HIV/AIDS and Pandemic Preparedness: PEPFAR’s Role in Advancing Global Health Security

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This transcript is from a CSIS event hosted on October 23, 2023. Watch the full video here.

Julie Gerberding: Good afternoon. On behalf of the CSIS Bipartisan Alliance on Global Health Security, welcome to this conversation about “HIV/AIDS and Pandemic Preparedness,” and really a focus on PEPFAR’s role in advancing global health security.

Just to set the stage here, keep in mind that PEPFAR just celebrated its 20th-year anniversary. And over those two decades, approximately 25 million lives have been saved and 5 ½ million children were uninfected who probably otherwise would have had HIV. So there’s been a tremendous human-life value in the $110 billion that have been spent over this period of time.

But, you know, the return on investment is more than lives saved. It really reflects the incredible investment in services, health-care strengthening, supply-chain strengthening, and a whole host of trained health-care workers, laboratorians and other infrastructure that has had a tremendous impact on the overall health system.

That health system has proven to be valuable for more than HIV/AIDS. Clearly, we’ve seen the value of those investments in the context of other infectious-disease outbreaks like Ebola, mpox, and certainly COVID. But I think, from my perspective – and I’ve been in the AIDS world from its beginning in San Francisco – one of the most important aspects of PEPFAR is really the signature of the best of America, that we have really put forward tremendous investment, tremendous health diplomacy, tremendous commitment, and really created confidence in many countries around the world that we were truly a partner, that we were true to our world, and that we would stay the course to get the job done.

So we are going to be talking today about PEPFAR and the reauthorization status of the program, given that Congress has not been able to reauthorize PEPFAR for a new five-year period. We want to really think about what’s at stake and what are the options on the way forward. And we do have a panel of experts here.

But before we jump into the panelists, I do want to introduce Congresswoman Barbara Lee. I think many of you know that she is a staunch supporter of all of the HIV/AIDS work that’s happened globally and domestically.

There’s a few other things you should know about her. She is a very strong champion working against the stigma and discrimination of HIV/AIDS, and has done so from the very beginning of the pandemic. She has stood strong for the PEPFAR reauthorization time and time again. And she’s a member of the Bipartisan Alliance here at CSIS. So she is a person who walks her talk and is really one of the icons of HIV prevention, treatment, and care.

So Congresswoman Lee, please share your perspectives with us. And we’re so glad you could join us. Thank you.

Representative Barbara Lee (D-CA): Well, thank you so much. And let me take a moment to thank Stephen also and all of our panelists for inviting me to be with you for these few moments, especially during this tumultuous time on so many fronts including trying to negotiate the reauthorization of PEPFAR – a clean reauthorization, five years. I mean, I never thought it would be this difficult but I think you know what’s going on. So I’ll just say we’re still at it.

You know, and thanks so much for talking about what all in addition to dealing with HIV and AIDS that PEPFAR has really accomplished for other diseases and especially with regard to the infrastructure. So we haven’t just delivered care and medicine, we’ve delivered, really, hope to an entire new generation and actually have helped build infrastructures and health infrastructures in many countries.

It is worth reminding ourselves just how bleak it looked two decades ago because we have to look at this in a historical context to know that – where we are now and why we have to move forward so we can achieve an AIDS-free generation by 2030.

Entire communities and societies were facing an existential threat from HIV and AIDS. Back in 2003 it was estimated that more than 26 million people were infected with HIV just on the continent of Africa, with another 3.2 million getting infected each year.

Anyone who knows the scale of the problem was motivated to solve it. There were so many people who decided that this would be their life’s work, and I have to remember today my mentor and my former boss and our colleague, Ron Dellums, who worked on this issue long before anyone else was paying attention to it.

When I got to Congress I remember going with Sandy Thurman, who was then in the Clinton administration, to put together a visit to Africa with some of my CBC colleagues to look at primarily orphans and vulnerable children as it related to the HIV/AIDS pandemic.

So we got back and we knew that something had to be done. I first worked with then my Republican friend and colleague Jim Leach, who’s from Iowa, to introduce legislation to create the Global Fund and we did this because he was chair of the then Banking Committee, and I was on the Banking Committee and we decided we would do that to have the World Bank as a fiscal agent for the Global Fund because we knew it was going to be tenuous to get it through the Foreign Affairs Committee. So we were strategic in our planning to make sure we did this with bipartisan support.

And so we did and the president signed the Global AIDS, Tuberculosis, and Relief Plan into law that December, right – no, that August before he left office. Then when President Bush took office I approached him about this issue also and needed to talk to him, which I did, about a bilateral approach.

Eddie Bernice Johnson, congresswoman from Texas, was chair of the Congressional Black Caucus and she arranged us to meet with the president and I told him that we needed to do something. So at the end of the meeting he asked me about the beaded pendant I was wearing and I told him it was for AIDS in Africa and it was a fundraiser or fundraising efforts for women who were raising money for people who needed care who were infected with the virus.

So I took it off and I gave it to him and that was really the start of the work to get PEPFAR enacted, just talking to President Bush. Colin Powell was in the meeting and also Condoleezza Rice. But that wasn’t the end. That was just the beginning. There was still a lot of pushing and organizing to get this done.

But we got to the beginning. There was still a lot of pushing and organizing to get this done, but we got it done in a truly bipartisan way. And everyone knows today how successful this investment has been: more than 25 million lives saved. That’s huge. AIDS-related deaths down more than two-thirds from their peak. Five and a half million babies born HIV-free. I can’t think of a more pro-life investment than PEPFAR.

PEPFAR did more than just treat the disease and its patients. Pretty quickly we were confronted with the fact that the response to any pandemic rests on society and social and institutional capital that we can mobilize to confront it.

So, yes, policy and science are extremely important but also the best public health policy fails without a workforce to implement it, and so when people lack trust in messages from authorities, you know, we have to have local people educated and involved in this response with our country-level responses, which is so important that countries take hold of their response with PEPFAR resources. So PEPFAR also did more than to provide medicine, as you heard from Julie earlier.

We have to invest in the countries – in countries’ capacity to lead their own fight against the pandemic. And that’s equally an important legacy which PEPFAR will leave – not what America gave, but what people in countries and communities around the world built, which is permanent. And I know that we’re proud of what PEPFAR has accomplished, but unfortunately, cliches aside, facts do not speak for themselves. We have to speak for them. There are only 55 members of the House, out of 435, who were around to first vote on the authorization back in 2003. Two hundred and one of my colleagues were not here in the last extension period, during the last extension period, in 2018. That’s almost half of the House that has never been asked to vote on PEPFAR. And people don’t seem to understand the urgency. We’re already seeing people who want to wreck PEPFAR and taking potshots and making unfounded political attacks, and believe you me, this is misinformation and it’s disinformation.

So I’ve worked with Republicans to reauthorize PEPFAR three times, mind you, over the last two decades, three times, and I’m committed to working, which I am doing as we speak, with my Republican colleagues to get it done again. We have strong bipartisan consensus around a clean five-year reauthorization, but we have some obstacles. I mean, you know what’s taking place on the Hill now; that’s part of – (laughs) – one of the obstacles that we still have to address, but we’re going to keep at it because we’re so close to ending this pandemic. That’s important not only to – so that’s why it’s important to keep this reauthorization clean now and extend it for the next five years. With the end of HIV and AIDS in sight, we don’t want to make the world – or let the world think that for a minute the United States might take our foot off the gas before we reach our destination.

People need to let members – thank you, CSIS, for helping us. Let members of Congress know that we want to see a clean five-year authorization of PEPFAR before this year is out. It’s past due. I mean, we were due September 30th to do this, so we need to get it done and to the president’s desk, and I intend to keep fighting alongside you to finish this job. The end is in sight and you can’t say that about a lot, but I know we can get it done and we can end HIV and AIDS for everyone everywhere by 2030.

So I want to thank you all for your hard work, your passionate activism, but also keeping up the fight and keeping your eye on the prize, and that’s what we’ve got to do. So all of you just know that your work weighing in with members of Congress right now is very, very critical and we’re going to carry this ball inside and what you’re doing is helping push the ball forward so we can complete this this year.

Thank you all again.

Dr. Gerberding: Thank you, Congresswoman. (Applause.) And it’s just incredible. (Laughs.) Your energy and your commitment to this cause is inspiring and I think you make us all want to hurry up and talk more about it during this meeting, but thank you so much for joining us and for your service on the commission. Thank you.

Rep. Lee: OK, thank you all very much. And good luck and look forward to doing this this year with you. OK.

Dr. Gerberding: Got it.

Rep. Lee: Bye-bye.

Dr. Gerberding: So it’s now my pleasure to introduce our panelists, Dr. John Nkengasong, who’s here on the podium with me. He is currently the ambassador-at-large for the U.S. global AIDS coordinator, and the senior bureau officer for global health security and diplomacy in the Department of State’s Bureau of Global Health and Security. You must have a very big business card. (Laughter.)

I’ve known John as a friend and a colleague for many years, going back to his time when he was serving CDC as the acting director of global health there, but also as the head of the TB laboratory, global HIV and TB laboratories at the CDC, where he was in country and really performed miracles.

I think you developed the first credentialed laboratory in Africa, so it was an amazing contribution. But your leadership has tracked throughout the world and I think your performance in Africa as the leader of the Africa CDC was exemplary. Many people were skeptical about the ability for Africa CDC to be successful, and you proved them wrong. You really managed to pull a continent together, and oversaw the distribution of millions of doses of vaccine, and really coordinated the overall response. So I think that leadership, in part, is why you were the obvious choice to lead the next chapter of PEPFAR, and the broader infectious disease agenda in the State Department. So it’s an honor to sit here with you. And we would love to hear your thoughts about PEPFAR reauthorization and the way ahead.

Thank you, John.

Ambassador John Nkengasong: Thank you. Thank you, Julie. It’s an honor to share the podium with you. Julie was my boss at CDC when we were all in HIV, and we were struggling to get a first lab accredited not in Africa, but at CDC, because people thought CDC had already accredited lab, but it was the first lab that was accredited at CDC – an HIV lab.

Anyway, I start there because needless to repeat the statistics. Julie, you mentioned that, and Congresswoman Beverly also give us an overview. All of us have been extremely effective in communicating the impact of PEPFAR to the extent that everybody can relate to it, to the 5 million lives saved, 5.5 million children born free of HIV/AIDS. And I think that that is a very good thing. But I like to approach by a few minutes from the angle of the job is not yet over. HIV/AIDS is still a pandemic. It’s a security threat. It’s a developmental threat. So it’s a health threat, it’s a security threat, and it’s a development threat.

So, first of all, the disease. The job, as Congressman Lee mentioned, is – we’ve come a long way, and we should definitely celebrate 20 years of remarkable progress. I remember when I was working for CDC in Cote d’Ivoire, in Abidjan. And my lab was over – it was just looking over the infectious disease clinic. And I would sit there every morning and see how people came in with their loved ones in the red taxis, drop them off. And within hours, they would die. And you hear a lot of noise, crying, and it was – it was pathetic. We’re doing with Kevin De Cock a lot of epidemiologic work, but we’re just counting. We were just counting, counting people who are infected, who was infected, why were they infected. HIV one and two, if you remember.

And the wards were so full, to the extent that people were – the patients were dropped in the parking lots. So I would turn to shut my curtain off because he was just emotionally unbearable. So you heard those voices, and you saw loved ones being dropped off, and die, and fold them in white bedsheets, and carry them away. I went back there in February of this year. And I really wanted to go back into my previous office. And I sat in there, look over the window that I used to look at 20 years ago. And you saw an empty lot, clean lot of the infectious disease clinic. But those voices were still in my ears, those voices were still there.

It shows that just the power of – and the miracle of what PEPFAR has done. When we count numbers, we throw out the numbers, to the 5 million lives saved, it sounds so much like statistics. When you’re in the field, and you go to Namibia, you carry that baby. And he or she looks at you, and smiles. You don’t know what that smile is. You just smile, just like the child you’re carrying. And you’re standing next to a woman who is HIV infected, but because of PEPFAR is alive and has given birth to her two healthy babies, and you’re carrying one of them. You feel like you bonded with that child.

And when I met with the leadership of the prime minister of Namibia, I said to her that child I just carried in the clinic is the future of your country. And she turned around and said something that was remarkable. She said, when we were fighting for independence for Namibia, your people, American people, were on the wrong side. But they came and helped us as a young country so that we can survive, because they’ve helped us to fight HIV/AIDS.

Just a few days ago, there was an article written in The Hill magazine by Festus Mogae, the former president of Botswana, and former Secretary Thompson, Tommy Thompson, and the title was interesting. It was, “How PEPFAR Saved Botswana From Being Extinct” – “From Being Extinct.” If you all remember, the rates of infections in Botswana in – pregnant women in certain parts of Botswana were as high as 70 percent, to the extent that when the HIV test returned negative you thought it was a false negative, right? Every person thought it was false negative because it was common practice that everybody has to be HIV-positive.

So I’ll start there because the human side of the statistics that we throw out there – and these numbers or the experiences that we all go to the field and connect with – are never old.

I was in Nigeria just in September with Peter Sands from the Global Fund and David Wilton from the Malaria Program. We decided to do a joint program. We went up to Kano. I walk into this ward full of babies, and these babies were almost grasping for their last breath because of malaria – not HIV; malaria. And the ward at the Murtala Muhammad Hospital was larger than this hall, twice as large, and all of them lay there with their mothers sitting next to them, looking at you. You know, when you walk into – at that hospital, with the minister of health, Muhammad Pate, and the mothers are looking at you and say: Tell us that our babies will be OK, but without telling you that. You’re looking at them. I know you cannot say they will be OK. You reach out to them. You touch them. You rub their back. And you lack the words to say it will be OK, because you see how desperate those children are.

That was a malaria ward, but it reminded me of the HIV wards that used to be there, HIV wards. So PEPFAR investment in life saved is just tremendous. You cannot even put a dollar amount to it.

The security part of that is that the gains we’ve made with PEPFAR are fragile. Every day, the 25 million people that have been saved, the 20 million that are on treatment in Africa, require that one pill to maintain their HIV viral load below suppression. If PEPFAR is not reauthorized, something has to occur in us that what happens to these 20 million people that are on – receiving lifesaving treatment every day? What happens to their families?

We were in South Africa with six senators in February, and – Senator Graham, Coons, and others – and we saw a family where – a discordant couple. The woman was HIV-positive, the man was HIV-negative, and they had two wonderful children that were HIV-negative. And the man knew that this – the woman was HIV-positive. Because of the miracle of PEPFAR, of antiretroviral treatment, they got married and had children. That’s how much PEPFAR has transformed HIV into a disease that we can live with.

We have to factor that into our thinking and say: What will happen to these people, the million(s) of lives that we’ve saved? So that gain is very, very fragile. So I think I would also like to mention that.

Let me just end my reflection here by saying that it is not about what we’ve done for others; it’s what we’ve done for ourselves, because the platforms that we’ve put in in an effort to save the 25 million lives have yielded tremendous benefits in terms of our security, protecting lives right here, disease infections and outbreaks here – Ebola outbreaks, COVID-19. The countries that did better in Africa in terms of responding to COVID-19 were those countries that have PEPFAR investments, period, in terms of reporting of number of cases, in terms of number of tests conducted. I mean, we have evidence and statistics for that. I was leading the response in Africa. The omicron that was detected in Botswana and South Africa, these were labs that we had supported, OK, and continue to support.

So it’s just to conclude my reflection saying that by helping others, we’ve helped ourselves. We’ve protected this country tremendously by putting in this platform. We know where all these biologic samples are hiding in Africa – I mean, all; and not just Africa, but in the 55 countries that we have investments there. So it’s my hope and plea that we all should continue to make a strong case for PEPFAR to be reauthorized clean for the next five years.

Dr. Gerberding: Thank you, Ambassador. I don’t think anyone could have painted the picture more clearly than you just did, so thank you for that.

I’d now like to bring my other panelists into the conversation.

Joining us remotely is Ambassador Dybul. Mark Dybul was the person who really had the responsibility for launching PEPFAR in the first place. I worked closely with Mark when I was at CDC and I know that the startup of this program was not 100 percent easy, but somehow his persistence and his passion allowed the program to get off to a remarkable start and created a trajectory that really continues to this day. Ambassador Dybul is a professor of medicine at Georgetown. He is the former U.S. global AIDS coordinator and the former head of the Global Fund to Fight TB, AIDS, and Malaria. So, Mark, thank you for joining us.

I’m also joined here on the panel with my colleague and friend – (sneezes) – excuse me –

Mark Dybul: Bless you!

Dr. Gerberding: – Jenelle Krishnamoorthy, who is the vice president for global policy at Merck. She is a quintessential professional with great expertise in all things policy. She also had an earlier career on Capitol Hill, where she was a major player on the Senate HELP Committee and someone who I found to be a source of common-sense problem-solving skills and the person who often brought two sides of the conversation together to solve problems. So it was my pleasure to work with Jenelle at Merck and to really see her evolve into a global policy expert who has a strong stake and a very strong commitment to the prevention of HIV/AIDS, as well as sustaining the pipeline and supply of innovative therapies there.

So thank you both for joining us.

Mark, let me start with you and just kind of ask you the question about this reauthorization situation. You know the ropes. How do you see the consequences of not getting a clean authorization bill at this point in time? What are you worried about?

Dr. Dybul: Thanks, Julie. And great – John, thank you for the really beautiful and moving introduction. And, Jenelle, always good to see you. Sorry I can’t be there in person. I actually planned to be, but then things got out of control and I couldn’t get into D.C.

Dr. Gerberding: (Sneezes.)

Dr. Dybul: Bless you! I hope you have a COVID test with you. (Laughter.)

You know, I used to know the ropes. They’ve gotten a lot slipperier – much more slippery. The consequences are deep and wide. The shredding of the bipartisan consensus on something this substantial in our – in our development portfolio is almost irrevocably going to collapse. And a year by year just isn’t going to do it. We all know how the U.S. government works. A year by year is basically asking for the appropriations over time to dwindle down and an irrevocable way. I mean, it’s inevitable they will go down over time, but this will accelerate it in ways that I don’t think we can actually anticipate.

And what it really will do – there’s been a – you know, there’s been a deal for 20 years now that people will allow the things they care about the most to go because there’s been a deal. There’s been a – each side has given up a little bit. And this time around, that willingness isn’t there. And so when that starts to happen, especially around the – none of these debates are new. We’ve had the exact same debates for 20 years. But this time there seems to be less interest, or at least by a handful, in coming to the same conclusion we’ve always come to to allow the lives to be saved. And so, basically, you’re putting 20 million lives at risk, which is a horrible outcome.

But the other piece – and this one I care deeply about, and John knows better than I do – if you talk to Africans, us walking away from a five-year commitment is functionally telling them that we’re not interested in Africa anymore. And that’s not a good message right now, given what China and Russia are doing in Africa. And I actually think it’s not just the humanitarian piece; it’s actually a national security issue, and a major national security issue. And that’s not getting enough airtime, and we really need to shift the conversation, I think, away from the social issues back to the saving of lives and to the national security.

But the consequences are immeasurable. And the notion that we can just let the authorization go year to year doesn’t – does not get its arms around the politics that we have right now. It will be the beginning of the end.

Dr. Gerberding: Well, thank you for that sober perspective, Mark, and for articulating it so plainly for all of us.

Jenelle, before we talk about what the private sector can do to be helpful in all this, I’d like you to put on your old hat for a minute. I was really struck by Congresswoman Lee’s comments that roughly half the House are new since the last reauthorization and have little familiarity maybe with the value of the program. So when you’re trying to build awareness and bipartisan support, what are the – what are the most important things that could be happening on the Hill right now – or, should be happening on the Hill right now?

Jenelle Krishnamoorthy: I think – thank you very much for that question. And I think, you know, really it’s important and incumbent upon all of us to really be educating and bring it home to each one of those districts why that individual should care about what John was saying earlier, about what’s happening in Africa. And understanding those individuals that really have, as Representative Lee said, disinformation, and how that disinformation is going to hurt our national security, or going to hurt individuals, that this could come back to your district. And so I think that’s upon all of us.

And we definitely – it’s easier to find our champions, but we have to kind of pull up our bootstraps and chin straps and be ready to go to those individuals that are not – are really grappling with that disinformation, and see how we can speak in a message to recenter this, deescalate the political rhetoric, and understand these are human beings at life. And as we talked about, global security – the reason, the brilliance of many people in this room, they saw that PEPFAR was dealing with global security. We just saw with COVID, you have a pandemic. Right now if people are very ill, that is going to affect the economic – the disorganization of our society. And so I think it’s really important we double down and we really try to educate people on the importance.

Dr. Gerberding: Get the word out, yeah. So, Ambassador, there are many myths and many pieces and components of misinformation floating around out there. But one that I hear a lot, and maybe it’s because I’m interacting more with research investigators now, but it’s really that there is no scientific competency or capability to do this in-country without the ongoing and sustained support of the United States. And yet, from my experience, people really underestimate the tremendous scientific advances that PEPFAR has helped support, but that countries have taken on on their own, and moved the agenda forward.

As you kind of pointed out, we know where the lab samples are in Africa. (Laughter.) But a lot of people don’t realize the incredible dual-purposing of things like PCR, and sequencing, and how critical that capacity was to our understanding of the pandemic in the U.S. Can you say a little bit more about your observations, and watching that capacity evolve over time, and why it matters?

Ambassador Nkengasong: Absolutely. First of all, we should take credit and celebrate the lives saved, but also the capacity, the infrastructure that has been put in place both for the response to HIV, but capacity that has been put in place to support – that can potentially support clinical trials, OK, across Africa. And how – the studies that have been done in Africa that have also benefited us here and have to advance our understanding of HIV. I mean, it’s just a tremendous thing.

There is always room for improvement. There will always be room for improvement, including in our own country, the United States, right, in terms of improving our healthcare system. Imagine 20 years ago where we were in so many countries. In Africa, I would just use lab, for an example, there were about 20 labs that were accredited, and mainly in South Africa. They were four in Sub-Saharan Africa. In Kenya, the DOD labs, Uganda. And today look at – the number of laboratories that are accredited – fully accredited by international standards. And I use that just as an indicator to say that today you can even think of trying to do functional studies for cure in Africa – functional studies for cure in Africa – because you have the facilities. The infrastructure has been there, and that has been supported by PEPFAR.

I think we do not usually project that enough. We do not talk about that capacity and capabilities enough. We should also think about the security of the world. Not just the United States but the world, because we just don’t know where the next disease threat will emerge.

I’ll give you the example of COVID. COVID emerged and within two months – within two months about a hundred and fifty-five countries were affected within two months, and we always thought of an emerging infection as being something that would probably come out from the jungles of the DRC or Uganda or Cameroon and then find its way to Europe. And here, look at with COVID it was the reverse, right. It became an airport disease – I mean, a disease from major cities to the remote areas.

So that’s how tricky this health security is. It’s just terribly unpredictable. So the best way to prepare for the unknowns is to prepare for the knowns and is to invest a lot in the known and the known is HIV. It’s TB. It’s malaria.

So if you have strong systems in place for that to deal with those three diseases and others – maternal childhood immunization programs – we are preparing ourselves for absolutely adequately for the knowns.

I think when people talked about preparedness for the unknown as well the unknown can truly be unknown and very embarrassing and surprising. Imagine if we have a SARS COVID hypothetical X that has the transmission rate of SARS COVID 2 and has the case fatality rate of SARS-COVID-1 20 years ago, and it’s as difficult to produce a vaccine against as HIV and we have a trickle down access to maybe diagnostics, vaccines, or infrastructure I think within just two years about 10 percent of the world’s population can very easily disappear.

This is not hypothetical. In 1918 within two years 5.5 percent of the world’s population was taken off by the Spanish flu – 5.5 percent of the world’s population. I’m not here to create an alarming situation but what I’m trying to do is to use real-life scenarios to say that these viruses we have lived with we’ve seen it around 20 years ago or 22 years ago when we saw SARS-COVID-1.

We’ve just lived the experience of SARS-COVID-2. We are still struggling with HIV. So it’s very, very possible that we may be dealing with something that is even bigger than SARS-COVID-2. I hope not. But the best way to prepare for the unknowns as I indicate is to invest a lot in the knowns.

Dr. Gerberding: Yeah. So, Mark, you, you know, were sort of in a vertical when you launched PEPFAR, really thinking about HIV/AIDS. But then when you went to the Global Fund your portfolio broadened and kind of broadened again.

Tell us a little bit about coordination because I’m going to come back to you and talk about your office. But, you know, how do you work across these verticals and create a more horizontal engagement? Because right now what we’re talking about is extending from infectious disease outbreaks to the broader global security agenda and that integration of horizontal and vertical engagement is tricky.

Dr. Dybul: It’s tricky because we make it tricky and because we build systems to make it tricky. As you know from your days of overseeing many diseases at CDC and at Merck as well, we do it in the private sector. We do it in the public sector. We do it everywhere. It’s almost human nature.

I think the answer is what John just said. The systems are the same. The systems are the same in many ways across diseases. Now, specific diseases need some specific drugs, needs sometimes specific supply chains. You do campaigns for various products like vaccines versus day to day therapy.

But when you’re talking about the actual people involved – the people in the ministries, the people in the health posts, the people in the hospitals and the people in the health system – it’s the same people and it’s the same underlying systems that are used from time – for different things.

Now, at the beginning because of stigmas – you well remember, both John and Julie – the testing in the clinics were often separated from the basic medical centers. But that’s not true anymore. And now people with HIV have hypertension and diabetes. (Laughs.) We started investing in cervical cancer when I was at PEPFAR because young women in Africa and Zambia proved this – were dying from cervical cancer because they had HIV. So there are two pieces that unlock it; one is systems and the other is people. Because a person doesn’t have one thing or another, there are – a person who needs help. We can fix one disease, but if they die from another, we didn’t do much for that person, that family, that community. And so if we think about systems and people, you naturally get to an integrated health system. And if we focus there, as John said, we’re not – the best way to prepare for the next pandemic is to respond to current pandemics, and it’s going to be different region by region, country by country. But certainly – (laughs) – HIV, even malaria if you’re in Africa, you’ve got to deal with. And it’s from those systems you will build diabetes, hypertension and everything else, and pandemic preparedness and response.

So if we just allow ourselves to get out – and to be honest, where the siloing starts happening is the higher up the system you go. At a community level, they don’t think about verticals, and I hate that term, actually, because everything that’s done has been systems. And actually, if you talk to people in rural communities, which we’ve been doing at Georgetown in some places, if you talk to young people now, even when there are very high rates of HIV, especially young women, young adolescent girls and women, they don’t think about HIV, and when we ask them, HIV is number 25 on their list. They’re worried about a job; they’re worried about food; they’re worried about water; they’re worried about education. HIV’s not on that list anymore, and so you have to actually bring everything together.

In Eswatini now, the government is actually holistically looking with the department of labor, the department of education, the department of youth, department of sport, department of health and finance, all working together on – and water and sanitation – all working together on an HIV response because we’re talking about people. So if we focus on people and systems and get closer to the ground, then these things will naturally fall away and we will have health for people and communities.

Dr. Gerberding: So, Jenelle, I’m just going to jump back in time to the private sector and the engagement in the initial support for PEPFAR and getting antivirals into an affordable state. You know, that’s a long way from kind of what we’re thinking about in the private sector today, which is much broader health system strengthening, in a sense, market developing for some companies. But where on that journey does the concept of security fit in? We see it as health, as health system strengthening, but do we see it yet as pandemic prevention health security? And what is the opportunity for the private sector to be supportive of what the government is leading?

Dr. Krishnamoorthy: It’s a good question, and I think PEPFAR has been very successful in bringing together the public-private partnerships, and then also ensuring access. And I think from the private sector we see, again, lessons from COVID that if you have a failing of a health care system in a place, you can have a vaccine and a treatment, but if you cannot actually partner with the community and deliver that vaccine or treatment, then it really does not matter. And so I think we see working with PEPFAR and then also the greater health care systems that that’s incredibly important, for the pandemic, but I think as the ambassador said, just for day-to-day prevention of cancer, cervical cancer, and other chronic diseases that it’s a really important investment that we should all be coming together for.

Dr. Gerberding: So we’re seeing a theme of convergence here. We’re converging on convergence. (Laughter.)

So your role in the State Department really is to create a much more integrated intersection of the traditional PEPFAR agenda and the broader global health security agenda. How are you approaching that and what do you think are the essential components of success here?

Ambassador Nkengasong: I think the – one of the lessons I think that historians who are still writing the history of this pandemic – there’s always a saying that there are three parts of history: those who make history, those who wrote history, and those who read history. I hope that the historians who are writing the history of this pandemic will say that we failed ourselves in cooperation.

It wasn’t about surveillance. When people say, what kind of surveillance? We saw this virus in December. We knew that it has been reported in a Wuhan. We saw it coming around. So we saw that all coming. So it’s – the centrality of the new bureau to address that gap is that it has to be anchored on the concept of what I’m advancing as the four Cs. That if we cooperate, we will collaborate. If we collaborate, we will coordinate. If we coordinate, we will communicate. So those are the things that we have to do, and promote, and use diplomacy – the power of our diplomacy, the muscles of our diplomacy, to advance the concept of the four Cs that we are advancing.

Because look at the – a lot of the concepts that were advanced or put – or, constructs that were advanced and put forward to fight the pandemic just didn’t go the way you were supposed to go. Like the COVAX mechanism, right, for vaccination, brilliant ideas that it took really time for it to pick up and became useful. Excellent idea. An idea that spoke to the need for solidarity, the need to help one another for humanity. But it just took forever because of the concept of cooperation, collaboration coordination was just absent. So we are living with that.

We also say that there are three things that the bureau should do. That is, we should elevate global health security as part of the foreign policy and national security. We should coordinate more amongst ourselves and with our allies. And that we should leverage the platform that – the assets that we have. If you look at the assets that we have, as U.S. government, is the largest global health security assets that you can think of, if you look at what CDC, HHS, DOD, USAID have across the world. But the coordination of that is just terribly lacking.

I say this from a unique angle, where I used to be the head of CDC Africa, CDC. And I would sit there in Addis Ababa, and people would come talk to me from USAID, from DOD. And most of the time, they didn’t know that I was U.S. government secondary staff. And the definition of health security – this was before COVID – the definition of health security was through the lens of what they wanted to do with me. If only you did this, you’ll be very, very successful in that. Then they’d leave. The next person come from U.S. government and say, well, if only you focus on this, you’ll be very successful.

Then after that, I would just – I would laugh. I’d say, well, I’ve heard this enough. If I did all of those things, I need to do all of what you all brought to me but not just one of those things to be successful. So I think that the State Department’s new bureau of global health security provides that unique opportunity for us to do the three things that I just mentioned, i.e., elevate, leverage, and coordinate efforts in global health security.

Dr. Gerberding: Thank you for that. And you’ve, you know, very eloquently described the complexity of getting the whole U.S. government apparatus to kind of cooperate and communicate in this regard. And you brought in the private sector point of view. What about other countries? Where are we in terms of bringing the EU into our alliance model? And is that important? And are we making progress there?

Ambassador Nkengasong: Absolutely important. And I think that, again, that’s a unique strength of what the bureau can do. Because at times, and most of the time when we think of global health security, we’re thinking of our relationship and partnership with the developing world, or the low- and medium-income countries. That’s not true. We should be thinking very broadly about our relationship with the EU. We started this in discussions, relationships with Asia and all the regions – the different regions, the geographic regions of the world. And build –and use the structures that we had put in place during the COVID response, like the global action platform where the Secretary Blinken was coordinating with foreign ministers to engage with other foreign ministers.

Again, if you have to cooperate and coordinate, it’s not with the ministers of health. It’s with foreign ministers. During my time at the Africa CDC, I can tell you that most of my time was spent with ministers of finance and ministers of foreign affairs, not ministers health. Because you start with minister of health, the discussion when we are talking amongst ourselves, we need vaccines, we need diagnostics, we need PPE. But they didn’t have the money. We had to engage with the ministers of finance to engage with the World Bank and the IMF – especially IMF – to look at special drawing rights, SDR, to see if we could liberate that and facilitate, liberate that money to buy vaccines, diagnostics, and PPEs. Foreign ministers certainly could exchange – agree to exchange information, so this way the platforms are there.

So we have the ability, the unique ability as the ministry of foreign affairs of the United States, to use that leverage and diplomatic power to engage with other countries, not just in the developing world but in Europe as well.

Dr. Gerberding: So Mark, I think in your opening remarks you made the point that one of the most dangerous aspects of not having confidence in the continuity of the PEPFAR authorization is the signal that it sends in the international community that we are no longer reliable allies in these kinds of efforts. And you didn’t say it, but I would imagine that the undercurrent of that is the possibility for other countries to step into that void.

The Alliance has been very interested in how we might be able to improve the intersection with China, for example, in the context of pandemic preparedness and find some channels of communication that would allow us to at least have a modicum of integration in the mutuality of preparedness for global threats.

But in the African continent, there are a lot of competing opportunities for one global power to interfere with the positioning of another global power. And I think, you know, you’re alluding to that reality. But it’s not something that’s on the front page of the newspaper. I don’t know that people have connected the dots between what’s going on with PEPFAR and the diplomatic consequences of it.

You’re on mute, Mark.

Dr. Dybul: They haven’t connected the dots, although I’ve been trying very hard to force people to connect them. And it’s not – it’s not sudden. We don’t have to jump around. It’s Russia and China. For anyone who saw the article over the weekend on Russia’s misinformation campaign in the Sahel that’s helped topple multiple governments, imagine what that misinformation campaign is going to do around the United States backing away from a signature development piece of our portfolio, which is PEPFAR, which is supporting massively the health systems of countries. Imagine what will happen with Russia and China as our capacity and our allies in China – or in Russia – in Africa dramatically changed since PEPFAR started.

This is a – that’s why I was talking about it. We need to change the conversation. If the only conversation is abortion, we’re not going to have a reauthorized bill. If the conversation shifts back to lives, systems, and national security – and the national-security argument we’ve been making for a long time. And it was true at the beginning and certainly would be true if 20 million people came off anti-retroviral therapy. But it’s very real in terms of how we’re viewed on the continent.

And, you know, if we back away now – you know, John’s had these conversations. He has to be more diplomatic than I do. I don’t have to be diplomatic anymore. Heads of state and ministers will tell you, I mean, that tells them we don’t care anymore; that we’re not committed to them anymore if we can’t even manage this. And we have enough openings.

I used to be privileged to be in meetings with heads of state when I was at PEPFAR under President Bush, and they would talk about China. And the reality is the majority don’t want to actually work there – (laughs) – with them; they’d rather work with us. But we’re not offering things the way they need to be offered, which gets back to partnership. We need to have a governmentwide approach to support countries to develop for end-to-end research and development, from discovery through to production. We need to be doing much more than we are. But, base minimum, we need to continue to support them in PEPFAR. And how can we do anything else? How would they trust us on anything else if we walked away from it now?

President Bush really pushed reauthorization in 2008, which was brutal at a time when the political capital was not quite as high as at the beginning of PEPFAR. And he did it – he gave Africans the confidence that this was going to stick around for five years. Year to year to year, what confidence do you have? And it just tells them, if our Congress can’t reauthorize this, that we don’t care anymore, that this is not an issue for us anymore; Africans aren’t an issue for us anymore.

So this is a very real issue. And I hope we get people starting to talk about it more and we engage others in the Republican caucus and the Democratic, for that matter, to talk about how broad-reaching the ramification would be of failing to reauthorize.

Dr. Gerberding: Thank you, Mark. And thank you for that candor.

Now we’ve come to a point where we would love to entertain questions from the audience here in the room. There’s a microphone in the back. If you have a question or a comment, please assert yourself so that we can have a conversation at this point.

But I do want to make reference to the report from the alliance. The report, if you haven’t seen, is available. And it really defines some very specific recommendations about things that could be done now, while we’re hoping to get this reauthorization established. One of them is really to build that bipartisan cohort of PEPFAR and global health security champions in in the Congress. Now, it probably seems ridiculous on a day like today or a week like this week, but nevertheless that’s what has to be done. And again, we have half of the House side, at least, who was not here for the last reauthorization.

So I’m just wondering, John, when you’re on the Hill, what do you say to the people who don’t know PEPFAR? Like what is – what is the – what’s the soundbite that really helps people understand what’s at stake here?

Ambassador Nkengasong: I think I’ve always led that by our values, that PEPFAR represents values, which is caring. And through caring and through those values, PEPFAR has been able to save 25 million lives. And, as the Congresswoman Lee mentioned earlier, I think that value part of it is so important for us, and it should be important for us.

I agree with Mark that security component obvious from the lens of our partners, I mean, there are many African countries that have benefited from our caring, our values part of it is so important. And it’s not just in the context of PEPFAR, but when the continent of Africa was struggling in their response against COVID, I mentioned the large amount of vaccines that we secured. They were Johnson & Johnson vaccines. And it’s very interesting to see the security angle which is very important, that our competitors were interested in creating more confusion.

So in other words they will refuse to join any corporate collaboration approach that were set up at the African Union through what we called, at that time, the African Vaccine Acquisition Task Team. Which was a mechanism to get the continent vaccinated to 60 percent. Rather, they will take 100,000 doses of vaccine to Zimbabwe and give you those vaccines. And the vaccines were not approved. They were not yet WHO approved. You take 200,000 doses and give it to country X. And then they would produce a map of Africa and color the map and say, look, we provided you all. And this is – this is not a story. This is – I was there. I was sitting in the front row where a partner, one of our competitors – someone at a COVID conference with the head of state to show how much vaccines they have distributed.

And at the end of that one hour there, everybody clap and smile. And I look around, and I thought the conference was going to happen. That was the conference. It had happened. So I had to clap and smile too, because you have to. You are sitting there in the front row as the COVID. But it’s not – if you sum all of that, the 100,000 here, 50,000, there 20,000 there, it didn’t even add up to 1 million doses of vaccines.

So when we step in, again, in the spirit of our caring. The first contribution was 15 million doses of vaccine. So that’s where you started turning the corner on vaccination. I remember flying to Tanzania to meet with President Hassan, the current president. The former president had died. And the EU said, go. This is an opening. Go talk to the president. That Tanzania, just has background, the former president said they were no COVID in Tanzania. I showed up there. The AU said, go. And I showed up. Met with her. And the conversation was Johnson & Johnson vaccines are coming. I want you to step up, talk about vaccines, and get your vaccine.

She looked at me intensely, and thought she was going to – it was a very difficult conversation. And turned around and said: I will. And the next day she was on TV receiving her Johnson & Johnson vaccine. That is our values. And the vaccines came from us. The first 1 million doses of vaccine to Tanzania came from us. That is a caring component that, I mean, we should never forget that it helps us promote, advance a diplomacy or foreign policy and advance our values, which is the caring component of who we are.

Dr. Gerberding: Thank you for that. We have a question. Please introduce yourself and ask your question.

Q: Hello? Can you hear me OK?

Dr. Gerberding: Yeah.

Q: Hi. Heather Ignatius from PATH, and thanks so much to all the panelists and for CSIS for convening this. It feels like a really important conversation to be having right now here in D.C.

Ambassador Nkengasong, you sit right in between these two very interesting portfolios in global health. On one hand we have HIV and I think we’re all very aware of the tremendous investments that have been made in data collection to really target where we’re putting our investments and really finding each and every case so that we can reach towards elimination goals, and that message has been extremely powerful in Congress as we’ve talked about the impact of PEPFAR.

And then on the other hand we have this portfolio around health system strengthening, which for those of us who’ve been advocating on the Hill for so many years has been a very challenging message to get across to our legislators about the power of that approach.

And I’m just wondering about your thoughts now what – how you would talk about the use of data in reaching elimination goals and health security and what’s the right investment and approach that’s needed, and what do lawmakers need to hear about that approach at this moment in time.

And I’d be interested in the other panelists’ views on that as well. Thanks.

Ambassador Nkengasong: Thank you. I think my greatest fortune is that before I came all of you in this room I can see that Chip Laren is there, Mark, Michelle, and Steve. You all have advised or interacted with the State Department at some level – I mean – (inaudible) – this year can see, many others – and advised them that it was important to consolidate the assets within the State Department and have a Bureau of Global Health Security.

By the way, and just by the way for political sensitivity, you have to tease out PEPFAR and health security. But HIV, as I argued at the opening, is a security threat. It’s a disease. It’s a virus that we’re dealing with. So it’s a security threat, right?

So if there was no politics behind PEPFAR and whether it would be one entity that we’re dealing with whether it is HIV or COVID, if you do it two by – two table or two-by-four table, and you put COVID and HIV, and you look at the – what we needed to respond to COVID and HIV, you can tick all the boxes without a – with the exception of a vaccine, right? If you just plot HIV and then you list the health systems and delivery, there – only one thing differs. That is vaccines. So I think it’s really literally dealing with the same thing, using the same systems to support that.

So I think there is – the way I talked about systems is not in a dichotomy. I mean, it’s, rather, that they’re commodities. The health service delivery that are required, whether it’s PrEP for HIV, treatment for HIV, or vaccines, do not deliver themselves, or – (inaudible) – do not deliver themselves. You need the warm bodies to deliver them – there is workforce to deliver there, either community health-care workers, nurses, or doctors to deliver them. That is health system.

You need to transport refrigerated systems to move these vaccines from airports to the remote areas. You need it for HIV. You need it for COVID. You need it for the next disease. Information systems, I mean, we need – so, again, it’s always a false dichotomy between HIV response which requires systems and a health system, that they all go together. I call it the triangle of an effective response.

You have the services, the systems, and institutions. Services do not deliver themselves. They require systems to support that. Systems do not deliver themselves in the institutions to support them. So you always need to strengthen that triangle all the time if we have to have the intended outcomes.

Dr. Gerberding: Thank you. We have a couple more questions here.

Q: Hi. I’m Dan Diamond, a Washington Post health reporter. Thanks for letting me crash your event.

I’m curious. For the ambassadors, what is left to do or say to break the political stalemate around PEPFAR? I’m hearing from experts who are watching this program. They find the arguments compelling but also note these are the same arguments that have been offered all year.

Ambassador Dybul talked about changing the conversation from abortion. So how do you actually do that?

Ambassador Nkengasong: I think that is probably a question for Ambassador Dybul because he has been – he started PEPFAR. He did PEPFAR. He did Global Fund. So, really, he’s more savvy in what language should be used and could be used.

I think – I hope that from where I sit we have to have a forum where we have an honest conversation about and listen to each other, hopefully that – and lead with facts and not misinformation and disinformation. I think that is – we’re still at very opposing ends there. People are holding to their position, even with no evidence and no facts, because there’s absolutely no facts – let’s face it – about abortion. PEPFAR’s never been an abortion program. It is not and will never be because there’s a law. The 1973 Helms amendment and others are there to protect the PEPFAR program. So where is this coming from? It could not possibly, I mean, from – I mean, and people are waiting from the continent of Africa. We really have to have a dialogue where we bring the beneficiaries and we bring the side that is – that accuses the beneficiaries of abortion and bring all of us around the table to have that dialogue, which hasn’t happened. I don’t know who is going to –

Q: Do you think congressional Republicans have misinterpreted what you’ve said to them?

Ambassador Nkengasong: Say that again?

Q: Do you think congressional Republicans have misinterpreted what you’ve said to them? Representative Chris Smith has said that you downplayed concerns about abortion in PEPFAR. Is that accurate?

Ambassador Nkengasong: Yeah, please go –

Dr. Gerberding: I was just going to – I was going to suggest that maybe Mark would want to chime in at this point since he has been there and done that.

Dr. Dybul: Yeah. So John’s right to turf it to me because he has to be a lot more diplomatic than I do.

I mean, Dan, we’ve had a bit of a conversation about this, but these are not brand-new conversations. These are the exact same conversations we’ve been having for 20 years at every reauthorization. The difference is this time really the misinformation is at – there’s always been disinformation, every time. The far right and the far left have tossed just misinformation around each time. But there was an understanding that each side had something that they wanted that they had to give up – the conscience clause and some things on the other side. There’s just been an understanding that the lives saved and the national security piece were too important.

The only way to break through something like this is for people to stand up, and I think we’re missing some of that. I mean, people who in the past would have stood up to say this is nonsense – and they know it’s nonsense – are afraid because of the current environment we’re in. And how do you break through that fear? I don’t know.

I also want to be really clear. There are some people who are doing this out of – in good conscience and raising questions in good conscience, just the questions got mixed up with the misinformation. The questions that they’ve had are the same questions that they’ve had for 20 years. They need to be answered and they need to be answered, but the cycles don’t allow for that in the same way. And so really not to plead to the people in this room and something Janelle said, it has to be everyone willing to stand up, to speak, and not allow the misinformation to win.

And that’s going to – so, for example – and the pieces that are coming out in the press about this, they are all about abortion. I haven’t seen a single piece talk about the national security angle, even though I’ve talked about the national security angle with everyone I’ve spoken with, because it’s not what the news – what makes news. So we need everyone to stand up.

I do think there is a moment, to your direct question, that we reach out in a very proactive way to members who have not been engaged. The national security people are – on the Hill are generally not the development people. They don’t think necessarily in the same ways. They can be different committees. And there are some people who are very strong on our need to step up in Africa relative to Russia and China who haven’t been engaged. So part of all of our responsibility is to not go to the same people we’ve always gone to; to reengage others and have them step up and say, we need to shift this conversation. Because it’s not going to shift within the current group.

You’re quite right: We’ve been doing this round and round for 20 years, and it’s not going to change now. But we’re all going to have to stand up and make a massive push. And to be honest, the only push right now is going to – you know, is to make sure that this gets passed through both houses without going through the committees, because we’re not going to get through them in the normal process. So it’s going to take a lot of effort, but we can do it. We’ve done it before. This has happened every cycle. This cycle in particular has just gotten a little out of control.

Dr. Gerberding: The voice of experience here, right? (Laughs.) We have two more questions. Can we ask two quick questions, and we’ll see if we can – just ask them in consecutive order, and then we’ll see if we can get a time to answer them. We’re just coming close to our end time.

Q: Sure. Very hard to follow that exchange, but I’ll try. I’m Mitchell Warren. I direct AVAC. And terrific to hear all four of you.

You know, we often think about PEPFAR as a commodity provider, but I think, John and Mark, both of you talked about research and development linking to delivery. And I’d love to hear all four of you talk about how, as a global community, we might do better with the next generation of technologies, treatment prevention, and, John, you mentioned cure, something I know close to your heart too, Mark. How do we do better than we did with COVID vaccines in terms of linking R&D with equitable, scalable, more urgent delivery? And how to all parties need to play, but with PEPFAR at a central role in that?

Dr. Gerberding: Thank you.

Q: Thank you. Good evening, everyone. My name is Pamela Donggo. I work with John Snow Research and Training as a senior technical advisor. I am based in Uganda. And it’s such a pleasure to attend this in person. Usually I attend virtually.

My question, for the ambassador, I have heard you speak about the reauthorization largely from the perspective of lives saved. But there is a perspective about the reverse of the gains of PEPFAR if PEPFAR is not reauthorized. I personally support JSI projects across Africa. And one of the concerns I hear across the countries, especially those that are on track for epidemic control, is we have 2 percent left to achieve viral suppression, and PEPFAR is not reauthorized. And yet, the new infections are really among the adolescent girls and young women and the young men. Are you worried that if PEPFAR is not reauthorized we risk losing the 20-year gains that have been in place? And does America see that? In Africa, we have a thing that the pot breaks at the door. Does America see the possibility of the pot breaking at the door after 20 years of PEPFAR investments? Thank you.

Dr. Gerberding: Are you worried, John?

Ambassador Nkengasong: Very worried. And I will steal that quote about the pot breaking at the door. We should avoid the pot to break at the door. I think I said earlier that the gains we’ve made are fragile. And I also said that the millions of people that we’ve saved still require that they get up in the morning and receive that one pill, still require that they do their viral load every six months, and that they go get their – that delivery at drug delivery store every two months, or three months, or six months. So the gains are very, very fragile until and unless we get to the point that Mitchell was leading to, about research. We continue to be very hopeful that – the hope based on the past that research in HIV needs to continue to be supported globally, so that we advanced down the line.

If you see where we came from 20 years ago, with a handful of drugs, and today with one drug. And today, we are actually in a position to deliver a long-acting PrEP, OK? That you can inject someone every two months or three months, and perhaps in the next coming months will be like an injectable every five months or sold for PrEP and maybe treatment going forward. It gives me hope that we need to continue to innovate.

That’s why part of our five-year strategic plan for PEPFAR taking us to the next – the next five years has three enablers. One is innovation. Two is leading with data. We need to know where the infections are at the granular level. And then the community leadership there. So those are enablers that, in addition to the five pillars, which is knowing the equity, that the remaining gaps in equity in children, adolescent girls, and young women. I mean, in some countries, like Eswatini – Mark knows this more than everyone else – young – adolescent girls and young women are times – six times more likely to be infected than the corresponding age in boys. And of course, as sustaining the response, I think we shouldn’t leave this conversation without knowing that we have to sustain their response. Which means it’s a joint responsibility and joint accountability by the partner countries stepping up and continuing to increase – (inaudible).

I was in Nigeria; the vice president voluntarily just said: Look, Ambassador, take my words; Nigeria is going to increase their own contribution. Same in Cameroon and wherever. So that is happening. I mean, the partner countries are not afraid to discuss sustainability. They want to have the sustainability discussion. President of Kenya, you’re sitting next to him; he looks up and he say(s): Look, if you support us through the next couple of years, we are going to step up. I say: Well, maybe by the year 2030. He said: No, by 2027 we should be able to take on this ourselves. And at times I’m reluctant to quote him, but his people keep saying the president said we should take this over by 2027. So let’s not drop the pot – break the pot at – in terms of the health.

Dr. Gerberding: No breaking the pot at the door.

Ambassador Nkengasong: Yes. (Laughs.)

Dr. Gerberding: I completely agree with that, and thank you for bringing that image to us.

This has been a remarkable conversation. You know, I love the end note on the possibility of future technology and future innovation being the way forward. Science is on our side. Our challenge is just, how do we bring society along, and not just in the country but in this country and in our leaders in Congress. So we do have our work cut out for us, but I appreciate the experience of Ambassador Dybul; your leadership, John, and everything that you’re doing in your current role and have accomplished.

And Jenelle, as the representative of the private sector here, I know we can’t do any of these things without medicines and vaccines and, you know, we need to stay the course on the innovation front in that space as well, and also have our eye on the prize of accessibility and uptake.

I want to thank CSIS for this conversation. I especially thank Katherine Bliss and her team for pulling together the report and having such a thoughtful and candid display of the criticality of the situation, the importance of PEPFAR to global security, and the need for us to all stand strong and articulate that need to Congress in terms that move beyond mis- and disinformation that is the current focus of our conversation.

And of course I also want to thank Steve Morrison and his team for all of the work supporting the Bipartisan Alliance. All of our panelists are members of that alliance and it’s been my privilege to serve as the co-chair with Senator Burr, so we look forward to our ongoing work.

And thank you all for being here. Very good discussion. Thank you. (Applause.)