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0:16
- I want us to first of all, welcome everybody. This is the first of our guest lectures for conversations in Health, Global to local for the spring of 2023. So welcome everybody, and we got our full class here tonight. Just one business item, and you'll see this for those of you enrolled in the class, Dean King, who was scheduled for March 21st, has been moved to April 4th. Now, if you check the updated syllabus and you have that Dean King, and April 4th is an issue, just send me an email,
0:54
but I'll update the syllabus after this class. So if that's all right. So tonight, we couldn't have asked for a better speaker to start us off for this semester's conversation. - [Man] You could have. - I could. Well, but I nevertheless ended up having a pretty good spot. - [Man] You ended up with me. - Exactly. No. What we'll do like as we typically have done in years past is we'll go around, I will give an introduction and I will ask each of you, we'll go around and ask you to say your name,
1:28
what program you're in, and what interest you have in Global Health, so Ambassador Kolker has a sense of your background. And then we'll engage in a conversation about your life and your background for about 30 minutes or so and then I'll turn it over to the students. We've got two students who thank you, Shreya and Gia for thank you both for volunteering to be the first to go. And we'll start off with you and then I'll open up questions to the rest of the class.
1:54
We're also lucky that we've got at least a few people on Zoom, though it's just webinar format. They won't be asking questions, but just so you know, as a reminder for everybody, we recorded this and it'll be posted on the Georgetown University Global Health Institute website afterwards. And our two student leads, again, Shreya and Gia will have a blog post next week. They'll accompany the recording. So anyway, we're very excited. So, why don't we start, before I introduce the ambassador,
2:27
why don't we go around and have each of you introduce yourself. So Shreya I'm gonna start with you and we'll go around the room so please. - Hi, my name is Shreya. I'm a junior in school health and I'm majoring in global health and the entire field (indistinct).
2:45
- Thanks Shreya, please. - I'm Madeline, I'm a freshman in the school of health as well, I'm human science major. I'm pre-med and I'm looking to do something in women's health as well. - And human science is one of our major pre-med tracks, please. - Hello, I'm Lily. I'm a freshman in school of law studying global health. So I have an interest in kinda the whole field, but I think I'm specifically interested in global security.
3:12
- So you're next. - [Brian] Hi, my name's Brian. I'm a freshman. - Oh, you can... There you go. - [Brian] (indistinct) college the pre med track. And I'm interested in studying global health. - [Collin] I am Colin. I am a freshman in the college. I'm gonna be studying neurobiology and I am kind of interested in like, because I'm in the pre-med track, I'm interested in like the global health (indistinct).
3:40
- Thank you. - [Sylvie] Hi, I'm Sylvie. I'm a freshman. I'm also a global health major in the School of health. And I don't know exactly what I'm interested in doing yet, but maybe something related to maternal and child health. - Thank you.
3:54
- [Ben] I'm Ben. I'm a sophomore in the college and I'm probably gonna go into the legal field probably. - The college is our main college of arts and sciences. - You know, although I'm in remission, I'm an adjunct at the school Foreign service, so I you know the difference between the college and. - [Alina] Hi, I'm Alina. I'm a junior studying global health in the school of health and my interest is refugee medicine.
4:23
- [Argen] Hi, I'm Argen. I'm a sophomore in the school of health. I'm studying healthcare management policy. I'm also really interested in health law and how that changes abroad and the differences between countries.
4:34
- Hello, I'm Maddie. I'm a sophomore. I'm a global health major as well in the School of Health. And I'm honestly like not exactly sure what like niche I want to do within global health (indistinct).
4:49
- Abby. - Hi, I'm Abby. I'm a sophomore majoring in nursing. And as far as global health, I'm really interested in health policy and how that affects people's access to health.
5:01
- Hi, my name is Gia and I'm a senior in the School of Foreign Service, majoring in STIA, which is science, technology, international affairs with a focus on global health. And I used to be pre-med, but recently I've become more interested in the policy side and I'm very interested in the overlap between international law and global health. - Great. - That's great. Thanks Gia. And I'll grab that from you.
5:25
So as I said, we are very fortunate tonight. Ambassador Kolker is, as you noted, is a, I don't know if you ever are like completely in remission as an adjunct, like once an adjunct always an adjunct with our school of foreign service but as you know from the email that Shreya and Gia prepared, ambassador Kolker has had an extraordinary career and tonight is a chance. So as you know, over the course of the semester, we're gonna be looking at people who work
5:51
at the community level, at the national level. A had an extraordinary career working as a foreign service officer. He's been the ambassador as you know, the two countries. He has had a leadership role on the HIV/AIDS program in the US Department of State Afar program, as well as a leading role at UNICEF and HIV/AIDS. He also was the assistant secretary for global affairs at HHS. We've had the chance to work together in various capacities over the years, I would just say,
6:22
and you'll hear more of his extraordinary life but this is an example of, tonight, I think you're gonna hear an example of someone who's made an amazing contribution to global health, not starting off as a scientist, not starting off as a physician, but as a diplomat who brought his skills around negotiation and understanding politics and understanding how to reach and move bureaucracies to make a difference, to save millions of people's lives. So this is really a just another,
6:55
one of the reasons we have this class is just to keep everyone's eyes open. There are many ways to contribute to health and so we're just saying, we're really excited Jimmy, to have you here. - [Jimmy] Thanks for including me. Glad to be the first speaker. - Well, you're our kickoff. So the kickoff, as I warned you, the question starts with everyone in the same place. You were once in college, like our colleagues here. And I guess I'd love you to,
7:18
and I should say the one thing that distinguishes you in addition to being the first, is you're the first time we've had a speaker who gave a commencement address that we assigned as reading. So everyone here has a little bit of a sense of your past, but could you tell us a little bit about where you started and where you were in school and what led you into the foreign service and then help us get to your journey on the path to global health. - Right. Well say first that I never took
7:48
a science course in college. So being a global health leader is certainly not based on any academic credential that I have but I did go to a liberal arts college and appreciated the fact that there were lots of disciplines and that I was able to look at my interest in international affairs, and my interest in US politics, and kind of wanting to take one course in every department as a virtue. And when I graduated, I actually got a fellowship that paid my way to Africa for a year and I joined,
8:24
but this was 1970, which was very politicized. And so I was also working in US politics. And so I came back from my year in Africa and went to work full-time on the political campaign and then on the senate staff for four years, but always looking for someone to pay my way back to Africa and so I took the foreign service test thinking it would be something I needed to get out of my system. And I guess I was in Mozambique, which was my first post for about 10 minutes.
8:51
And I said, no, I think this is what I'm gonna do the rest of my career. And so I had five posts in Africa and three in Europe. I was a political reporting officer for most of my career. And that uses a huge combination of skills you need to say what's going on in, for instance, Uganda, which was my last post overseas, and what does that mean for the United States? So what these things are happening abroad and that turned out to be just a lot of fun, and they paid me to travel and talk politics
9:27
and write about it and that's what I would've done if I were a person of leisure not looking to be paid.
9:36
And in retrospect, I had a very logical career, but it didn't seem like that at the time I had no, not even on the back of an envelope, did I have a sort of career mapped out and absolutely did not have a special interest in health. They say that if you're a master, you have a license to be a dilatant. And I took full advantage of that because there was no subject in which I was uninterested, but health didn't rise to the top early in my career or anything.
10:04
What happened was that when I was in Uganda, president Bush announced 20 years ago today in the state of the union message that we were gonna spend $15 billion on to fight AIDS mostly in Africa. And the way the program was organized, embassies and ambassadors had to make a lot of the decisions about what programs to invest in, how to find partners and which government agencies would be responsible and then be accountable for results. So I been interested in AIDS,
10:35
we already had a lot of experts in the post, we had some things going on, but I suddenly was in charge of the biggest AIDS program in the world. And this PEPFAR program, the president's emergency plan for AIDS relief changed a lot of lives and mine was one of them. And I realized that I had some skills that could help with scaling up this program and trying to meet the goal of helping every Ugandan who needed treatment. I guess that a very quick excursion from college,
11:03
but I don't think there was anything, it wasn't as though I took one course or had one experience of travel or of study that said, oh yeah, I know this is where my career's gonna end up and if you come to a fork in the road, take it. There isn't anything predetermined and maybe these roads not traveled, just haven't been traveled yet. So that's why I liked when I gave that talk to talk about how to prepare for jobs that don't yet exist because I've kind of made my reputation last 20 years
11:37
of my career and jobs that literally did not exist that no one could even imagine when I was in college. So don't worry too much that you've got to pick out your desk or your location.
11:52
- So, (indistinct), it's not quite working, but I'll still go ahead but anyway, Jimmy, so when you said you maybe just a couple more sentences about what was like to be an ambassador because yes, the PEPFAR program when President Bush announced it obviously was a huge change in what we were doing in Uganda, but you had an enormous range of responsibility. - Absolutely, I mean, and about half an ambassador's time is running a very large mission.
12:21
We were 400 employees and it's quite a hierarchical system and ambassadors really are in charge and make decisions and set priorities and Uganda was just in the perfect sweet spot in that there were lots of issues and things that were interesting to do. They had troops in the Congo and we were able to help convince them to at least withdraw them officially. There was a war going on in the north with the Lord's Resistance Army. I don't know if you remember the generation of Coney 2012,
12:47
you're probably too young even for that but there were kidnappings of school children and ransacking of villages in Northern Uganda by a horrible rebel force. There were issues of democracy, there were issues of trade, there were issues of mineral exploitation, certainly just a variety of things that the US was interested in, but not so interested or at such a crisis level that there were people in Washington micromanaging what the post would do. So as a ambassador and as a country team,
13:20
we did get to figure out how we would spend our time and try to report things that people in Washington didn't know, but we had a very full range of USAIDS, Centers for Disease Control and Prevention. We had a refugee program, refugee coordinator. So a lot of things that in the end fit into the PEPFAR program but had to be scaled up very quickly but pretty much every day of being ambassador was more fun than every day of not being ambassador.
13:54
I did have a rule of ambassadors don't do parking places, the competition for on-campus parking was probably one of the main morale issues on post. So I tried to delegate that, but the the sense that you have a lot of discretion over who you meet, what you do, what you prioritize, and you're a celebrity, if you're the US ambassador to a country, you're one of the most media identifiable people and someone who's considered one of the most influential people in that country.
14:27
And that was true in Burkina Faso and Uganda when I was there. So you have some obligations, how you use your time, who you see, how you deal with opposition, how you deal with the government, how you look at culture compared to economic and commercial issues compared to consular issues. And these applications really does matter. And so it was a good challenge that you did have to have a little bit of dexterity and variety of things to do. So I encourage you,
14:56
if you have a chance to be an ambassador, take it. - So you were in the foreign service, you're an ambassador at this point. As you started to imagine all those skills
15:09
when PEPFAR came along, how did that change one, how your embassy worked and then how did it change your time? Did this become your primary activity or how did it still balance with all those other duties you (indistinct)? - No, I would say I still was spending half the time just getting the embassy to function and finding good staff and figuring out, answering day-to-day questions or approving things but Uganda was PEPFAR's showpiece. The people who designed the program had actually done
15:43
post-doc work in Uganda. And this was a place they knew that there were people ready to receive antiretroviral treatment and all they needed was money to put to make that happen, but we were all coming from a tradition of a much different kind of aid and development assistance, the USAID programs, and to a great extent CDC programs in health were proof of concept or a pilot program or a center of excellence. So in one or two sites you would do something that worked,
16:15
but then it was someone else's responsibility to scale that up. And what made PEPFAR different from anything else in my experience was we were trying to reach fast everyone in the country who needed help, hundreds of thousands of people within a couple of years. And that just took a different set of skills.
16:32
You figuring out how health could be a development issue or how health was a biomedical issue were important prerequisites, but you actually had to figure out whether the politics of providing this care, the economics, the logistics, the ethics, the sociology, how do you deal with conflict zones, how do you deal with refugees, how do you deal with women who were afraid to tell their husbands they were pregnant or the fathers of the children,
17:00
how'd you deal with men who didn't seek medical care at all? And it was about sex.
17:09
I mean, you contracted HIV through blood or sex and these were things over which people had control, but the sex part of that was very stigmatized and people who were, there was still an atmosphere in Uganda at the time that there weren't biomedical causes to illness that this was a curse or that someone that someone had been bewitched. If you had a physical ailment, it was because you'd somehow earned it through some non-biological factor. And so dealing with how do you get traditional healers
17:41
who could deal well with the psychological aspects of that to get on board to say, there's some medical things here, we just can't heal. This is really about just being cursed or having bad luck. They're actually things you need to do about it, both in terms of prevention and care. So the challenges of scaling up and trying to reach everyone who needed help was complex but I realized that diplomatic skills actually were valuable in that pursuit
18:11
and that Uganda was unique in part because most ambassadors at the time said, this isn't what I do. I'm not a medical person, I'm not a scientist. We'll leave this to USAID and CDC. And I think they missed that opportunity to really make a quantum leap in how you dealt with a health issue as a political, economic, sociological ethical issue and who your partners needed to be, how you reached target audiences, how you enlisted the support of the host government in that scale up.
18:44
So Uganda was able to actually make a lot more progress the first couple years at PEPFAR because we put a lot of energy into it. So yeah, I was directly involved, but I can't say it that I spent more than maybe 20, 25% of my time on health issues. - And I'll just add this as a bit of editorial. I think it's widely regarded by people who are involved in PEPFAR that you distinguished yourself as the most effective ambassador we had out there.
19:13
And so I think that was one of the reasons why I think you came back to Washington at some point and to take a role as one of the deputies. - [Jimmy] That's half the story. - Half the story. - I did come back to be number three in the PEPFAR program. - Number two. I just call it number two.
19:29
- There were definitely some others. I was a deputy, one of two deputies in the program, but there is a back and I was motivated to do that and I thought it was important to bring the field experience back to Washington and that turned out to be the case but there is actually probably an even more important reason. - [Man] Sure. - I was sort of in line for a third ambassadorship,
19:51
but the way ambassadors are picked from among the career of foreign service, the geographic bureau proposes names of people for each post. And then there's a committee that's the mostly political appoint, he's a very senior people within the state department who goes through that list and tries to balance the ticket and bring people different things.
20:15
The bureau, which was not Africa, which was actually for which I was being considered, had proposed this was the Bush administration and had proposed a very ideological candidate, someone who was politically aligned but not especially senior or well-know in the career foreign service. And I was the systems candidate opposing that nominee so that when this person as they correctly expected, was not blessed with the approval, they said, well, sort of who else do we have?
20:48
Well, we only have Kolker here. And so, but one of the people of the eight who were in this room was John Bolton, who was then under Secretary of State, who you may remember as Trump's national Security advisor, but had a long career of, and he was the most outspoken supporter of the fellow who had just been rejected. And so he, I think just to turn the table said, well, who's this Kolker guy? He hasn't been in Washington, he's sort of, not one of us, and aren't there any diversity candidates?
21:21
Which was probably the right question to ask. And so in the end, they appointed someone who was not a white male to the position, but I then was looking for a job because I had sort of been led to believe I was gonna be a ambassador again, and it turned out that that was karma because I would've been good as an ambassador a third time, but this really is something different. And being able to work on a program that's brand new that didn't have a lot of experience in how to deal
21:52
with the various stakeholders who had to be successful to make a global health program work at the level we were investing in,
22:00
it really did change my life. And the idea that there was a pond of global health diplomats, but no fish in that pond to be the first one was a really interesting, and I learned a lot and I had to learn to speak science as a second language or I had to learn to deal with a whole lot of people, I wouldn't have had to if I were ambassador in another episode. - So, say a little bit more of when you came to Washington and then you brought that experience,
22:28
PEPFAR was ramping up dramatically around the world at that point in time. So you also then led the US engagement with the global fund too as I recall at that time. So maybe a little bit about how you saw those early years of PEPFAR, because I think we're gonna gonna be looking back, we looking back now 20 years later
22:48
and looking at this extraordinary bilateral program, but you were there at the beginning, not just in country, but also here in Washington. - As the US often does, I mean, we sort of announced this program was a surprise to everyone, including the post in the field, we did not know this was coming. Although we had been, the CDC fellow came to me, head of the CDC office, came to me, said, something's going on. We're being asked for information that there just isn't any need for our program.
23:16
Something's going on in Washington. I'm gonna try and find out what it is, but we didn't find out until the next day when this was announced. And so the, I guess the sense of, we started this with our own rules and the announcement
23:35
and the US just throws its weight around a lot. I mean, we wanted to do this program, we wanted to be branded as the US President's emergency plan for AIDS relief, it was brought out of US embassies, but there was hardly a vacuum. There were thousands of people in every country already working on AIDS. So the question was how do we relate to them? And we didn't have a good answer to that. That was sort of up to ambassadors. And it's one reason I think I got a good reputation
24:01
that I at least got a coalition of people who thought our program would help their own programs and that we had some common purpose, which was not universal among the countries where we started. So just building that coalition and then figuring out at the global level how to deal with the World Health Organization, how to deal with the global fund for AIDS, TB and malaria, which was also a new program. How do we deal with the British, the Germans, Japanese and others who had small AIDS programs
24:30
but were now being dwarfed by ours, but how did we recognize that their contribution was really important to us? And then how did you know how to deal with major players in the world, the Russians, the Chinese Indians, Brazilians, these are countries that have major influence were certainly places where they had their own domestic programs dealing with AIDS that were not part of our US government program of providing direct financial assistance,
25:01
although I guess India and Brazil were in some ways, but we weren't in any way able to deal with the national scale of programs in countries in major populous countries. So we had to take a different approach to them. How did we develop those partnerships in ways that were different from a kind of USAID relationship and a CDC, just technical support relationship because we really were trying to be programmatic. - So I'm gonna ask you to think,
25:30
because you were in an embassy then you were at the state department and then also you've had these two other sort of key roles. One at UNICEF, a major international organization, and then you left the state department world and we lured you to come over to HHS and you provided leadership at HHS too. I guess, I would love your just thoughts about the distinction between, or the differences between your life at the state department and then when you went to an international organization
26:02
and went to HHS, again, working on HIV and health issues, but from a different platform. - Yeah, I guess that's been what I've liked about my career that I've done things that were in some ways familiar but did them in different places with different people and therefore different challenges. So one advantage of working in the US Embassy is that you're working in English, so you're living abroad, but someone's providing your housing and you have sort of stove that works
26:28
and that the people you're working with are used to working with people like yourself. So the the cultural and international challenges, and I'm sure many of you have had 'em, if you've lived abroad, some problems are new and you wanna solve them and you wanna use your ingenuity and imagination to do 'em, but some problems you don't have to solve. And that's a huge advantage in doing that. And I think that's how I felt toward these was really fun to see things from different perspectives,
26:56
to look at the comparative advantages of the organizations, but to bring to each of them what I'd done in the other organization and said, there are things we're missing, we have opportunities here because we should be the lead in UNICEF prevention of mother child transmission, but we weren't the main funder of that sometimes it was a maternal health issue, it wasn't a child survival issue. And so just figuring out who are your partners and how do you assert your primacy
27:28
or your leadership or your value added to that operation is something that again, takes diplomatic skills, it takes coalition building but also a kind of sense of who are the other actors and how do you make sure that they're feeling rewarded, that this is putting your priorities onto other people's agendas with a real sense of why is this a priority? Who are these other people and whether their agendas and how are we gonna relate to that in the real world?
27:55
That this isn't just our program and we can do it because we have a strategy or we've designed it well or we have a budget for it. Really have to look in the real world at who else is already there and how are we gonna add value or have them think we're adding value to what their goals are. I don't know if that answers the question there. It wasn't... - And HHS maybe a little bit because that's a... - It's intensely domestic agents, right? - Exactly. - They're 80,000 employees
28:19
in Department of Health and Human Service. It's budget is bigger than the pentagons.
28:25
It is a major international actor. There are 2,000 employees of HHS working at embassies overseas, but none of the US Department of Health and Human Services Systems or culture or thinking is that they're an global actor. They are domestic agency and they're involved in Medicare and Medicaid and community health clinics and doing national institutes of health centers for disease control. Very important institutions who have their own cultures and reputations and budgets and what they do,
28:56
often, the global parts of their programs are the leftovers after they've served dinner to the domestic audience. And so as sort of coordinator for what HHS does internationally, part of it was to get those parts of their dinners more involved in the actual meal service and getting the people who are cooking and serving the meal to look at international opportunities in that the metaphor is getting weak but in that opportunity. - We got the picture, I think, and no this is good.
29:32
- And also then to figure out who within the US government, who within the non-government sector in the US huge number of advocacy organizations and then what's our comparative advantage? What can CDC do that no one else can do? What can NIH do that no one else can do? And how do you take advantage of the fact that even more in health than almost any other issue of soft power where the US is involved in the leadership role, people look to the US for leadership, they want the US partner,
30:06
they want our validation and so on. And as you go through careers in health, I think you'll realize that we do about 50% of the biomed, publicly funded biomedical research in the world is in the most NIH about 50% of the privately funded biomedical research in the world is with US private sector.
30:29
CDC is absolutely the gold standard. WHO often under the table looks to CDC guidance to establish their own and we have to figure out how to do that without looking like we're fixing the result at the same time providing our best people and our best information to all of that. And so none of these questions is kind of linear, you need to think about them in different ways, but be sure that they're in the back of your mind both as opportunities come up
31:00
and then as people are challenging what's happening and that happens in the direct negotiations at WHO, but also in kind of day-to-day things of who are different countries gonna turn to if they have a health problem to solve. And every country has a health problem to solve. And COVID has made this clear to everyone. I mean, there's no country or institution or community that hasn't had to think about how are we gonna prepare for a pandemic?
31:27
How are we gonna deal with the one that's that's with us? That was not the case before. And the fact that HHS's solutions are a prerequisite, you need medical countermeasures, you need products, you need systems that HHS is more responsible for than others, but every system's decentralized. We have state and local people. We have a huge private and faith-based health provision in the United States and in most places around the world. How this is financed, how the priorities are set,
31:57
how you assure quality, how you assure access. We've realized in the US and that's why all of you are motivated to be in this field because we didn't get it right, but nobody got it right. And the the sense that these rules are yet to be written and these priorities need to be set by people who really care and who can overcome some of the things that broke down when COVID hit is why you're here in this class and I hope that you're the generation that's gonna solve this problem.
32:25
- That's a perfect segue to the, my final question before I turn it over to Shreya, maybe you could share with us a little bit about the work you're doing right now because it does not surprisingly, given the breadth of your experience, the administration of the state department has asked you to help think about how do we organize our diplomatic, like we've learned a a lot of things didn't work in COVID, you all lived through this. Among the things I think that didn't work well
32:54
was how the global community responded. I'm not sure that we led the way that we could have
33:01
and part of what you're working on is how the state department is thinking about organizing itself differently to respond to health security. - I was brought back a little over a year ago. I hadn't asked to come back to work at the State Department, but they were nice enough to see if I'd be interested in coming back part-time, which I was and under a circumstance in which I could keep a lot of the NGO work I was also doing, but I had no other paid responsibilities
33:30
but I am on five boards and three advisory committees and two think tanks. So I've been trying to use my experience and expertise, but to learn things and to be involved in things that I didn't directly have responsibility for before but in state they ended up, after a good deal of triangulation, I got two portfolios. One was helping to review how the state department itself was organized for global health leadership. And my premise was, and I'd written an article about this
33:59
as well during COVID, is that we were horribly organized for this. We missed a huge number of opportunities and state department when confronted with the outbreak of COVID, the professionals who had been working on health policy and health security said, oh no, we need to engage a lot of em, get our embassies involved. What does each country need? What's our comparative advantage? Who needs oxygen? What are we doing in terms of travel restrictions? These travel restrictions clearly don't work
34:31
and are counterproductive. How are we gonna actually engage everyone and look at vaccine production distribution, look at access to care, look at the status of health workers in each country, what can we do to address this? That was firmly rejected. And the administration at the time said, we are evacuating American citizens and US personnel. That is our response to COVID and that's what they did for a year. The US State Department was involved in evacuating Americans
34:59
from overseas, which was just an unbelievable missed opportunity. I think it was unethical and immoral. It didn't even necessarily help the American citizens because we were a hotspot here in the United States and the disruption involved in the travel and where they'd stay and how they'd be quarantined when they got here and how their families would be affected and so on was never thought through. And at the same time we did miss the opportunity
35:25
to actually figure out how warp speed connected to other, which was very good. I give the administration high marks for operation warp speed and it was well done. They put a lot of money in it, put a lot of effort and got the military involved, got the private sector involved. So credit where due but in terms of diplomacy, the State department underplayed its hand fairly consistently. And then the other thing I've been trying to work on is global, is what's called global health governance,
35:56
meaning the institutions didn't work, no one was in charge, no one had a lane, no one was accountable for results. When there was need for international cooperation, every country became very nationalistic. And even the facility that was set up called COVAX and the access to coronavirus tools accelerator, which was a way to try to get vaccines, especially to low and middle income countries bet on the Astrazeneca vaccine, it was not an unreasonable bet, but it turned out not to be a good bet.
36:28
And they bet on the Serum Institute of India as their sole manufacturer for the Astrazeneca vaccine. And the Indians within a month put complete export restrictions, absolutely forbid their own manufacturers from exporting this vaccine on which the world was depending through the one institution we'd set up without the US being involved, but which the world had set up to kind of be the parallel to warp speed. And so we were in trouble. And the sense of what institutions do we need?
36:59
What political accountability, who needs to be at the table? How do we get the private sector involved? What's WHO's role? What's the role of financiers like the World Bank or other donor countries in dealing with a global health emergency? We just didn't have good answers to that. It was a very anarchic situation. And every country's health, health is a national responsibility. There is no international organization that's responsible for everyone's health.
37:29
And even within the US as I know you're all studying this, but it's not even that the federal government is responsible for the health of its citizens. You're kind of on your own. You have to figure out what kind of insurance you have, what kind of providers you have. These, questions of cost, access and quality are universal, and our answer in the US is quite complicated. We have a good health system, we have high quality care, we do have a lot of money that goes into it.
37:57
We do have access for most people, but nothing, there's nothing logical about how we've organized this. And other countries may be more logical, but there's no international standard of what really is a best practice and how do we deal with those who fall through the cracks or who are vulnerable despite what their best efforts of health professionals. - Well I'm glad you're helping the US government sort this through but anyway, this is a perfect segue I think.
38:27
So Shreya, I'm gonna ask you to start us. So again, the way our class works is that we'll start, this second half is gonna be questions from you all of Ambassador Kolker. We're gonna start with Shreya and Gia because they sent the briefing memos out and got us all up to speed and and we'll go from there. So here. Oh, I'm sorry. I'm gonna hand this to Shreya. - There's even another mic. - This one's not working. - Thank so much for coming to speak to us today. So given the Department of Health
38:58
and Human Services increasing global presence as well as growing number of health (indistinct) located across the world, there have been some discussions
39:07
about potentially creating a foreign health service for HSS Foreign service. I was just wondering how are you thinking
39:12
about these ideas and maybe in your opinion, if there could be better alternatives that could be more effective overall (indistinct)? - Right, it sounds like you've read an article to which I contributed slightly by Matthew Brown in "Think Global Health," which he made the case about three months ago for foreign health service. I actually, I understand the motivation for that. And as I described, we need to get HHS thinking about how it develops a career track and develops a sort of,
39:39
are there landing spots once you've been overseas, what do you do when you come back to headquarters? And every job is a one-off and it means that you have to find a brand new job and there's not a promotion track, there isn't a family support track. If we are evacuated from a post, say, I'm sure in there are places in Turkey now from which we may be evacuating families just because it's not safe to be there. If you're in the State department, if you're in USAID,
40:04
if you're in the Commerce Department or the CIA, you have a network, which there are apartments waiting for you. There are people who help get your kids in school. There are people who look at the practical aspects of evacuating either the whole family or dependents from a post. HHS has no such system. You are on your own. You can come back and maybe you have something in Atlanta, maybe you have something somewhere, but it's kind of live with your in-laws or figure out what to do.
40:30
So just those basic things that you need. There's no facility for language training, there's no facility for cultural courses and introductions. And so you need a budget, you need a just a way of thinking in a system for that. So I've encouraged that setting up a foreign service would do it, but I'm not a fan of a foreign health service. And the reason I'm not is that the foreign service, you're worldwide available and you're a generalist, there are some specialties within that,
41:02
I was a political reporting officer, have people who are specialized in consular management or other things, but you kind of go where there is and there's an inherent surge capacity in that, which is HHS also could use, but what the world needs now are not generalists in global health, they need the world's best experts and the US comparative advantages that CDC NIH, even SAMHSA, the Substance Abuse Mental Health Services Administration have the world's best experts running programs
41:31
for the world's most developed health system. And the idea that oh, I can do immunization today and tomorrow I'm gonna do AIDS and then I'll look at health systems and health financing and I'll be an expert and I'll advise Kuwait how to deal with non-communicable diseases and then advise them the next day what to do about water and sanitation isn't the way we should, that isn't what other countries want from us. And it's not the way I think a health professional
42:03
would want your lives to be if you're in global health. I think your value to all of us is if you really are the world's best expert on whatever it is you're doing. And so this sense of being available as a generalist to sort of go anywhere and do anything, I don't think matches what the need is for US investment in global health. So there certainly are some things that can be done to make HHS better equipped to have a cadre of people who have careers in global health.
42:37
And I hope you'll be part of that and it'll be attractive, including people working domestically in Washington or Atlanta on global health issues not just with state departments of health or other things but at the same time, I think the foreign service, we are dilatants and that's kind of the advantage that you go different places and can do different things and you try to land on your feet, but it wasn't because I knew more about the potential
43:09
for child labor and the artisanal gold mines of Burkina Faso that I was ambassador to Burkina Faso. You kind of learn that on the job and you try to figure out, well this has a huge tradition and there are a whole lot of things at stake and no, it's bad and we shouldn't have child labor and we shouldn't be doing artisanal gold mining and you use cyanide, I think to arsenic or something to get this out and horrible profession but it's not, if the embassy in Burkin Faso,
43:39
you need to draw an expertise for that. You don't have to be the expert yourself. And that I think is why the foreign service has been successful where it has and the things we need to look to, to be more successful but read Matt Brown's article, he makes a good case for what you're talking about.
44:01
- Thank you ambassador, I also have a question that's kind of broad, but I was just wondering like how would you define the idea of like global health diplomacy, especially post COVID. This is something I'm sure a lot of countries are talking about, but just like, how would you like in your words, define this concept and like what do you think are like the largest opportunities in this new field? - No, thanks for the question because it really is a dilemma
44:23
and the course that I co-taught at the security studies program in the School of Foreign Service was on global health security and defining both global health diplomacy and global health security was how we spent the first day. And there's no one agreed definition or anything. I saw you were assigned for this course, Ilona Kickbusch's article, which makes an attempt to do that. And she talks about seven pillars and various academic pursuits and she's good at this. I mean, she has a school
44:56
which teaches global health diplomacy and this is what she does. And so I wouldn't wanna second guess what she does, just as a practitioner's point of view, global health diplomacy to me is, how do we use diplomatic skills and positioning career to advance public health goals,
45:21
and then how do we use health to improve relations between countries? So that to me would be a shorthand way of doing that. If I had to critique of her article, I mean, she's very knowledgeable and this is the academic sort of mainstream that you are safe sighting her article in that but I think because she's based in Geneva and because she's very obsessed, I would say with WHO very focused on WHO, that she over emphasizes the sort of negotiation, working on resolutions
45:57
in the WHO context and working on things that multilateral organizations put forward as an agenda. And there certainly are some diplomats who spend their lives doing that but when I was in Uganda or even before I spent that much time on health as I was in Burkina Faso or Denmark or Uganda, I was oblivious to these kinds of discussions going on in Geneva. You needed to look at what's going on in the country, what's our value added, how do we add value to people that are doing things already?
46:28
And then what's our comparative advantage are the things the US should be doing here that would advance our national interest, would help protect our own people, would help protect the people in the partner country or were in institutions that we think should be paid attention to or supported or have their voice multiplied. So to me, the sort of practical part of global health diplomacy of what you do if you're a diplomat in the field, I think she under emphasizes in her report. - I agree.
47:03
And one of the reasons we assigned it is I wanted, I mean, she does a terrific job and the piece I think is very well done, but it is focused on international relations theory, I think at least to some extent at the expense of the practical, which I tend to lean toward where your definition but it is a good summary piece, but it is definitely focused on Geneva, I would say.
47:32
And that's not surprising. So let's open it up to the rest of the class. Other questions?
47:39
All right, let's stop, be shy. There we go. Once we get going, here. - Hi, I introduced myself. I'm Madeline. I don't have a strong background in politics and foreign service, I'm in a school of health. - You're a freshman in college, you don't... You're doing fine. Don't, don't worry. No's an imposter here. - You mentioned just a few moments ago when you were talking about the US's response to COVID-19, how you thought that it was somewhat unethical for them to pull out a lot
48:12
of their ambassadors and employees, if that's the word in other heir countries. And I was just curious, okay, I was curious how ethics has played a role in your career and how it plays a role in the career role of a lot of ambassadors
48:30
when it can be put up against a lot of very political diplomacy, if that makes sense.
48:38
- Yeah, there certainly are, there's a hard edge kind of diplomacy where the interests of the United States are in conflict with interests of other countries. And we're there to represent the interests of the United States and we're not gonna say, oh, well there must be a happy medium here or let's just be equidistant between what we think are the justified interests of our own country and people and what other people are saying are a problem with that point of view.
49:05
So it's not that we just negotiate everything and find a happy medium and happy talk about everything that goes on, but it does seem to me that in these circumstances that our credibility as diplomats depends on empathy and integrity. That we have to have a certain sense of why are people behaving the way they are and to understand that and kind of meet them where they are. And then of integrity that you have to be honest with yourself, you owe something to the people that you work with
49:37
and doing what you say you're standing for if you have a policy that you can be consistent in supporting that. And I think the evacuation failed kind of those two tests. I don't think we we're doing this genuinely in the best interests of our own employees, I think it was damage control on the part of the people who were making the decisions that they didn't want our people dying overseas. And of course, if you died in the US hospital, it no longer was the government's fault.
50:07
And that's oversimplified for sure because there were places where there wasn't quality care, so that if you did contract COVID, you couldn't get the kind of healthcare in Burkina Faso that probably would save your life if you had the same symptoms in the United States. So, fair enough, we need to make those judgments in every post, but the idea that this was done wholesale and that all of our energy, all of our personnel went into trying to get special flights
50:32
in to violate what country's rules the countries are making for their own populations in order to give ourselves special privileges, I would say, or special opportunities, we weren't evacuating the people who most needed the care, we were evacuating the people for whom we could be held kind of responsible if there were congressional investigation afterwards. So that's why I would say it was kind of unethical and the fact that we were developing vaccines
51:00
and we're not looking at ways of how do we deal with the world's demand? How do we prioritize the national academies did a prioritization exercise, which we didn't follow even for our own country but there were people who were seriously looking at, in a situation like this, okay, healthcare workers, older people, people with preexisting conditions in what order and how do we reach them and who's responsible for saying who fits into those categories and so on.
51:32
They're actually with some expertise there. I don't think in our relations with other countries that we use that optic at all in saying, what are we gonna do here in Uganda or here in Brazil or China to try to deal with the issue we're both facing, it's a universal problem. It's American citizens did not, I don't think we had an obligation to look only at the welfare of American citizens when we're in a embassy overseas. I don't know, what do you think?
52:07
- Well, I feel like it was unfair to just throw that on you because I'm looking at global health right now and part of the reason that I've been wary about going into global health, I feel that it takes so much to be able to deal with someone, an intimate issue such as an individual's health but I also feel like it's one of the more interesting aspects of the specific field that you worked in,
52:32
especially with HIV/AIDS like how sensitive this subject is. - Yeah, it's probably a good thing if this is global to local. One thing public health doesn't do and health policy doesn't do, is to say, what's the ethics of a provider and a patient or a provider and a facility that isn't our thing. And so while I understand the ethical questions that's coming, I'm gonna pose a different one to all of you. That really was one of the first things I inherited, unfortunately from John Zera at HSS,
53:04
the first month I was there, some researchers, not actually Americans, but researchers supported by the US National Institutes of Health found ways to make bird flu, H5N1 bird flu,
53:19
more transmissible among mammals. So the bird flu, if you remember, is very fatal more than 50% of humans got that, but very difficult to catch, it spread among birds but you had to have really extensive contact with fowl birds in order to get as a human being and probably do something stupid like share liquids with them or something. So the idea that this could be aerosol transmissible was a huge issue. Now the researchers said, and National Institutes of Health sponsored
53:56
the research saying, well we need to know whether the mutations in this virus that could make it transmissible to humans, is we need to be on the lookout for those. And that's part of our prevention, our detection, our response strategy is, we should know whether this is gonna be contagious among humans, if it's gonna get worse, gain of function research it's called as many of you know.
54:19
On the other hand, other people, and I think I was among them in my role as the global person said, wait a minute, we are paying people to do this research and actually create these viruses ourselves, right? And is that ethical? Should we be manufacturing at taxpayer expense a more lethal
54:43
or more potent version of bird flu? And this is of course, the fundamental question that some critics are raising in Wuhan because they were doing gain of function research on viruses, which turned out to be in fact horribly contagious. I don't rule out the lab leak theory, but I don't think that's the most likely cause. I'm not trying to put blame the lab in Wuhan for anything, but they were the ethics of what we were doing, US government was a partner in that,
55:16
US academic institutions were partners in that research in Wuhan and a number of other labs around the world. We've now suspended again,
55:25
we had suspended for several years and I was part of that saying, let's take a look at it. They took a look at it, they started the program again, now they've suspended again, but as you're looking as health professionals on ethics, that to me is just a classic Gordian knot of, do you do the research? If you have results, do you publish the research so that bad actors could learn how to make these things more fatal? If not, whose responsibility is this to stop that publication?
55:54
Is that restricting free speech? Is that restricting academic inquiry? So that's your next class project is to solve that one. - That's why we handed it off to you, Jimmy. - Yeah. - 'Cause it was too difficult.
56:08
Other questions? Let's see. Oh, there we go. That's why we start coming down this way. So who.
56:15
- Yeah. Hi, I'm Sylvie again. And I was just wondering, you mentioned that obviously there were a lot of problems with the initial international response to COVID. So as you're working with the government to try and fix some of those mistakes that we made during COVID for preventative reasons for future pandemics and health crises, do you think that on an international level we'll be able to use what we learned from the COVID pandemic productively and kind of reconstruct some of our systems
56:47
and intergovernmental cooperation as global health is kind of emerging as an even bigger field? Do you think like we can use this opportunity in a good way, is kind of my question. - Of course we could. Will we? I mean, there's a bookshelf of good lessons learned from previous outbreaks and epidemics, which have only grudgingly been advanced and mostly, I was in government during Ebola
57:20
and we learned a lot from that. And I was I guess lucky or unlucky enough to be the co-chair of the WHO drafting group that put forward a 74 paragraph resolution of how WHO and all of us in the global health community were gonna do better because of lessons learned from Ebola. And a number of the suggestions were adopted, a number of 'em were very good, including merging WHO'S outbreaks and their emergencies departments, which has turned out to be very helpful.
57:49
They did a good job both in other Ebola outbreaks and at the beginning of COVID in getting, for instance, testing diagnostics out to the field.
57:59
So yeah, I mean, there are a lot of lessons to be learned and yes, we can and should learn them. My experience is though that this cycle of panic and complacency that we're moving very quickly back into the complacency side and that there
58:17
are very few institutions that really are taking pandemic preparedness seriously enough to be contagious toward all of our institutions doing that. And the battle for power among various organizations, including WHO, but national governments, the global fund, the (indistinct), the World Bank,
58:39
other (indistinct) of pandemic preparedness, I'm afraid, is gonna paralyze a little bit, doing something that really is more than incrementally different from what we've done in the past. So again, there are lots of good ideas and some of those good ideas have been directly advanced by, for instance, this group called IPPPR, three P's,
59:02
Independent panel and preparedness and response, and the pandemic preparedness and response.
59:10
Helen Clark is now advocating for this, there's gonna be a special session, UN general assembly the summer in September on pandemic preparedness and response. So there are people working on it,
59:24
but the way you phrased the question, can we, yes, do I think it's gonna happen? I'd be skeptical. It's gonna require more heavy lifting than I've seen by the political leadership to get this done.
59:39
- So why don't we pass along here. Whoever is next. - Excuse me, I'm a little congested, but I read your commencement speech at Carleton the other night and I thought it was extremely well spoken and a lot of great points in there. And something that really stuck out to me was when you said, part of the problem with kind of the global society is we we take 1.1 steps forward and one step back. And I was just wondering, over the course of your amazing career,
1:00:06
what is maybe an example of a way you found to increase the steps forward and decrease the steps back? Or what advice do you have in general just regarding that? - Well, PEPFAR because it's an easy example of that, and I think has been unique. I wish there were more examples like that in the US government's role and the prerequisite from my point of view was a huge amount of money. I mean, we simply took on that we are gonna be
1:00:34
the leaders in the world and we're gonna pay the bulk of the cost. Yes, others have to contribute and we can't do this alone and you need buy-in from other partners, including financial buy-in, but that we were just gonna put an unheard of amount of money into a single disease and committed over five years and then hold someone accountable for results that you actually measured everything you did and in a kind of medical response to one disease and a prevention program where we were testing
1:01:04
and we could tell whether we were preventing the disease and to some extent what might be factors in bringing that prevention in. I think we succeeded. And the fight against AIDS is not just one step forward and one step back. We're we're making remarkable strides. And in the majority of countries where PEPFAR has been active, we have reached epidemic control. Most people, almost all people who need help are getting it, are getting the medications, number of new cases is declining.
1:01:34
And the kind of the medical system is able to deal with the HIV burden that it has, which is the goal. You're never gonna say the disease is absolutely eradicated, and so on. So that I'd say we've made many steps forward. The contrast though is that you can't do this piecemeal and you have to do it at scale. You can't say that the proof of concept, your lab experiment, which has been successful and you've shown that what you set out to explain or to some anomaly
1:02:02
or some pattern that you've noticed and you've found the cause for that, that you've solved that problem, you know what the cause is, that's not gonna make people healthier unless you get an enormous amount of other partners and other resources behind that. And it's the dilemma that scientists have in that they say, well, we know the answer to this problem, we know what to do, it's just lack of political will. As though political will is a light switch you could turn
1:02:32
on and off just by publishing better data, research data. That's not my experience. My experience is that it's the beginning of the beginning and that the sense of how are we gonna actually make this happen? Who do we need as partners? How much money do we need? How long a timeframe do we need? And that the sense that the private sector does look at quarterly returns means that they're not gonna look at public health investments as things that corporate social responsibility finds easy.
1:03:03
It's much easier to have something that's measurable and has a short term result and public health just doesn't work that way. So I don't know if that answers your question. Do you have an example, something that worked? What should we be looking to to say, oh yeah, that worked. - [Man] I do not have a specific example, but I understand... - No, I don't wanna put you on the spot. - No, that's all right. No, that's the right question, but thank you, no.
1:03:32
So let's go, I think we have two more down here or so, what please. - Yeah, I just wanted to thank you again for discussing your work. It's really interesting and you might be aware, but as seniors in the global health major, we go abroad. So one of the two options that we have are Uganda or Tanzania. And so it's really interesting to hear your work there. And I know you said only 25% of your work was related to health issues when you're doing your on-ground work,
1:03:58
but I was really interested when you mentioned dealing with HIV and AIDS and how it was stigmatized and how you incorporated traditional healers. And so I just wanted to ask if you could elaborate more on that process of like, how did you do that? And then in conjunction with that, you also mentioned that as a US aid program, we tend to overshadow other aid programs. And so how did you work with others such as Japan, Germany, in working with those issues? - Yeah, I mean on AIDS we did that,
1:04:29
that was a factor in I think question about (indistinct) PEPFAR, we don't, in general, I would not make the pretention that we overshadow other AIDS, other development aid programs. No, it's great that you're going to Uganda and Uganda's a perfect example of the 1.1 steps forward and one step back on almost every front you can imagine, including for while AIDS after the initial scale up of treatment, they actually let down their guard and had some backsliding in terms of new cases
1:04:57
and how they dealt with testing and with referring people to treatment, but first, just on the traditional healers, I mean, you do a lot of things. One is we got a Ugandan employee of CDC to reach out to the association of traditional healers and to talk first about what they had found in treating symptoms. If you have HIV and it's progressing to AIDS, there are a lot of rashes and mouths, especially, they had a traditional remedy for mouth sores
1:05:31
that they maintained, and I'm prepared to believe them was very effective and that a lot of people were coming to them to treat these symptoms
1:05:41
of what really was an insoluble medical problem, but that they made them feel better. And so you first recognized that and said, we'd like to do that, but you've probably found that you're actually losing patients that your patients are dying, that what you're doing isn't effective enough and here's why. And we now we realize that they were coming to you because they didn't have an alternative but we're trying to scale up the alternative and can we work with you in a kind of referral system
1:06:08
so that if someone comes to you, that you one, suss out the behavior, are these people putting themselves at risk, even if they're not thinking about, even if they're not telling you that, or if they aren't admitting it to themselves. And then, can you recognize some symptoms that you're not going to be able to deal with traditionally? And we actually, because we were right, that the traditional healers were feeling that their profession was threatened because their patients were dying.
1:06:38
So they actually became, in many ways a good referral system for that. And it's something we probably should have learned more in COVID vaccinations and vaccine hesitancy is partly irrational, partly it's rational, but who are the messengers who can say, this you can do irrationally, but we're gonna get to the point where we're not gonna be able to help you anymore. So that was one, I think the other part of that was to make this a whole of society thing,
1:07:12
to have actual people who were on the medication, people who had relatives who had died of AIDS and other things also be your spokespeople and talk to their own communities in ways that would hit home. And I think that the sense that this is something we now can do something about.
1:07:35
And the drugs were so effective and we had lots of worries because people in Uganda were not getting, in the US You had to be treated by a specialist, epidemiological specialist. You had to have a $10,000 a year series of tests to find out how you were, whether you were having side effects or whether the drugs were working and so on. None of this was gonna happen in Uganda. So the question was could you have high school graduates on bicycles going out and visiting people
1:08:05
every two weeks and doing a checklist, do you have a headache?
1:08:09
Are you vomiting or do you have sores and so on? And using that proxy kind of follow up system, whether that would work, it turned out it worked phenomenally well and that both the adherence rate to taking the therapy in Uganda and the cure rate, not cure, but the control rate, the effectiveness of the treatment exceeded that in the United States. And the reason for that appears to be that many people in the US had been experimenting with other toxic chemicals which had been proposed
1:08:39
as AIDS remedies, but didn't work, but it screwed up their system and their virus was more resistant and Ugandans were treatment naive and so that they responded very promptly, but that word spread instantaneously and you were getting people turning up at clinics even before the clinics had any drugs available just because they seen the results of their friends and relatives.
1:09:04
So it wasn't as though this was really hard to persuade traditional healers. They were part of a society which had realized that the posse had had arrived.
1:09:14
- So let's see. Any other questions out here? - Yeah. - Arjun and (indistinct). Okay great. Please. - Hi ambassador. Thank you so much for taking the time tonight to speak with us. I guess something in your conversation earlier that really sparked my interest was when talking about the PEPFAR program, you mentioned that a lot of other countries engage in HIV/AIDS activity as well, and specifically maybe countries that don't necessarily share US interests like Russia and China.
1:09:40
So, I kind of had a broader question to that effect, which was how do you manage those very apolitical global health kind of activities with the US in terms of promoting health in these countries while confronting those very real political objectives from these other countries in terms of maintaining US international relations and US interests in these countries? - Yeah, I think you have the mindset you have in the question, one is that nothing is genuinely apolitical
1:10:06
and that in no society are you gonna be involved in a US run program without stepping on some toes or having to adapt to the cultural and political sensitivities of the people you're working with or that you're trying to help, if you wanna look at it that way. And certainly if you come in the attitude we're from America and we're here to help, that's not going to win a trusting audience. And one of the other things COVID taught us is that even more of an access to actual biomedical care,
1:10:41
trust in the system, trust and expertise, trust that the government is actually putting your best interest first, it's a problem here, it's a huge problem in virtually every country. And a few places like Finland and the Republic of Georgia and so on, where there was a unusual trust in health facilities did better. Vietnam, even though a authoritarian country, there was tremendous trust that the government knew what it was talking about. United Arab Emirates and Qatar have actually
1:11:13
the highest vaccine prevalence in the world, and it's a dictatorship. They insisted they do it, but they had every employer, many migrant employees there, people who were interested in migration,
1:11:29
they went through a very significant program of training employers and having handouts in other languages to employees of why these vaccines were valuable, necessary and it turned out people accepted that they had that their interest to start. So looking at the local circumstances and figuring out who are your messengers, what's your message and so on this one but the other part is, I mean we really are good at what we do. The US does have the best technicians.
1:11:59
CDC has the best people if you're gonna try to set up an immunization program or a non-communicable disease program, you should want CDCs help because they've done it for the most sophisticated health system in the world. And they know what they're doing. So the question is, how do you as an ambassador use those people and say, okay, in Burkina, I guess I was awakened in some ways to this potential, there was a meningitis outbreak, it was during Burkina's world famous in Burkina Faso,
1:12:28
not anywhere else for having an international film festival. And this meningitis outbreak came when they had thousands of international visitors for this Francophone film festival. And so they covered it up and so suddenly it was a real crisis when they finally admitted it. And so I just kind of wrote that up and called and said, we need the world's three best meningitis experts to get here, like now. And then 72 hours we got meningitis experts from CDC
1:12:56
on the scene, they worked, they did the surveillance, they looked at what they knew, they tried to gather data, they tried to figure out how this was being spread and it took a couple months, but they got this under control and we can do that. So it's not like we have to be apologetic for what we do, but we do have a certain sense of humility that these people have been living in their, there are millions of people there who've been living their own lives for many, many years.
1:13:25
And the idea that we can come in and say, well now you're gonna do this differently and here's why. And to have them believe that just because we said it or just because we've convinced some academic journal that that's true isn't gonna be very good health diplomacy.
1:13:42
I don't know if that answers your question. If you have tips for us... - [Man] We're open. - We're learning.
1:13:49
- There was one more question there. - Gaby I think you had one. Please. - Yes. So my question was actually very much related to the last two, I like what you said about how you involved local people in what you were doing in Uganda as to not step on their toes and what their sort of remedies were for AIDS, but also offering the solution that you had from the United States and census is global to local as a class, I'm wondering more locally in the US what are your thoughts on the extent
1:14:20
to which the government can control whether people are getting vaccines and whether they're getting treatment for certain things without really getting in the way of their opinions,
1:14:32
whether it's rational or irrational, like you said. - Well, you've made the question easy by using the word control, we obviously can't as government control that. I think we can create conditions in which there's trust both in science and then in authority. And that politicians have the public interested at heart and they're not posturing or being opportunistic in positions they're taking. And I don't know how we get that sense back in the United States.
1:14:57
I think that right now the cynicism with which people view what almost any leader says, well, what's the vested interest in this? Why are they doing this? Is is to promote one institution or one line of thought or political party or commercial interest ahead of others.
1:15:22
We have to get back to that idea that we're looking at the evidence is evidence, I mean even the WHO
1:15:29
when we were negotiating how to deal with non-member states and how their voices could be heard because it's a completely member state organization, believe it or not, they really were trying to say, well, we're gonna have four categories of evidence and evidence that's brought by health-oriented, non-government organizations will have one standard of kind of scrutiny, but if it's brought by the private sector, it'll have a higher standard of scrutiny because they're in it to make money.
1:15:59
And we fortunately, as the US and some others said, evidence is evidence. I mean, yes, you wanna have scrutinize the evidence, everyone has interests and can be partisan or can have a vested interest in what they're proposing, but the idea that evidence generated by the private sector is inherently less valuable than evidence generated by advocacy organizations to me, hasn't been true in fact and is certainly a dangerous policy for organizations like WHO to undertake,
1:16:34
to say that we're gonna judge evidence by the quality of the proposer of the evidence, not the quality of the evidence itself. So I think that's the underlying frame of mind that we need. And people do tend to believe their own doctors, their own kind of health community and so to the extent that you're those people to think about, this is one of your responsibilities to say, here's the evidence as I see it, this is why I'm prescribing this, this is why I think you should change your behavior
1:17:07
in this way, but I can't make you do it. And I can't promise that there aren't risks in that because there are risks and you just have to kind of explain risk management rather than risk avoidance in how we're looking for behavior change, how we're looking in introducing new products of public policies, anything there. And that's hard because they're gonna be people who have adverse reactions to vaccines. So we can't say, oh, this vaccine is completely safe. It's not.
1:17:41
On the other hand, the risk of getting the vaccine is so much less than the risk of not getting the vaccine. How do you make that clear to people who say, well, but so-and-so got a heart attack after this vaccine, some football player dropped dead.
1:17:57
It's not rational, but that's the world we're living in. - Well that is a great question that ties us global to local and maybe just first off, thank you Jimmy, that was really terrific. And so you can see the tour to force of his career and the way in which you can affect health from a nonclinical perspective, let's put it that way but also the lessons of diplomacy aren't just international, it's about how we also think about how we engage in our own communities.
1:18:29
So anyway, I would like to ask everyone to join me in a round of applause to thank you. - Thanks very much. (audience applauds) - And as you can tell I'm into this. So I'm jjkolker@gmail.com. Maybe if you can (indistinct). - We will circulate that. - If you need career advice, you want a second opinion or you say, something you said doesn't make sense or what did you really mean? That to me is fun. I'm living through legacies and proteges and you're now part of that number. - Thank you Jimmy.
1:19:02
- Feel free to do this but it really, it's a very underpopulated field, the idea of health policy and health diplomacy globally. And we need a next generation of people who take this seriously and they're motivated to get it better than we did. - So there you go. There's future job opportunities here. So thanks everybody. So I will update the syllabus with the change for Dean King and we'll see ya in I think two weeks if I'm not mistaken. So thanks.
1:19:34
And I also wanna particularly shout out to Shreya and Gia for volunteering and kicking us off and we'll be ready for the next speaker. So thanks everybody.
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