swamps that they feed off. But in many respects, we have many, many options for improving health, and in a lot of ways, it's the indirect approaches to improving health that may well be the most effective.
For example, when we conducted focus groups in four villages in Thailand and four villages in India and four villages in China, the number one answer to the question of "What would improve quality of life?," it was not about education, it was not about health; it was about roads. They said, "Build roads; build infrastructure." Then we asked, "Why?" — because you can do that when you [conduct] a focus group — and the answer that we were given is, "Because if we have good roads, then we can actually get to the health clinics, and we can get to the schools, and we can get to market and to labor markets, where we can get jobs and/or sell our produce."
So I think it teaches a very important lesson here, that there are many, many interventions available. We don't know nearly as much as we need to about how to set priorities among them and how context-specific different options are, but certainly strengthening public infrastructure perceived broadly, I think, could be the best of all the interventions and is very, very important.
A malaria vaccine is not the only approach or treatment for malaria. There are many, many other ways to skin that cat.
PHILIP J. HILTS: The thing that's worth emphasizing is that this question goes back to history, and we should remember that we've learned a lot in the last 30, 40, 50 years. One of the things we've learned is these various solutions, in order to put them in place, you have to work within the country with the people on the ground who are going to carry it forward for years. So the various solutions come from them, and the aid comes from us, and the two mix together. I think we know better than we did 30 years ago how to do this, even though there's always problems.
ROSENFIELD: I do agree with the general issues that [David] raised, but also that one has to make some attempt at broad development — which is very complicated, very difficult to do, particularly in terms of global funding — and that that should not stop us from eradicating or dealing with these various problems. If we were to come up with a vaccine, that would have a huge impact on malaria. If we come up with an AIDS vaccine, that will have huge impact on AIDS, no matter what we do with the much longer-term development issues. But I wouldn't want to say one versus the other; somehow I think we have to be thinking about both.
HILTS: In Botswana, we had a situation where there was an intervention delivering antiretroviral drugs in the middle of all kinds of other problems. But the impact of it is there and growing, so that one intervention is one of those cases where you really need to do something now.
Intervention was something that was called for by the people in the country, [by] the president, Festus Mogae, when the donors were nervous about it; they didn't really want to put money into drugs. But [the people of Botswana] really wanted that, and they went forward. And that's one of those things that you have to do sometimes, is try the high-impact intervention.
BLOOM: Allan is, of course, right about the potential for a malaria vaccine to promote good health and reduce malaria mortality. But the fact is, we have to go into that effort with our eyes open, because it's a very difficult vaccine to develop. The same vaccine may not work in all populations, or it may not have the same efficacy in different populations.
There may be side effects that are basically troubling; think, for example, of the rotavirus vaccine that was developed a couple of years ago and had to be pulled off the market in the U.S. because of a problem. We may have the emergence of a mutated form of malaria that is not susceptible to this vaccine, etc.
All I would say is we also need a Plan B, and we need a Plan C, because when it comes to people's health, it's really, really important. I don't think we want to put all of our eggs in one basket; we need a diversified portfolio of approaches here.
MODERATOR: When health care in some areas of the United States is no better than in many developing countries, shouldn't we attempt to make the U.S. a model for global health before trying to fix other countries? We seem to be throwing millions of dollars into relief efforts somewhat randomly without really knowing where the money and/or the supplies are going.
HILTS: The sense that he has about a lot of money going in these random places is probably not correct. There is a general sense in the American public that we're spending great deals of money on foreign aid and emergency aid. There have been six or seven different polls; they show people feeling about 20 percent or 25 percent of the entire American budget is going into these things when, in fact, we're down actually around 1 percent.
As far as how you divide it up, I don't think we need to separate out aid to other countries from emergency aid to other countries or emergency aid in our country, health aid to other countries, health infrastructure building in the U.S. See, these are all decisions about how to deliver infrastructure and aid, doing the smart things, the efficient things, and not spending money on things that don't work.
People in these focus groups all say the same thing: that when you tell them we're actually spending very little money, they come back saying, "Well, we're willing to spend more." The key message is that we have to first understand how much we're spending and how well, and have that debate, and then address them.
BLOOM: If the proposition is that we need not address the basic health needs of people outside the U.S. until we've achieved the highest level of health for everyone in the U.S., I don't agree. I don't think it's terribly rational. I actually think that health care in the U.S. is quite outstanding already for most people.
I understand that there are big pockets, unacceptably big pockets of poor health and that we can do better there, but I don't think it's a zero-sum game. It's not a fixed pot of resources that we have to direct towards health in the U.S. versus abroad. I think we should just be increasing the size of the pie in terms of the resources that we direct to health abroad.
I also think we have loads of information about where our international assistance goes. The problem is that not much of the information gets out of the computers of U.S. government officials. But the information is certainly available, and we probably need to do a better job of indicating what the resources are being used for and where. People need to understand that actually we're devoting precious little resources to international [aid] just for health. It's a lot lower than I think anybody recognizes, as mentioned, and that's something we need to put in front of people.
ROSENFIELD: Two general comments. One, I agree with the issue that what we spend here and what we should be spending overseas are not related directly. The amount of money for foreign assistance, in general, is 0.16 percent of GDP [gross domestic product], and the recommendation of the G8 and others is that we should be spending 0.7 percent, so we're way down on foreign assistance, and health is only one part of that.
I will say that we have major problems — and I would disagree with David. I think we have major problems in our health care system, in a system that has 15 or 16 percent of the population uninsured, getting care only through emergency rooms. Our problems of the uninsured are a huge issue that should be solved, but they're not competitive in terms of where the dollars should come from.
BLOOM: The fact that there are 40-plus million people in the U.S. who don't have health insurance is a gigantic gap — agreed. But globally speaking, would you not agree that it's the best in the world? …
ROSENFIELD: If you have insurance and if you're wealthy, yes. If you're able to run to an emergency room, yes. But in terms of the quality of the care for the uninsured and all of the issues around that, it's dramatically worse than anywhere else in the Western world, so I think you have two issues still there.
MODERATOR: To get back to this Question of generosity and perception: Many Americans perceive themselves as a generous people, yet critics say that the U.S. doesn't give enough. What is the true picture of where we stack up compared to other developed nations, and is there a perception issue that many Americans think we give far more than we do?
ROSENFIELD: In terms of dollars, we are probably number one, but in terms of a percentage of GDP, we fall way behind most of the rest of the Western nations, with the Scandinavian countries coming close to 0.7 percent, the French and the British up above 0.3, with a goal of going up to 0.7. So dollarwise, we spend a lot because we're so huge, but in terms of percentage, we're way behind the rest of the Western world.
HILTS: That's the general picture; the question is what the word "generosity" means. So generous compared to what? Compared to ourselves? Compared to what we have done in the past, we're down. Foreign aid has dropped dramatically from the '50s and '60s. It's at the lowest point in history.
MODERATOR: Could that be because people just don't understand what the reality is, that they have this real problem?
HILTS: I think the history of it is quite complicated — why we change our minds about what to spend money on, what's going on in the world. We gave much aid during the Marshall Plan to build Europe to fight the Communist insurgency and so on, so there are different reasons. Right now we are in a period where we have gotten complacent and forgotten to build these infrastructures, forgotten to work on these issues that matter.
MODERATOR: Please comment on the differences between what individuals can do versus governments. Is there need for both kinds of support? You can frame this in terms of generosity, because many Americans feel that they give a lot to charitable organizations. How does that stack up compared to what governments can do.
BLOOM: Maybe a case in point would be charitable giving in the aftermath of the tsunami that occurred in Asia [in December 2004]. It was a tremendous amount. There was an extraordinary response at the individual, the grassroots level, down to the level of schoolkids foregoing their allowances and birthday presents, etc., a very, very high proportion of them as well as individuals giving through their workplaces and various charities, etc.
What struck me as most extraordinary about this is, it seemed to signal that it was individuals' way of correcting the government's lack of generosity in terms of its response. And that goes on. Bill Clinton and the elder George Bush, the former president, they've gone around as private citizens trying to collect money for what I think in a lot of ways could probably be handled better by the government itself.
To some extent, individual giving is a substitute for governmental giving, and I think that in the case of the tsunami, a lot of the individual giving was a correction for what was perceived as too little by the government. Individuals, of course, when they give money, can also direct it at the causes that they want. They can fine-tune it to a much greater extent than if they're lumped in as part of governmental giving. But, of course, governments can give. They can have much, much more oomph with respect to their giving because they're giving much larger sums.
MODERATOR: The scale is quite different.
ROSENFIELD: There are a few individuals who do many things — obviously [Bill] Gates and major philanthropists. In terms of the level of funding, when we talk about, let's say, the $15 billion AIDS commitment from the Bush administration and the amount of money for some of the large MDGs [Millennium Development Goals of the UN, such as health, education, agriculture, nutrition, the overall goal being reduction of global poverty by the year 2050], I think that's going to be predominantly government. That's not going to be predominantly private funds.
HILTS: There's two things going on that are actually rather different. The perception, the psychology of it is different. One is philanthropy, and that's [that] people have the impulse to give. Historically, if you go back [to] when there have been disasters around the world, we've always given a lot, and other countries have as well. That's something [people] want to do regardless of what the government is doing day to day and in the budget.
But what the government is doing and what we've at least attempted to do since the 1950s is, with our aid, actually invest, invest in building up the world that we have to live in and building up our partners. And there are two kind of different things, and we should put them in different categories, and we should accept both. We should work on building up our investment, build it up to a point where it makes sense, what we're getting out of it, and then expect also individuals will be reaching out whenever they feel that they really want to and need to. They're not really the same things.
MODERATOR: Are there other policies or measures besides foreign aid that can help developing countries improve their health and climb out of poverty? I'm thinking of trade, relieving debt burden, repaying interest, reversing brain drains. Can you give us some other ideas? I know The New York Times ran a series of editorials in 2003 called "Harvesting Poverty" on foreign trade.
BLOOM: There are many policies that have all sorts of implications for economic development, and trade policy is generally regarded as extremely significant. But actually more important than trade policy, probably in terms of its potential to yield improvements in the overall standard of living going forward, is international migration. You mentioned, Linda, reversing the brain drain. Let's leave that aside for the moment, because that's a very difficult problem, and I don't think there are any good answers on the table.
But international migration insofar as the wealthy industrial countries have lots of capital and lots of jobs, and the developing countries have lots of people in search of jobs, there's a natural bargain that has to be struck there that actually would lead to a tremendous boost in income. I think it's been estimated that if we just had 100 million more international migrants in the world — and in a world population of 6 billion, 100 million is really a relatively small number — but an additional 100 million international migrants would result in income per capita in the world rising by about 8 percent. That's an awful lot of money to leave on the table in a world where 1.2 billion people live on less than a dollar per day. So at the moment, we do have a global framework for international trade and capital mobility, but we don't have a global framework for international migration. We keep, if anything, raising the barriers to international migration, not reducing them.
With respect to the health area [and] the issue of brain drain, there is a tremendous flow of health personnel from poor countries to the rich countries. You see this especially in Africa, and you also see it in countries like the Philippines, where you have Filipino doctors now that actually are better off taking positions in, let's say, New York City working as nurses. They actually earn more as nurses in New York City than they would earn as doctors in the Philippines. A great deal of their training is just going completely to waste, and that kind of brain drain of health personnel is leaving many developing countries very underserved with respect to trained personnel.
But again, that is a very, very difficult problem to rectify, and it's made even more complicated by the fact that the reality is that a great deal of the income that the Filipino doctors or African doctors in England earn actually ends up back in-country via remittances that they send back, so the country does in many ways actually benefit, although the benefits are more diffused because the money goes to many different uses, not just to health improvement.
In general, the globalization process, which essentially involves lowering the barriers to trade, capital mobility, and international migration, has great potential for raising standards of living and bringing along with it improvements in health and education and the quality of life generally. But in terms of targeting resources, perhaps we're looking more at policies that have some conditionality to them. For example, debt relief could be conditioned on devoting more resources to the health sector. That kind of policy might be what we need to be doing more to bring about.
ROSENFIELD: Allow me to say something about the health care workforce issues and some of the things that you just discussed. [WHO Special Envoy on Human Resources for Health (HRH)] Lincoln Chen chaired a committee that recently released a report … on the health care workforce. And to my mind, there are two or three issues that are of critical importance for the health care infrastructure and workforce. And one of them does relate to brain drain, and it indirectly relates to policies of the World Bank, the IMF [International Monetary Fund], and various other agencies and their policies, which limit investment in social programs such as health, education, etc.
Until salary levels of health care workers, particularly physicians, are increased to a reasonable level, we're going to continue to see brain drain. And brain drain is not only moving to the UK and the U.S. and elsewhere, but it's also working for the NGOs [non-governmental organizations], the UN, the universities, and everybody else who works in the various countries and wants to hire local people rather than bringing a bunch of Americans or Europeans in.
So there's two types of brain drain: the ones that are working with Harvard and Columbia, for example, and the second is moving to Europe and the United States. And until such time as there are reasonable salary levels, I think that's going to continue.
Another issue that wasn't as much discussed is, particularly for rural health care issues, redefining who can do what. Just as one example, in our maternal mortality initiatives in places like Mozambique and Tanzania, the governments have redefined who can do what to the extent that surgical technicians, who are not physicians, have been trained to provide emergency obstetrical care, including the provision of Caesarian section, doing it as safely and as well as doctors.
Until we redefine who can deliver care in the rural areas — for example, who can provide the antiretroviral therapies: is it only doctors, or can we provide care through the training of other workers? — we are going to have difficulty in delivering the kind of care we're talking about in a variety of areas as part of the MDG's goals in the health care field. So I do think that a key factor is definitely to undo some of the past policies of the financial community.
MODERATOR: Allan, could you just play out that example a little bit for us? Explain what may happen to a woman who is experiencing complications of pregnancy. Paint the picture for us.
ROSENFIELD: I think it has been embarrassing to the international health community that we've got a problem of somewhere between 500,000 and 600,000 women dying each year from complications of pregnancy and several millions with complications when we have the technology; we know what to do; we know how to put in place programs. The various governments and international agencies have talked about it for the last 20 years, but until relatively recently very little change has taken place.
There are a couple of countries, like Sri Lanka, for example, which has made maternity care a priority, and they have a program comparable to what we see in Europe and North America. A couple of countries in Latin America, the same situation, like Costa Rica. But in much of the world, people have not given attention to either what could be done at the community level and the fact that for certain women, emergency obstetrical care is an essential to keeping them alive — where they need a Caesarian section, where they need a blood transfusion, where they need a D&C [dilation and curettage] to treat a botched and unsafe abortion. Women should not be dying from these causes.
We've actually described our program as a human rights issue. Women have the human right to have access to appropriate maternity care when it's doable, and it doesn't require research and new methodologies.
MODERATOR: So what would be the kind of workforce that would be able to deliver that?
ROSENFIELD: Well, that's why I made the mention of Mozambique. For emergency obstetric care, as compared to most other interventions, you need health professionals available 24 hours a day, seven days a week, to provide emergency care. We aren't in the foreseeable future going to have sufficient numbers of physicians in many countries in Africa and South Asia to provide medical care that is essential if we're going to meet this need in rural areas.
We're actually going to be holding an international meeting somewhere in the next six months on the experience of poor African countries who have used other levels of personnel. I think it has direct relevance to the provision of AIDS care and treatment as we begin to move out of the urban and suburban areas into the more rural areas, even though there you can develop a 9:00-to-5:00 type program. But still, we're going to need personnel beyond doctors in many communities.
HILTS: Basically, when we're talking about trade and debt relief and these kind of issues, these are the high-profile issues. These are the things that draw the protests, and they raise the questions of legitimacy of globalization and legitimacy of our efforts to deliver aid and development.
We should remember that whatever we're doing on health aid, these other ones are the ones that are going to be putting people in the streets. So these are vital, and we should not forget that the protesters, whether they're very coherent or their argument is diffuse or whatever, it's still forceful and can have a big effect. We have to pay attention to the issues of legitimacy, and so on the issues of whether our trade is fair and whether we can relieve debt, I think those are important to address.
MODERATOR: Getting back to foreign aid: Does foreign aid sometimes come with strings or conditions attached that make it difficult for developing country health ministers to meet the health needs of their people?
ROSENFIELD: In response to the AIDS pandemic, we're beginning to see the donor community being willing to let the government set their policy and then let the government have one policy, and the various donors buy into it. This is being promoted by the donor community and local governments, particularly in Africa.
That's a major change from many of the programs in the past. The gag rule — which had been in place in the original Reagan-Bush I era, and then undone by the Clinton administration, put back in place by Mr. Bush when he was elected in 2000 — is an issue in which anybody having USAID [U.S. Agency for International Development] funding working overseas on family planning programs, that no funds can go to a private organization that provides abortion services, abortion advocacy, or anything to do with abortions.
More recently, with our PEPFAR [President's Emergency Fund for AIDS Relief] funding, there have been some restrictions on abstinence-only education programs for teenagers in schools, which causes a restriction on a full-blown prevention agenda. There has been an issue that funding recipients have to sign a policy against prostitution and sex trafficking. No one argues that they are against sex trafficking, but on the prostitution issue, there are some misunderstandings about what drives women into prostitution other than sex trafficking. For those organizations overseas that do have any kind of efforts to try to legalize prostitution, only to try to help the women who work as sex workers, that's still a no-no for the U.S. government.
Fortunately, for U.S. organizations providing care to sex workers, there has been no real inhibition on the ability to work, provide condoms, provide care and treatment and counseling. But such prohibitions can have a chilling effect in some settings.
MODERATOR: Allan, that last thing that you just said is a little bit hard for a layperson to comprehend. What is the restriction, and why would that prevent a health worker abroad from having a tough time combating HIV-AIDS? Can you give me a for-instance?
ROSENFIELD: Sex workers, if they're not HIV positive, need education on how to protect themselves; if they are HIV positive, they need care and treatment. The current policies allow care and treatment to go forward. But if there is a group of sex workers in a given country who have gathered together to try to legalize prostitution so as to attempt to improve their lot and their ability to earn money, that is opposed by the U.S. government. And in theory, you cannot fund a group that is doing that. But fortunately, this policy does not inhibit working with sex workers in terms of care, treatment, and prevention education.
HILTS: I was in Zambia this past summer working there with some journalists and, at the same time, sex workers. They have their own rogue group in which the sex workers have decided on their own that they're going to start enforcing the idea of using condoms, even though the men don't want to do it. So they have kind of an informal union pushing this, and pushing against the policy that is suggesting they don't do it. So it's kind of nice to see that they are pushing back against this.
BLOOM: There is actually a very sad irony in the gag rule. As Allan described it, it's basically that no U.S. foreign aid assistance, for any purpose, including non-abortion-related family planning services, is provided to foreign NGOs that use funding of any sort to perform abortions or to provide counseling and referral for abortion, etc. So the idea of the gag rule essentially is to cut down on abortions, and I want to suggest that the evidence appears to indicate it may actually have the opposite effect.
The idea is the following: when you provide less assistance for family planning, what we know is that fertility rates are higher. But fertility rates are higher mainly because the rate of unintended pregnancy is higher, and we know that unintended pregnancies are greatly elevated. We know that a relatively high fraction of unintended pregnancies are the pregnancies that lead to abortion — and that's not just safe abortion; it's also the botched abortions that Allan was speaking about.
So by cutting back via the gag rule on family planning assistance, higher rates of unintended pregnancy ensue, which have higher rates of abortion associated with them, and high rates of unsafe abortion. Thus we are in a situation where actually we have more abortion and more maternal mortality contributing to the half million to 600,000 maternal deaths a year. That really is, as Allan said, to the global health community "absolutely unacceptable." And it's really tragic beyond that.
MODERATOR: I've heard it said that 60 percent of American foreign aid is spent by organizations within our own shores and never leaves the country. Could each of you comment on your experience of whether that is true, and what could be done to perhaps see to it that more of the dollars that the American public does give gets to the people working on the front lines?
ROSENFIELD: I think that's a misconception. The criticism is that a lot of the U.S. government money goes to American intermediaries who work overseas. But at least in my experience, with not only our own programs but programs which I'm familiar with, many of the other organizations, the bulk of the monies for work in developing countries is programmed for work in the developing countries, and a relatively small percentage goes for the central office and for the cost of staff who work in-country for that organization.
So I think it's a misconception. There will come a time when more and more of the money goes directly to developing country organizations without going through American intermediaries, but I think that most of the intermediaries are quite effective in getting the money to where it's supposed to go.
HILTS: That particular figure, 60 percent, comes from a specific comment about one PEPFAR program, which had 60 percent of the money staying home. That's a criticism of that particular program partly because it's getting started and it has been top-heavy. But in other programs you see quite a different picture. I think the Global Fund to Fight AIDS, TB and Malaria is trying to develop the model now for how to keep the administrative costs down and actually deliver the money to the programs that the people in the country want done.
BLOOM: Allan's pointing out that this is a misconception is a very important point, and Phil's comment about their being a life cycle to funding, and the share that is basically spent internationally versus domestically, I think that's also a very, very important point. Also, we should recognize special skills that are needed to make a program work.
In many cases, that involves people that are Americans. I don't think we should forego those special skills which are actually vital to making a program work because the people with these skilled are relatively well-paid Americans. I think we should be pragmatic and spend the money. As experience shows us, what happens is that increasingly these programs rely on capable people from the countries being helped.
MODERATOR: That's a good point I'd like to follow up on. Is foreign aid delivered more effectively through governments; in other words, directly to ministries of health through multilateral institutions like the World Bank or the World Health Organization or UNICEF, or through non-governmental organizations that may have local chapters like Save the Children or CARE? Can you talk about what seems to work best in terms of spending money and really getting the health care to the people?
ROSENFIELD: That's a very difficult question to answer, because one can make a case for almost all of the organizations that you have mentioned. Clearly the World Bank can be overly bureaucratic, and loans to very poor countries no longer makes sense. There's been a big push that the World Bank should be giving grants to the low-income countries and not loans. Now that debt relief is being provided to the poorer countries, let's not increase it again by giving loans to poor countries.
But other than that with the Bank, I think some of the money should go directly to local ministries and other organizations. Some aspect of funding does need to go to the UN. We do need UNICEF and WHO, for example, which, despite some bureaucratic problems, are most important in development efforts, and we need to support them for what they can most effectively do. Some monies are going through NGOs and university groups and others, so I don't think there's one answer to that question.
MODERATOR: Are there certain lessons learned of what has truly worked? Give an example of the kind of partnerships that you believe are most effective.
ROSENFIELD: Well, let's say with the U.S. government, over the last 25 years, despite the fact there were some other issues, the U.S. contribution, using some direct to governments and most through U.S. intermediary groups, the support for the family planning programs during that period of time have been dramatically successful, with the exception perhaps of parts of South Asia and sub-Saharan Africa.
The funding of the child survival movement begun by USAID, again through a variety of organizations, has been equally a success story, albeit we still have major things that have not been done and need to be done. In the area of child survival and particularly under the Jim Grant era [executive director, 1980-1995], UNICEF has demonstrated a unique contribution in that area.
Similarly, the way the Elisabeth Glaser Pediatric AIDS Foundation and UNICEF, when they first put in place programs for the prevention of maternal-to-child transmission of HIV to try to decrease disease in children, was both a private agency and a UN agency working together, which I think did remarkably good work. I think as we introduce the women to our MTCT-Plus Initiative [Columbia's Mailman School of Public Health's programs to provide care to HIV-positive mothers and their HIV-positive children and families], that's a university. So we have three different types of groups, all of which I think have made contributions.
HILTS: There are cases where these different groups work together. For example, in Bangladesh, the group called, BRAC [Bangladesh Rural Advancement Committee], which is a Bangladeshi NGO, started out working with its own money from some donors, starting with the Swedes and then with the Americans. They did a series of health programs, and as they got successful, the government got interested and then started partnering with them.
One of the things they did as partners was building the immunization rate over the six basic shots from 2 percent in the country up to over 80 percent. And that became a partnership between the NGO and the government. Another thing: the NGO went on its own. So the different things can work together.
ROSENFIELD: I think BRAC is perhaps the single most dramatically successful NGO in the world today, and a large percentage of what they've done was done by themselves. In many parts of the country, they're doing much more than the Ministry of Health, even though there are some collaborations. But by and large, they're on their own.
HILTS: They're actually teaching the government rather than the other way around. And again, some of that is with aid money. [When] they started out, 80 percent of their money was aid money, and now it's such a successful program, 80 percent is their own money, and the donors are only putting in 20 percent. But it's an extraordinarily successful program.
BLOOM: I agree completely with Allan and Phil's singling out of BRAC. And I agree with Allan: I don't think it's just channeling money through government. Let's keep in mind also, there are many different levels of government that we're talking about, and it's not just channeling money through NGOs or international donors, or dealing with them. It's really all of them, all of the above.
So the example would be from 1998, when there were massive, massive floods in Bangladesh. Bangladesh is basically a giant floodplain. They have massive floods every year, but never before, at least in the previous 100 years of recorded history, had so much of the country been under so much water for so long. And we're used to hearing about all of the health problems and the mortality — you know, 40,000, 50,000, 60,000 people dead in circumstances like that. With a larger population in 1998 than they'd had when they had severe flooding before, the world had a tremendous fear that it was just going to be a catastrophe.
It's sad for the people who died, but the fact is that less than 1,000 people died in those floods, and it seems to be a combination of factors. Obviously it matters that people are more educated so they knew to stay away from the water until it was basically treated or boiled, but there was also a tremendous amount of cooperation between international donors and the government and the NGOs. Not just BRAC, but also organizations like USHA [Unity for Social and Human Action] and PROSHIKA [an acronym of the three Bangla words for training, education, and action] demonstrated that they have phenomenal reach into every little nook and cranny in the country.
They were able to pay a great deal of attention to this little subdistrict or that village or what have you, using especially informal methods of communication — cell phones, e-mail — to find out where the affected districts were and where food rations needed to go.
They actually worked in tremendous cooperation with the international donors and the government for the first time, really, to just make sure that the alum tablets for decontaminating the wells and the food basically got to where they were needed. They had tremendous success in dealing with that particular flood.
MODERATOR: One of our viewers writes: "I'm deeply troubled by what appear to be an incomprehensible lack of political action and commitment on the part of governments around the world. If the resources are really available — readily available — to improve the lives of millions of people, at what point will such resources be appropriately allocated to those most in need?"
I'm going to combine that with a question from someone else who said: "What are the chances that the U.S. and other major nations will lead a big effort to build up global health, to apply what we know and help poor countries achieve a basic level of health and development? Do you think Americans care, and will they help to lead such an effort or go along with it?"
HILTS: I think there's a misperception there that the countries are not putting up the money. A number of the countries are putting up the money and have done it for a number of years, especially in Europe. Other countries that have been somewhat behind, or at least proportionately behind, like the U.S., are putting in more than they have in previous years. So while you can say it's not up to what we need, it's getting better.
There's still hope, because there's still arguments that we should do this, and there's debate that we should go higher. And there's been commitments both on the part of the Bush administration and British government and German government to get up to higher levels. Now, the question is, how serious are these commitments? But at least we have them on paper, and we're going forward.
ROSENFIELD: I would agree with Phil that we're doing a lot, but there's a lot more that could be done, particularly as the Western world begins to respond to the call to 0.7 [percent]. At one point, [U2's lead singer and debt relief activist] Bono was giving out T-shirts with just "0.7" on the front of the T-shirt for kids to walk around with as part of a campaign.
ROSENFIELD: That 0.7 percent of gross domestic product should be allocated by Western nations to assist in, let's say, the Millennium Development Goals of poverty reduction in poor countries. I think some credit needs to go both to [UN Secretary-General] Kofi Annan and to [UN Millennium Project Director and special adviser to Kofi Annan] Jeff Sachs for work he did both while he was at Harvard and since he's moved here to [head the Earth Institute at Columbia University in] New York.
At one point Jeff Sachs said to me: "If people in public health don't have the right thought process, you have a problem. You try to figure out, 'How can I fix it with the money I have?' What you ought to be doing is thinking about, 'How do I fix it? How much would it cost to fix it properly?,' and then go get the money. That is, we should be thinking in terms of billions, not millions." I think we are now in global health, preventative issues, as well as in broader development issues, talking more in billions than we ever did five or 10 years ago.
There's a total misconception in the Western world. If you ask people on the street, "Are we giving enough, or should we give more money?," they say, "Oh, if we're giving 10 percent, we should be down to 5." I will then remark, "Gee, that would be wonderful; I'll take 5," because in actual fact, it's 0.16 percent of our GDP. So I think that we're moving up in the level of support for development. For some of these issues, like AIDS care and treatment, this is a long-term commitment, because even with the lowered costs, even though we've gotten it down from $12,000 per person per year for drug therapy in the U.S., we're now down to $150 to $300 per person per year in the developing world. But even that figure, though it's a dramatic decline from what it was in, say, the U.S., is still well beyond the budgets of most countries and poorer parts of Africa, and will be beyond their budgetary capacity for the next 10 to 20 years.
BLOOM: I think it's absolutely certain that there are two parts to the answer. One is we have to do better with the resources we have, and the second is, we need more resources. For me the big question here, though, is how are we going to mobilize those resources?
MODERATOR: That was the first part of our question about political will, and where are we going to find that.
BLOOM: Many people feel, and I agree, that the first argument in support of devoting resources to the promotion and protection of health is moral, ethical, and humanitarian. Bill Gates said this last week: it's the humanitarian argument that does it for him. It's basically the idea that devoting resources to health is the right thing to do. It's a good thing to do; it's the fair thing to do, the just thing to do.
That argument does it for me and for most people that work in the public health area, but I don't think it's the only argument. And I think to mobilize political [will], we have to appeal to other arguments as well.
So a second argument — and Allan mentioned this in connection with the project earlier — would be that health is a fundamental human right and that the opportunity to enjoy good health is a legally just claim to which all human beings are entitled by virtue of the fact that they're human beings.
Then we have yet other arguments. A third argument would be that health is essential to building strong societies. Improved health is a key ingredient in forming social capital, in building societies that are secure, equitable, cohesive, peaceful, and so on.
So if I actually engage in risky behavior that puts me at elevated risk of contracting HIV, that also puts all the people I will come into contact with in the future at elevated risk as well. I may not take into account the cost to all of these downstream people I'll meet in the future, but that is something that is appropriate for governments to do, and also to recognize that health providers have important informational advantages that can be used to exploit health consumers. That also is a justification for regulation and devoting resources to the health sector.
And then the problem here in a lot of ways is that these arguments — the moral/ethical/humanitarian argument, the human rights argument, the social goals argument — are coherent, but individually, and also I would say collectively, they have not proven decisive with respect to mobilizing political will and resources. So the fact of the matter is, Bill Gates' view notwithstanding, there's no consensus on methods or principles for resolving moral and ethical issues.
In the sense of garnering stated support, human rights has sort of carried the day in some circles, but generally speaking, it hasn't proven a particularly strong rallying cry for action. I would say the same about social equity, except perhaps in a handful of Scandinavian countries.
And so I think actually we have a new argument now that's come to the fore, and that is the idea that population health and also demographic change are very powerful engines of economic growth; in other words, the idea that "healthier means wealthier." That seems to be gaining some traction in the international community, especially among people who have the power of the purse and who are accountable for economic growth and who are trying to achieve the Millennium Development Goals, the most important of which is the reduction of poverty, which has everything to do with income growth.
The oldest question in the whole field of economics is, why are some countries rich and other countries poor? Economists have pursued that question since the late 1700s, when Adam Smith, the "father of economics," wrote his book, The Wealth of Nations. And the answer that has been provided for most of the last 200-plus years is that the accumulation of physical capital and technological improvement is what leads to income growth, and health is very much viewed as an afterthought in that process. In other words, when countries get rich, subsequently the populations get healthier, because when countries get rich and people have more money, they have access to better food, safer water, and sanitation; they have access to more health care, better health care, etc.
But the idea is very much that health improvements happen after countries get rich. But this idea has really been stood on its head, and it's increasingly being recognized, and there's a tremendous amount of really overwhelming evidence, I would say, for the view that not only does "wealth make health," but also "healthier means wealthier," because when you have populations that are healthier, people are more productive; they can work longer; there's less absenteeism, so greater productivity. People have incentives to undertake more education if they're healthy, and they benefit more from the education they get. Kids are better off, too, because healthy kids just have better cognitive development.
When you have healthier populations, these are populations that have more incentive to save, and savings is what leads to the accumulation of capital and to research and development and technological progress, which are key engines of economic growth.
Also, health improvements set in motion processes of demographic change. In particular, health improvements are usually disproportionately enjoyed by infants and children, which tends to result in rapid declines in fertility. The transformation of rapid population growth and high fertility to low fertility actually is associated with very favorable demographic circumstances with respect to economic growth and poverty reduction.
So there is very, very much a new paradigm out there, and health improvements are not any longer viewed as a luxury that only rich countries can afford. They're actually viewed as investments in getting rich and in development and in achieving the reduction of poverty and the achievement of the Millennium Development Goals. When added to the humanitarian and the social equity and the human rights arguments, that's an argument that actually is supplying a great deal of traction and helping to mobilize political will.
That's the reason that one of the main things that Dr. [Gro Harlem] Brundtland did, when she was head of the World Health Organization, was to convene under Jeff Sachs' leadership the Commission on Macroeconomics and Health. And it was really the first time that macroeconomists and finance ministers and Central Bank governors and planning ministers came together with health people to actually see the links that go from health to wealth.
HILTS: If I could just punctuate that with a little wisdom from Bill Clinton, who was at that global health seminar the other day. He was saying that if you're trying to sell this to people, you have to remind them of things like what happened in Aceh, when we had the tsunami in Indonesia. This was American troops and the NGOs [going] in to deliver health aid, building aid, emergency aid. At the time, we had been routinely polling people's attitudes towards America, and after the aid we delivered, the attitude — and this is the largest Muslim country in the world — the attitude towards Americans rose from 36 percent positive to over 60 percent positive, while the feelings toward Osama bin Laden dropped from 58 to 28 percent positive.
So [Clinton] says this is really a potent foreign policy issue, delivering aid, probably not just emergency aid but long-term aid. And people are aware of it: they can feel the difference in your attitude, whether you're delivering help or not.
MODERATOR: There's a lot of perception in the American public that a lot of foreign aid gets wasted or siphoned off for corruption. Can you comment on that factor?
ROSENFIELD: There's always a danger of funds being lost and some corruption in all societies, including ours as well as poor countries, and there are some examples that are egregious in some countries. But I think by and large, at least in my experience, the majority of health-related programs in which I've been involved, both myself and also various colleagues and the various NGOs, there's been very little evidence of major corruption in the various programs in which I've been directly involved or friends have been involved in — universities, NGOs, and even within the UN system, by and large. I'm sure that there are exceptions and there are examples of some egregious corruption, but I think it's blown out of proportion in terms of foreign assistance.
HILTS: There are a couple of recent cases that are interesting that way. The Global Fund was delivering funds to Ukraine, and they detected that there was some money being siphoned off. Their system is built with close monitoring, so as soon as they detected that, they stopped the money quickly.
The same thing happened in Uganda. This was a particularly tragic case, because the monies were going directly to ARVs [antiretroviral drugs for HIV and AIDS], and people were getting treated with the drugs. But they found the money was being siphoned off to the government, and so they stopped that money to Uganda. Now, people who were delivering the ARVs said, "It's very tragic, but on the other hand, we support that cutting off of funds, because we're not going to be able to sustain these things if we cannot do it honestly." So that kind of attitude of monitoring them closely is something that is being built in to programs more and more.
BLOOM: There clearly are problems with corruption, and it's troubling. But I do agree with Allan: it is much more the exception than the rule with respect to the dispensation of foreign aid, and we really have to be careful not to let the tail wag the dog in this area. Just throwing up an argument about corruption and the results — kind of disassembling our foreign aid programs because there's some degree of corruption, or there are some anecdotes or examples or whatever — that would be letting the tail wag the dog.
We should remember that in the case of BRAC, this organization we were mentioning earlier as a kind of classic case of a really good organization doing a lot of work, that organization has been working in a country with corruption all the way along and has gotten a lot done, so corruption is not the thing which decides whether your programs are going to work.
MODERATOR: One of our viewers says: "I would like to see more progress on fighting malaria, which kills so many young children in Africa and other tropical countries. I was shocked that so little is needed to stop the high death rates — bed nets and anti-malarial medications among the possibilities. How many mosquito nets are needed in Africa, and how would I as an individual citizen get nets to the right places where they're most needed?" It's basically a question of "How can I as an individual do something in a big way?"
ROSENFIELD: As an individual, unless you're a Bill Gates, there's not an awful lot one can do in a big way. On the other hand, there's no question that we can encourage people to donate to the appropriate agencies. For example, there's a hedge fund person here in New York who is putting together a malaria initiative, bringing on a number of young, wealthy hedge fund people to contribute to several countries in a major attempt to bring bed nets and such things into these countries.
So with some wealth, one can contribute to initiatives like that in the private sector. But once again, the Roll Back Malaria effort of the WHO, which sort of stymied after a while, is back on the agenda.
Advocacy with the governments to increase funding support, both here in the U.S. and other donor nations, can play an important role in moving the malaria agenda forward. It is clear that we're still losing 2 or 3 million children primarily to malaria each year, and that is something that should not be continuing. We should be more effective in getting it done. It's hard to know what an individual can do, except through the advocacy world, and to find the best organizations and get your friends to contribute to it.
HILTS: If you'll pardon the reference to my book, [Rx for Survival: Why We Must Rise to the Global Health Challenge], thinking about this is a public issue, and trying to move forward the debate of it, in the back of my book I included a resource section where people can follow the details of the issues, get involved, the Web sites of the main organizations involved, places you can go to volunteer working both in the U.S. on these issues and in the countries on these issues. If you look in the back of the book, there's many places to get started.
MODERATOR: Where should mental health-related aid fall in terms of our priorities? How does each of you see mental health in the larger picture of the global health crisis?
ROSENFIELD: It's been a very neglected area in our country as well as abroad, and mental health issues are of very serious importance, particularly in areas hit by disasters, whether it's the tsunami, the Gulf tragedy [Hurricane Katrina], AIDS, people who lose children from malaria and other things, kids whose parents have AIDS. I think mental health has been a neglected area, which is one that should be deserving of much greater attention.
And you could broaden that. There's a group of people saying that the Western world is ignoring chronic diseases in developing countries, the advent, thanks in part to smoking, of chronic diseases like cardiovascular disease, cancer, mental health issues and such, and those issues by and large are not on the global health agenda of the donor communities.
BLOOM: Measured in terms of the loss of disability, adjusted life years — which is a measure of health-related morbidity — I'd say mental health is a gigantic problem. Not only is it a gigantic problem, but there actually are lots of things that could be done about it, whether it's through drug therapies or just counseling, so it contributes a lot to human misery and failing to reach our potential.
Insofar as we can do things about it, it needs to go on the agenda. Allan is absolutely right: it's neglected. But in a way, identifying the problem of world mental health is still 10 years ahead of its time. I have a colleague, [Harvard Anthropology Department Chair] Arthur Kleinman, who has produced for some years the World Mental Health Report, which is really quite a breathtaking piece of work, and I would highly recommend it.
BLOOM: There are many direct approaches to addressing health, but there are also some indirect approaches as well. One that I think is really worth paying some attention to relates to the fact that we have a world of 6.5 billion people; more than 2.5 billion of those people rely for heating and cooking on biomass fuel residues, straw, dung.
They burn this stuff; they use it in very traditional ways. A great deal of effort is put into gathering it by women and children, and it burns very, very inefficiently. Most people use what's called a three-stone stove, which is basically three stones put near each other. You put a pile of dung that's dried usually, or some straw or wood in the middle, and you burn it for cooking or heating.
But the fact of the matter is, it creates an enormous amount of indoor air pollution. The smoke is absolutely stifling. It burns the eyes and makes people cough; it causes respiratory infections. Women, because they spend so much time cooking, are especially vulnerable. Even more vulnerable are the children that are with their mothers. They're especially vulnerable because of the fact that their passageways are so small that the particulates, when they get into their respiratory passageways, are more likely to cause irritations and infections.
We're talking here usually about poor people whose nutrition is not very good, whose immune systems may be somewhat depressed by poor nutrition. And if, for example, you look at the list of major causes of child death, respiratory illness is either number one or number two.
If you look at the more macro level, the reliance on biomass in these kinds of traditional ways I just mentioned is associated with greatly elevated rates of infant mortality, greatly elevated rates of child mortality, and also reduced rates of female survival; in other words, lower life expectancy for women and higher rates of fertility, because if children are dying, then people are going to have more children — that is, the demographic transition to lower fertility rates is impeded. It appears that as a result of the use of fuel wood, because of its health effects and because fertility doesn't come down, economic progress is slowed.
What we have here is very much an example of what you might think of as a kind of an energy/poverty trap. The use of dirty fuel leads to poverty, and poverty makes people more likely to use dirty fuels in the future.
The great paradox is that in the end, the poor are paying more per unit of energy. It would actually be cheaper for them in the long run to rely on liquefied petrochemical gas, but they have tremendous sensitivity to the price of getting hooked up. Just the deposits on canisters are prohibitive for them or too risky. Or just giving the dung that they collect from their yard animals and putting it into biogas digesters so it could generate methane gas that they could use to run a generator or to have some cooking fuel — they have to wait 60 days from when they give the dung in to when the gas is generated, and they don't have the risk tolerance for that.
MODERATOR: So what would be a good answer to this, David, do you think? Do we need a better stove, or a different fuel?
BLOOM: Well, actually there are three parts. Allan mentioned at the outset the importance of scientific advance in connection with the development of a malaria vaccine. The analogue of that here is the ongoing development of more efficient stoves that basically control the flow of air so that you get a more efficient burn, so you get more energy out of the biomass.
Something [else] that needs to be worked on and developed technologically would be ventilation systems that do a better job of eliminating the smoke, but not necessarily the heat, from households, because if you aim to vent as much as possible outside, you don't actually get enough of the heat that is important in many climates.
But most importantly, we need more work on clean cooking fuels. I mentioned about converting dung to biogas, and you see examples of that in China and India, but liquefied petrochemical gas, ethanol, and dimethyl ether are also important. Also, there are policies that could be adopted that would actually allow people to make the jump from reliance on fuel wood to reliance on clean cooking fuels. But that requires different cooking devices, so they need a different kind of stove.
Solar, photovoltaic — that's another. Wind is another alternative. But the idea here is that if we could help people climb what's called an "energy ladder" by providing subsidies, for example, for clean cooking fuels, that's not a subsidy you'd have to provide in perpetuity. You're not creating dependency; you're just helping people get out of the quicksand and allowing them to move to cleaner, more convenient, and ultimately less expensive fuels.
It's a little bit out of the box, but as a way to improve health, the fact of the matter is that we know that energy policy can make a difference. So we know from the case of Brazil that subsidies for the use of ethanol and LPG, liquefied petrochemical gas, can achieve a massive transformation in the fuels that are actually used. And we know from all of the epidemiological studies that have been done around the world that if different fuels are used, then that will have greatly beneficial effects on health. There are pilot studies that have been done in India and in Pakistan as well.
In the end, dealing with biomass and its alternatives is the kind of investment that will pay for itself by promoting better health, more education, fertility decline, income growth, savings, and ultimately self-reliant development, and that's very important. There are organizations like the International Energy Initiative [IEI] that are very, very keen to work on these kinds of projects.
I would also mention in this regard, in September , there was a very novel development financing idea that was introduced. It's called the International Finance Facility [IFF]. The idea came from Gordon Brown, chancellor of the exchequer in England, and essentially what he did was he married ideas about commercial finance with notions of international development assistance.
As an example, suppose that every year countries give $20 million routinely, but they decide it a year at a time. If, instead, these countries are actually willing to say, "Yes, every year we give about $20 million; we'll guarantee that for the next 15 years," well, then a country could take that promise that they're going to get $20 million every year for the next 15 years, and they could go to a commercial bank. They could borrow on the strength and their demonstrated promise that they can repay because of the foreign aid, and that would actually allow them to get a very big upfront loan as a result of the foreign aid.
That would allow tremendous investment up front, whether it's invested in vaccination, which is how the International Finance Facility got started in September, or in the kind of pubic infrastructure, Linda, that you asked about at the outset. Whether it's an investment in safe water or clean cooking fuels or what have you, that is the kind of investment needed to allow people and communities to get out of the poverty traps that they're stuck in, which aren't just about low income but also poor health and not having access to good education at the primary and secondary level.
ROSENFIELD: One thing we didn't discuss — and I'd like to give credit to [Gates Foundation global health director through the end of 2005] Rick Klausner and the Gates Foundation — is that while some of us feel that there's much that can be done with our existing technologies, particularly in relation to child health and maternal health and others, mainly through improving the health care system, the Foundation has been giving a fair amount of priority to technological advances.
The Foundation's Grand Challenges program, which was to get basic scientists to devote attention to what some would call the neglected diseases of the tropics, that would start with research on a malaria vaccine and more modern approaches to medication. The same thing with tuberculosis. We have been using the same drugs for the last 30 years. In both cases, because these are not diseases that impact the United States and the Western world, the corporate world has not invested in them.
And this is [true] also of some other neglected diseases like [the parasitic disease] schistosomiasis and others that get no research. This initiative has now developed a research agenda, and I think NIH [National Institute of Health] will actually follow the lead set by the Foundation. But in some areas of child health and maternal health, as I stated at the beginning, there's a lot more that could be done with existing technologies, and we need to be focused on that as well.
Finally — and I think there's many who agree — as we focus on developing new technologies, it's equally important that we focus on building the health care infrastructure and system, so that when we develop new technologies, we have the mechanisms to deliver these new technologies that are effective.
MODERATOR: So the basic [goal of the] health care infrastructure is to get technologies out there.
ROSENFIELD: I think that's at the core. In our Millennium Task Force Reports on maternal health, child health, AIDS, TB, and malaria, that was one of the key issues, that we all agreed that developing the health care infrastructure of developing countries was a high priority if we're really going to move forward in an effective way.
HILTS: About three years ago, I started on the road looking at health projects, and I wasn't feeling particularly hopeful at the time. I knew what I would see in some ways: a certain amount of suffering and death and difficulty. But when I got finished, I was actually feeling much more hopeful. I had seen a lot more things working and things that are more hopeful than I expected to see.
At the end, I think the message is, "We really have a chance to do this that we have not had previously." Twenty years ago, we didn't have the wherewithal and the technology and the understanding that we have now. So I actually feel more hopeful, and I think people should feel that way as well.
BLOOM: In a lot of ways what we've been doing here is getting our minds wrapped around the problem, and there clearly is a problem, and we all acknowledge that it's really, really important, and I think that message is getting out there. We need to get that message out there about "It's a big problem; it's really important."
But also, the bottom line is there are things we can do, and I share Phil's and Allan's hopes about that and their optimism about it. For some of it we already have the knowledge about what to do. In other ways, I'm referring to a general optimism about human ingenuity and the capacity, if we think really, really hard about things, that we'll be able to crack these problems, because usually, human beings have.