Remarks by USAID Administrator Dr. Rajiv Shah at the National Institutes of Health in Bethesda, Maryland

Tuesday, February 15, 2011
David E. Barmes Global Health Lecture Series
Administrator Dr. Rajiv Shah and Dr. Francis Collins
Administrator Dr. Rajiv Shah and Dr. Francis Collins
Credit: USAID

FRANCIS COLLINS: Thank you for coming to a signal moment in the life of the NIH community, the David E. Barnes Global Health Lecture. Apologies that we are getting started just slightly late because our distinguished speaker had a number of challenges this morning, such as the fact there was a fire in the Reagan Building where his office is and they wouldn't let him get access to a car, which made it a little hard to get here. I think maybe he walked.

But anyway, Rajiv Shah has now arrived and we are very much blessed by his presence and looking forward to what I think is going to be a very substantive and important lecture from the administrator of USAID.

So I'm delighted to welcome you to this lecture. It is, of course, in the name of David E. Barmes and is sponsored by the Fogarty International Center and by the National Institute of Dental and Craniofacial Research, NIDCR, and held annually to honor a colleague, who prior to this untimely death, made significant contributions in the field of global health both in his time at NIDCR and in posts he held at WHO in Geneva. David Barmes was a strong advocate and a signal influence on the importance of primary prevention in improving oral health globally.

I would also very much like to welcome Lois Quam who has joined us today as the newly appointed head of the Global Health Initiative and Amy Batson from USAID and others who have come to hear this important lecture this morning. Thank you and welcome to all of you.

It's a real pleasure for me personally to introduce our speaker today who I've come to know over my time as director in the role that NIH is playing in President Obama's global health initiative. It is Raj Shah, along with Tom Frieden and Eric Goosby, who oversee this complex, $63 billion effort which is the major initiative by the president in global health.

We actually did some consulting with the NIH history office and searched our databases and I believe this is the first time that a sitting – a USAID administrator has addressed the NIH community. So this is a historic moment. (Applause.)

And I think that speaks volumes for our speaker and his connection to science, which you will hear is both passionate and based upon a rich fund of information and also for the times, where the involvement of all of us in global health is growing.

I remember last year's Barmes lecturer, Julio Frenk, when he was here, making the point that global and domestic are not the opposites of each other that in fact, domestic and global have blurred together in ways which I think we can all see quite clearly, when you consider how rapidly diseases can move across the world and how much we're all invested in the health of all nations.

Raj Shah was appointed administrator of USAID last December. Within two weeks of his Senate confirmation, he was overseeing a massive rescue and recovery operation in Haiti. His management of that crisis was broadly hailed as were his efforts over this past year to position USAID as a transformative force in international development.

He has a distinguished prior record. Immediately prior to his appointment at USAID, Raj served as under secretary of agriculture for research, education and economics and chief scientist at the Department of Agriculture. And prior to that, he held leadership positions at the Bill and Melinda Gates Foundation as director of agricultural development, director of financial services, leader of the strategic opportunities initiative and manager of the foundation's $1.5 billion to the vaccine fund.

He's originally from Detroit, earned his M.D. from the University of Pennsylvania medical school, a master's in health economics at Wharton, and I would also note with pride that he has a degree from the University of Michigan.

Among the many things that have caused me to spend time with Raj, I particularly want to point to this effort to focus some of the Global Health Initiative attention on research.

And this past summer here on the campus, USAID, NIH and CDC as well as many other agencies established a research committee to examine where cooperation could actually enhance our effectiveness and efficiency. And that includes some things such as exchanges of staff, sharing information about research plans and funding announcements. And we're looking forward to additional new partnerships as this all goes forward.

The challenges are considerable. But compared to past eras where people looked at global health with hopes and expectations, but not much evidence of success, that is all changing. And I think when Raj speaks to you today, you will get a sense of the momentum that has been building in terms of success stories in global health and where that can take us next.

Raj is not somebody with small plans or small ideas. When I had the pleasure of leading the Human Genome Project, one of my favorite quotes was from Daniel Burnham, which was: Make no small plans; they have no magic to stir men's souls.

Raj is not one to make small plans, but it is a need globally, that encourages the breadth and sweep of the vision that he brings to us today.

We're privileged to have a scientist at the helm of USAID. It's a personal honor for me to be able to work with Raj Shah and to introduce him to you today. Please welcome Raj Shah. (Applause.)

ADMINISTRATOR RAJIV SHAH: Thank you, Francis, very generous. Thank you, thank you. Good morning and thank you so much, Francis, for your – for that very kind – overly kind introduction and for your outstanding leadership of this institution. For me, it's a – I get to learn from and be inspired by Francis Collins as everyone in this room and that's a great thing, especially since we both have ties to the University of Michigan, which – (laughter) – I'm glad you recognized.

It's also wonderful to be here and see Dr. Isabel Garcia, to see Dr. Harold Varmus, Dr. Roger Glass. I could go through so many others who are friends and colleagues and people who demonstrate the relevance and commitment of science and technology to really creating positive change in the world.

And I think everyone at the – in the leadership roles at this institution perhaps more so than any other place in the federal government, bring a full commitment to envisioning the world as it could be, not as it is today. And for that, I want to thank you personally and let you know that we all take great inspiration in your science, in your excellence and in your vision and your commitment.

I'm also pleased to be here with Lois Quam, who did just join us, I guess, two weeks ago, Lois, and is directing the Global Health Initiative, which is a great thing and it will help us be even more effective and efficient as we bring together so many different parts of the federal government to really work on a singular goal of making the world a healthier place with a real focus on the needs and the aspirations and the diseases that affect the very poorest.

To me, the NIH represents one of the America's core competitive advantages. Advancing science, technology and innovation aimed directly at improving human welfare. And I believe if we can harness that capability for the poorest communities in the world, we can leave an unparalleled legacy in global health and in global development throughout the upcoming decades.

To seize this opportunity, I recognize that we all need to do some things very differently. First, we need to improve the efficiency of our efforts and focus on building, really, country-led health systems instead of donor-driven, disease-control programs. NIH brings great excellence to that and Francis has done wonderful work to highlight the role of NIH fellows in the countries where we work that really demonstrate that core ethic and commitment to local leadership and local ownership of health programs.

President Obama's Global Health Initiative is making real progress in this effort, proving that in global health, saving money, driving efficiencies can save more lives. In Kenya, we worked with PEPFAR to couple HIV/AIDS treatment to maternal and child health services. As a result, in just the past year, we've extended access to reproductive health services from two to all eight of the country's districts at no increase in cost.

And in Mali, we were able to integrate five separate annual health campaigns into one streamlined program. The program boosted provision of vitamin A supplements and neglected tropical disease treatments while cutting the cost of delivery in half.

These efficiencies, from dollars, to lab time, to hospital beds, to specialized labor that can be deployed against other tasks, allow us, now, to extend services to more people in need, delivering greater progress at no extra cost. But integrated service delivery alone will not achieve the success we all seek.

Our real opportunity rests in harnessing the true power of invention, scientific, technological and behavioral on behalf of the developing world. Doing so will require us, particularly those of us in the development community, to redefine our role as it relates to global health. We cannot simply seek to do more of the same in an effort to provide services using currently available tools and technologies.

Instead, we need to focus our efforts on facilitating a continuum of invention and innovation from bench to bush. That will not be easy. Our politics will tend to prioritize doing what we can achieve today over inventing, introducing and scaling up new technologies for the future. And often, these technologies are criticized as unproven and costly, as many of them are in their early genesis.

But this is – and this is fundamentally why it takes new technologies so long to reach those in most need, the very poor. It can often take two, three or four decades for people in developing countries and resource-poor settings to benefit from the same technologies we take for granted and have propagated widely here in the United States.

But we can build a new global health system that better connects what's happening in labs here in the NIH with what is needed in USAID field sites and produces real breakthroughs in our capacity to improve the health of the poor. If we can target the freed resources provided by the GHI toward the expansion of those new scientific breakthroughs, I believe, by 2016, we can achieve great goals.

We can save the lives of over 3 million children. We can prevent more than 12 million HIV infections. We can avert 700,000 malaria deaths, most of which will be kids. We can ensure nearly 200,000 pregnant women can safely give birth, prevent 54 million unintended pregnancies and cure nearly 2.5 million people infected with tuberculosis.

This is an ambitious and aggressive agenda. And while hopeful, I realize that it is also daunting. But it's an agenda that we must embrace because the challenges we currently face in global health are extraordinary. This year, more than 350,000 women will die in pregnancy or childbirth. Eight million children will die of preventable diseases before their fifth birthday. And another 2.6 million new individuals will become infected with HIV/AIDS.

It's really difficult to comprehend the massive degree of human suffering represented by these statistics. It means that a woman in Southern Sudan whom I recently met is more likely to die in childbirth than finish high school. It means a child born today in Swaziland will half as long as one born 11 years ago due to a rampant HIV epidemic. And it means that a girl born in Chad is only 10 percent more likely to learn how to read than she is to die before her fifth birthday.

As Secretary Clinton has noted, this undermines social stability in all of these countries. And ultimately, this threatens our own national security. Compounding these challenges are a number of deficits that limit the effectiveness of health systems in exactly the countries where health is needed the most.

Poor infrastructure limits the ability of people to reach sparsely distributed points of care. Health facilities are dangerously understaffed. Health ministries have limited access to funding, unable to rely on domestic taxes or stable revenue from donor partners. In fact, in Malawi, per capita health spending is less than $17 annually.

But despite these current challenges, expanding the reach of scientific and behavioral breakthroughs in global health has the potential to drive huge, huge gains. And we can prove that U.S. investments in global health can and does deliver real, concrete results. As Francis noted, in recent decades, we have witnessed the most impressive global health gains the world has ever seen. The invention of vaccines for smallpox and polio have led to the eradication and the near-eradication of tremendously debilitating diseases.

The innovative work by the Clinton Foundation to lower the cost and increase the volume of antiretroviral therapy, coupled with new investments from PEPFAR and the Global Fund have turned HIV from a death sentence to a treatable illness for millions of people. The invention and propagation of oral rehydration solution, a very simply intervention spearheaded decades ago by USAID prevented 3.6 million child deaths in communities and villages upon its introduction.

In each instance, these specific breakthroughs in diagnosis, in treatment and in prevention technologies or breakthroughs in product production and product pricing led to massive progress in global health. The breakthroughs unlocked political support as heads of state and donor governments began to see what was possible. And most importantly, they extended beyond the reach of formal health systems and touched people directly in their villages, in their schools and in their homes.

But the truth is, we cite these examples because to some extent, they're outliers. More often, our global system sees big delays in getting new technological breakthroughs to the poor. Two decades after Haemophilus influenzae B vaccines reached almost all the kids in the rich world, they're just now reaching developing countries at real scale where their health impact will be much, much, much more profound.

So today, we stand on the cusp of the next generation of scientific, technological and operational breakthroughs in global health. If we can find the courage to do things differently and quickly deliver these breakthroughs to the field, we can usher in a new decade of unprecedented global health gains.

The most transformative new breakthroughs we have at our disposal are in fact, vaccines. By expanding the coverage of existing vaccines and introducing new immunizations, we believe we can save the lives of 4 million children over just the next five years. To do this, we need to deliver pentavalent vaccines, combination immunizations against diphtheria, pertussis, tetanus, hepatitis B and Hib to the 60 percent of children born every year without access to those basic protective immunizations.

We also need to dramatically expand the reach of new pneumonia vaccines. Every year, 1.5 million kids die in a manner that's directly attributed to pneumonia. If countries are successfully introducing a pneumococcal conjugate vaccine widely, they can save up to 500,000 of those lives every year. Similarly, a rotavirus vaccine that combats diarrhea could save 300,000 of the 1.5 million children who die every year from diarrheal diseases.

Currently, pneumo costs about $3.50, thanks to advanced market commitment negotiations, while rota costs nearly $5 a dose. Even at these prices, these vaccines represent at fantastic bargain. But with rapid, widespread introduction, we can generate much higher product volumes and lower the long-term unit costs of these vaccines for the poorest countries.

Finally, we need to reach the remaining children who suffer from polio. The U.S. has been the largest support of polio vaccination and eradication campaigns around the world. USAID hopes to use our extensive programming platform in Afghanistan and Pakistan as a unique way to tackle polio outbreaks in otherwise difficult-to-reach and sometimes conflicted regions.

The work we do today to build cold chains and last-mile delivery systems in health systems around the world will also prepare us for the transformational vaccines of the future. Even establishing simple technologies like barcode labeling and computerized inventory tracking will make a world of difference the day we're able to produce and introduce safe and effective malaria, TB, and HIV vaccines.

The evidence is clear: Vaccines are the best public health investment we can make. Our best hope of sustainably eliminating malaria, TB and closing the chapter on HIV/AIDS will, in fact, depend on their development and widespread use.

But despite this evidence, despite the fact we have proven mechanisms like GAVI to procure vaccines at the lowest-tiered price for poor countries, despite having delivery systems in place that reach nearly a hundred million children a year and could be expanded, despite the case for vaccines being so compelling that warring factions in southern Afghanistan will lay down their arms during days of tranquility to immunize their children – despite all of this, we struggle to find the resources to invest in vaccines.

For USAID, this will change. We will build up our vaccine team in the agency so that we can become leaders in developing the innovative procurement and financing solutions that make vaccines more available and more affordable.

Each of our missions around the world will identify opportunities to improve cold chain and delivery systems. And we will support countries in developing aggressive new plans to introduce rotavirus, pneumococcus and meningococcus vaccines. We are supporting product-development partnerships such as the Malaria Vaccine Initiative and the International AIDS Vaccine Initiative.

And we will focus on one of the best lifesaving investments USAID has ever made: the first public funding of GAVI, the Global Alliance for Vaccines and Immunization. That initial investment has led to the prevention of more than 5 million childhood deaths, a mammoth return on investment by any account. We will expand our support of GAVI and help it address its current funding shortfall.

But going forward, we will do more than simply provide funding. Our field staff has a strong sense of what interventions are needed, and of the financial, operational and behavioral constraints that define the environments in which we operate.

We will begin publishing target-product profiles that can serve as a guidepost for vaccine developers, describing our sense of the realistic cost-formulation and performance characteristics of desired new vaccine products.

When a child cannot get a vaccine and dies of a preventable disease, it really does offend our conscience. When an AIDS patient cannot access or afford lifesaving treatment, it affronts our dignity. But when a woman in the developing world dies during childbirth, we too often consider it a fact of life. Too often, we find it somehow acceptable.

I've given a lot of thought to why this is the case. I've heard many experts say that reducing maternal mortality is too complex, that it's too difficult to achieve in countries where most women will really never see the inside of a – of a Western-style hospital. But I really cannot escape the conclusion that our current state of affairs where a pregnant African woman is 135 times more likely to die during childbirth than some of her Western counterparts exists simply because she is, in fact, a woman. And this is unacceptable.

That's why we've scoured our data to identify best practices for improving care, often in the community-based setting. We have now asked each of our 28 missions in the highest-burden maternal-mortality countries to implement these best practices in an effort we appropriately call BEST. It will require first addressing the significant unmet need for family planning in the developing world. Innovations in products can allow us to provide a broad range of family-planning options to women. And innovations in service delivery, like social marketing, can leverage the private sector to reach well beyond traditional health systems.

New approaches to counseling are resulting in better health outcomes, and are helping women ensure healthy timing and spacing of pregnancies. And this work can be done in a manner that builds sustainable health systems over time. I just recently visited Guatemala, where we have graduated our commodity support because they have built a strong internal, domestic system to continue decades of USAID investment in family planning and contraceptive access.

We've also entered in an important partnership with DFID, AusAID and the Gates Foundation through which we can work in these 28 countries to avert 54 million unintended pregnancies in the developing world in the next five years.

And for pregnant women, we have to collectively invent a new, technologically capable support structure built around trained birth attendants that can eliminate childbirth-related deaths for women and save newborn lives. By training community-health workers and midwives, providing them with new uterotonics like misoprostol and Uniject-administered oxytocin, rolling out active management of third-stage labor and using mobile text messaging to deliver targeted – (audio break).

ADMINISTRATOR SHAH: (In progress) – that first provided the evidence that USAID should increase its involvement to combat birth asphyxia. As a result, we're now working with Laerdal Medical to develop and roll out a cheap, new newborn-resuscitation device that community-health workers can use to save newborn lives. This and other new technologies will allow us to save the lives of nearly 2 million newborns.

These advances don't lie in building more hospitals or training more doctors. Frankly, that will take decades, and we don't have the time. They lie in bringing quality services and new and appropriate technologies directly to women in their own communities.

Development professionals spend a lot of time extolling the virtues of investing in women and girls, and USAID is no different. But when it comes to maternal and neonatal mortality, we must ensure our investments, our scientific inquiries and our politics live up to our rhetoric.

One area where our commitment has in fact successfully lived up to our rhetoric is the huge progress we've made in combating malaria. And I'm pleased that our leader for the President's Malaria Initiative, Tim Ziemer, is here with us today.

The previous administration created the President's Malaria Initiative because they saw how an effective campaign of scaling antimalarial breakthroughs could fundamentally change the disease's epidemiology. Just five years ago, we were all talking together about how malaria killed nearly a million children in sub-Saharan Africa, and that the cost to the continent in economic terms was nearly $30 billion a year in lost productivity.

Today we have helped cut malaria cases in half in over 40 countries, reduced childhood malarial deaths by 200,000 and even seen a reduction in all-cause child mortality in seven initial PMI countries. I find that statistic astounding. It means – the all-cause mortality reduction. It means that through one basic program, the PMI, we are generating an entire cascade of public-health benefits. By preventing children from contacting malaria – contracting malaria, we are reducing co-morbidity, making them healthier over the long run and freeing up resources to attend to other needs.

In development, successes this impressive are far too rare. The main reason PMI has been so successful is that it uses a number of outlets, including schools, community theater and women's groups to target people where they live. Last September, UNICEF released an important study detailing progress against the Millennium Development Goals with a focus on inequality. It won't surprise you to hear that almost all of the progress against the MDGs has favored relatively richer people over relatively poorer people, has favored urban residents over farmers, and men over women, except when it came to the reach of malaria interventions.

The community-driven approach of PMI has led to a remarkable result: an equitable distribution of malaria prevention and treatment across rich and poor, urban and rural, men and women, boys and girls. To distribute the same kind of gains across our entire global-health portfolio, PMI's efforts must serve as a model.

In the meantime, we can push the initiative's success even further. The global-health community is now poised to remove malaria as a major public-health problem across sub-Saharan Africa. That would save an additional 500,000 lives annually and free up African health systems to have space and service support for communicable diseases and a whole range of other things that they would be able to focus on. To do this, we need to continue to increase distribution of long-lasting, insecticide-treated nets, boost indoor residual spraying, expand the provision of artemisinin-based combination therapies and target pregnant women for preventive treatment.

But then, we must invent new solutions for malaria. We need to give community-health workers a point-of-care diagnostic that's cheap and easy to use so they can determine whether a fever is actually the result of malarial infection. We need to develop new classes of insecticide that can deter mosquitos without harming human health or local environments. And we need to explore ways to lower the cost of artemisinin either by breeding higher-yielding plant varieties or making it synthetically. And we're seeing real progress in both of those strategies.

Finally, we need to seek the ultimate biomedical answer to malaria: a cheap, effective vaccine. The RTS,S vaccine currently in phase III trial seems very promising. And through the Malaria Vaccine Initiative, USAID will continue to support that and other candidates that may show even more progress over time.

You know, in a time of fiscal austerity, it may seem wise to look at recent gains and decide that we can draw back our commitments to this assistance. Current budget proposals circulating this week on Capitol Hill would in fact do just that.

But we should be very clear about the impact of that decision. If major donors withdrew their support, malaria infections would not hold at current levels. They'd regress, devastating an entire continent and unwinding half-a-decade of miraculous progress. This actually happened recently in Sri Lanka and Zanzibar: a lack of sustained funding prevented the elimination of malaria and led to surges of new infections and new deaths after they thought they had largely gotten the disease under control.

So our choice is clear. We can continue to build a bipartisan legacy and eliminate malaria as a serious public-health threat, or we can unwind that progress and put millions of children's lives at risk.

And PMI's success has helped chart a course to one day eliminate the threat of malaria. But despite tremendous gains in the last decade, we unfortunately cannot say the same thing about TB and HIV. TB has always been the signature disease of the urban poor. In a world that is urbanizing at a rate of 200,000 (people) every day, we must fight TB now before it becomes an unparalleled global killer.

The frightening growth of drug-resistant strains of TB, some of which cannot be treated, make the case for combating the disease more urgent than ever. But continuing to do more of the same, often the result of the relentless drive to report on the sheer number of people in treatment, will not work to turn the tide against TB. The reason we have seen such a rise in drug resistance is because we are simply not able to accurately detect infection. Current diagnostics require specialized lab facilities, trained personnel and weeks to deliver results. And they frequently yield false positives.

Our current best hope is to improve TB detection using rapid genetic diagnostics that can identify the presence of tuberculosis and its resistance to antibiotics. These diagnostics, such as the GeneXpert genetic assay, are quick, easy to perform and accurate. But as with all new technologies, they're not cheap. The GeneXpert machine costs $25,000. And each diagnosis can cost between 20 (dollars) and $60.

USAID will use its commodity-procurement capabilities to accelerate the distribution of GeneXpert and other cutting-edge diagnostics that are in development so that we can deliver economies of scale and lower the costs of these important interventions. This would essentially replicate our experience with vaccines and with antiretrovirals.

But even if TB is accurately detected, our current treatment regimens require direct observation and long courses of treatment, up to two years for MDR-TB as you know. This makes patient compliance challenging, leading to incomplete treatment and further problems with resistance.

Late-stage clinical trials of short-course treatments are currently underway, and within a few years should be registered and ready for use. The shorter regimens will result in improved adherence and higher cure rates, decreasing transmission and drug resistance. So USAID will strengthen its capacity to assist the development of these new courses of treatment. But we also need NIH, CDC, WHO and so many other partners to focus on dramatically reducing the length of the therapeutic regime, and on integrating TB control more effectively in existing health systems and existing points of reach and touch for people who suffer from disease in resource-poor settings.

Together, if we can craft a new approach to TB based on these new technologies and new treatment approaches, we can actually turn the tide and see the endgame over time.

The most important letter in the acronym PEPFAR is “E.” When the previous administration introduced the program – and I know many of you in the audience here were a big part of putting it together – the world truly was in a state of emergency. HIV was killing 2.1 million people annually. And infections were raging out of control, ravaging sub-Saharan Africa and leading to significant drops in life expectancy.

PEPFAR's push to treat HIV-positive patients has saved millions of lives. And crucially, it has given the world a sense of optimism that the war against HIV is a war we can win. But to win that war, we must now engage on additional fronts. Having achieved success in our campaign to treat millions with antiretrovirals, we now should sharpen our focus on evidence-based prevention strategies to reduce the number of new HIV infections.

Our administration, led by Ambassador Eric Goosby, has conducted an analysis describing what it would take to turn the tide on HIV, bringing the current number of new infections below the number of patients treated.

First, we must start with behavioral campaigns aimed at curbing risky sexual practices, similar to the successful models we saw in the 1990s in Thailand, Senegal and Uganda. More recent data from sub-Saharan Africa validates that rapid declines in HIV infection rates have primarily been associated with these types of behavioral change, delaying sexual debut, reducing the number of sexual partners and practicing safe sex.

The greatest potential for future rapid declines in HIV lies in supporting these population-level behavioral shifts. Here, last year's landmark CAPRISA trial provided us with a preview of the next big breakthrough in this fight, a gel microbicide. Empowering women with this powerful tool, we can counter the pernicious gender imbalance that limits a woman's ability to protect herself from the risk of transmission.

Now, there's been some debate about the next step for the CAPRISA program. The reality is, like contraception, women should have many different options and many different microbicides available to them through health systems, through private-sector mechanisms and through community-distribution channels. We are committed to working with FDA, NIH and the government of South Africa and others to accelerate further testing, regulatory approval and availability of this and the full range of potential microbicide products. This is a transformational breakthrough in HIV prevention. And we all need to act with a much greater sense of urgency to achieve results.

USAID will also embrace the success we've witnessed in reducing HIV infections through circumcision campaigns. In fact, it was NIH that first discovered the dramatic effect circumcision could have on limiting the transmission of HIV. We are now supporting the government of Swaziland's bold strategy to circumcise all eligible men within a one-year timeframe. We've been surprised pleasantly at the success we've already seen in attracting teenage and adult men to join these programs, proving that this innovation can work at scale if we are more aggressive about getting it out there.

We will also need to strengthen attempts to reduce mother-to-child transmission of HIV. The power of this intervention is very clear. In the developed world, ARV treatment and safe infant-feeding practices have virtually eliminated pediatric AIDS. We can achieve that same result throughout the developing world by focusing on more aggressive community outreach for PMTCT programs.

In South Africa, we fund a program called mothers2mothers, training women who have received PMTCT to promote its own benefits and fight social stigma. We know these programs work. And we can scale these programs more effectively.

Finally, we will need to look to the future. We were encouraged by studies driven by NIH research that showed ARVs taken as prophylaxis could reduce HIV acquisition amongst men who had sex with men by as much as 44 percent. USAID will work to ensure we bring the ARV PrEP as well as microbicides to market as soon as possible. And we will continue to support IAVI to build on the really important results in last year's Thailand studies.

You know, last November, my third son – third child, second son – was born at Sibley Hospital not too far from here. And to date, he has received all of his basic vaccinations right on schedule. And even though some of those shots stung, they will help protect him for the rest of his life. Today, because of success and because of GAVI, in addition to others, 90 percent of all children born in Tanzania will receive those same vaccines. They will receive the same protection and their parents will experience the relief I take for granted, knowing that their child won't needlessly die of a preventable disease.

But while my son received his vaccine at the hands of very well-qualified doctors, between the walls of an outstanding hospital, a Tanzanian boy is more likely to receive his doses in a village, administered by a community health worker. To be successful in global health, this is a paradigm we must embrace. A world-class vaccine does not need to be delivered in a world-class hospital for it to be effective.

Our experience with GHI has made very clear that our largest opportunities to improve human health and the human condition do not lie in optimizing services to the 10 to 20 percent of people in the developing world who have good access to world-class facilities. They lie in extending our reach to the 80, 90 percent of people who do not.

That is where the success of everything I've discussed today will ultimately be determined. That is our battleground. And I'm proud to say that is where USAID will try to lead the fight.

But doing so will require a change in our own mindset. We cannot focus exclusively on delivering services with current tools and technologies or with a focus on Western medical interventions. We need to focus much more on inventing solutions that extend the reach of health in the poorest settings on the planet.

So we will set goals, design strategies and cut the time it takes to transform discoveries in the lab to success on the ground, shortening the distance between bench and bush in everything we do. We will develop at USAID a center of excellence to accelerate product development and field introduction, bringing in industry experts and academic fellows to inform our thinking and investing seed capital in promising ideas wherever they're found.

There's been a huge amount of progress in the last decade in the knowledge of how to aggressively scale new interventions and technologies and we want to capture and harness that. We will work with firms to make sure their biomedical products can reach the poorest people in the poorest countries. And we will leverage our commodity procurement systems to prioritize buying new technologies so that we can get volumes up and prices down in more creative and innovative ways.

To keep us all focused on whether we really are changing the field of global health, we will release an annual accountability review of global health technology, detailing product introduction and adoption and identifying those areas where we can accelerate progress.

And finally, across this next year, we will unveil a series of scientific and technical challenge grant programs, designed to focus the community on inventing the breakthroughs that can truly span the last mile. This will range from efforts to invent new ways to empower community health workers with foolproof diagnostics, to using mobile phones – (audio break).

Our collective efforts have led to real, concrete results: that the majority of all children around the world have access to – (audio break); that through voluntary family planning services and new contraceptives, we've literally averted tens of millions of unintended pregnancies; that nearly all childbirths are attended to by skilled health workers, increasingly empowered by new technologies and new approaches; that declines in malaria are so dramatic that African nations and their health systems are now more focused on non-communicable diseases than on treating kids that have malaria; and that we turn the tide against HIV and TB, just as new microbicides, diagnostics and short-course treatments are entering marketing and distribution channels and scaling up.

But for me, the real sign of victory will be looking into my son's eyes and knowing that children born throughout the world have a chance of leading the same type of healthy and productive life. I know that that's what motivates all of you to pay attention to global health and to commit yourselves to it. I know that that's why Dr. Collins has created the new global health program and institute here.

And we look forward to being – (audio break) – Dr. Collins has created the new global health program and institute here. And we look forward to being a partner with you, as the inventors and the visionaries who can define the future to create the solutions that will allow us to succeed. Thank you.


DR. COLLINS: Do you want to take some questions?


DR. COLLINS: Thank you, Raj, for an inspirational presentation. It's a rare opportunity indeed to have the USAID administrator here. Even though we got a little bit of a late start, I hope we can participate in some questions and answers. Microphones are in the aisles here; I would encourage you to approach one and pose a question to our speaker. Yes – beginning over here.

Q: My name is Sulma Mohammed; I am from Sudan. And because of this vaccination, I'm alive today. I'm a professor at Purdue.

And I got malaria at least 20 times. And I know how painful and how dreadful is that disease. But women my age and – women my age and younger: We are facing with a new problem. We are getting breast cancer and cervical cancer and we're getting it at younger age and we die very young from it. And this is problem with my sisters, who are in Africa right now.

So I wonder what (sic) the international organization and the government in Africa is still ignoring or not admitting that cancer is a problem.

ADMINISTRATOR SHAH: Well, let me just thank you for that comment, both for the inspirational story about malaria and vaccines and for the very accurate reference to cancer. I was reading Julio Frenk's lecture here last year, where he made the case that in fact, the non-communicable diseases are the next great frontier.

And I agree with that. But I also believe strongly that we have to make the most cost-effective investments over the course of the next decade to essentially finish the job that so many of us have been working on for the last couple of decades to really tackle the basic communicable diseases.

And the fact that there's so much low-hanging fruit in those areas and that the technology frontier is so rich now – that if we can solve this problem of how can we get the newer vaccines introduced? How can we get community health workers seriously empowered? We can put that era of global health history to bed and that will free up resources for health systems and donors and other partners to really turn to that next frontier of non-communicable diseases. So I don't mean in any way to invalidate the significance of that. But I do think for us and for the Global Health Initiative, staying very focused on seeing this job through is our top priority.

Q: I just wanted to add, from the NCI, that there are vaccines now – cervical cancer vaccines.


Q: That's a low-hanging fruit that you can work with – on – as well.

I did have a question on south-south collaborations. And I was wondering what USAID was doing at all to try to partner regional collaborations between countries, rather than U.S. working – you know, multilateral, more collaborative atmosphere in your work. And if you touch on that –

ADMINISTRATOR SHAH: Well, thank you for that. You know, many of the partnerships we get to be a part of, whether it's GAVI or Stop TB or some of these other programs, essentially facilitate a great amount of south-south learning, south-south partnership.

I don't even know if we should be calling it south-south anymore. When I look at the innovation – if you look at just global vaccine production, most of it, especially the low-cost, high-quality products that power the international system, come from Indian manufacturers. When you look at the types of strategies and interventions for empowering community health workers with mobile-based technology or with medical services that they can put in a backpack and walk around with, a lot of the most innovative efforts are happening in Bangladesh and Nigeria.

I just think that we have to dramatically expand the scope of who we think of as an inventor in order to usher in the technology and the ideas that will help solve this problem in very resource-poor settings. And the fact that some relatively resource-constrained countries are on that frontier is often the first place to look for those types of solutions.

I'll venture to say something else a little controversial for my own team. Most traditional development agencies are not set up well to ferret out those innovations, inventions and take them to scale. It's harder for us to fund local partners in countries.

And I've launched a very aggressive procurement reform, which I know sounds a little bit mundane. But it is actually quite critical to allowing us to provide that small seed capital free from constraints, without 25 different objectives that have to be listed so that someone who's creating an ambulance-referral system outside of Mumbai can figure out how to do that at a price point that will ultimately scale in other parts of the world.

And we've brought partners like BRAC, the Bangladesh Rural Advancement Committee, to Afghanistan and to Africa because a lot of times, they're pioneering those efforts.

So I appreciate that point. I think we can do a lot better.

Q: Thank you very much. I'm Randan Gupta (ph) from NIID. I just wanted to say, first of all, thank you for the lecture in which you covered a lot of excellent points. There was one thing I wanted to bring to your attention. In many countries around the world – developing countries and middle-income countries, there's oftentimes lack of information.

I work with South Asia region – I mean, just in India, which seems to be more developed than many other developing countries, you do not have access to – a person on the street does not know what is HIV, even today. And when they get the information, they get wrong information from a friend or somebody else. In hospital, I've seen people at this last stage of tetanus because they didn't know that they were supposed to go to a doctor and get a shot when they were bitten by a – rabies – bitten by a dog.

So one thing which we do very well here in the United States and in Asia as well is we have so much printed material. You can go to a doctor's office and while you're sitting there, pick up pamphlets and read about what is flu, what is this or that. And that sort of information is lacking there.

I know we are doing a lot on e-health. But I think one way that NIH, USAID and others can work together is work with local governments to print and disseminate very simple pamphlets of information that people can access, even when the subject is taboo – that they feel afraid to go to a clinic but they know somewhere else neutral – like HIV – where they can pick up a pamphlet and read it on their own and learn about it. That would be very helpful, I think. Thank you.

ADMINISTRATOR SHAH: The point of getting information to people who need it and benefit from it is such an important point. There's of course a decades-long history that has been studied about the value of pamphlets versus oral communication and what makes people really listen and pick it up.

Just give you one anecdote: We launched an agriculture program in India. Most of the very small, very poor farmers we're trying to serve are not literate. So when we were trying to get them information about which seeds to use and which fertilizers to use and how do they make those kinds of decisions and who do they turn to, we launched a partnership with a company called Bharti Airtel that probably has more than 100 million cellphone accounts in India.

They reached, in less than a year, 8 million smallholder farmers. And they had a voice recording and so farmers could basically call in and hit one for information about different seed varieties, two for information about a fertilizer, three for weather. And the farmers pay for it. They pay for – you know, pennies per interaction. And I think if we're really creative about the thinking about how we want to reach the people we're trying to reach, the mobile phone is the thing that has changed their lives the most over the past 15 years.

And if we can invent solutions like that, that might be the most effective way to reach them, as opposed to – not that – it's not a bad idea – but as opposed to a more traditional way of moving paper and pamphlets.

But, again, the health system isn't exactly on the frontier there. There are some great examples but we have a long way to go.

Q: Hi, I'm Linda Wright and I'm the scientific director for the Global Network for Women's and Children's Health Research. And we have been working on the information that you mentioned on helping babies breathe – we did FIRST BREATH –


Q: – We got the data on misoprostol and oxytocin. So I want to thank you for recognizing that but also for emphasizing the need for collaboration. We've been working with Fogarty and our newest partners are USAID, to work with the helping-babies-breathe rollout. So I'm hoping that you will very much encourage this collaboration to really coordinate research efforts and make it more cost effective.

I also want to congratulate you for the new emphasis on mental health. It's really an emergency in Afghanistan, especially. And we've started working with USAID on that area. Certainly, cancer is critical. But mental health is affecting millions and millions of world citizens.

ADMINISTRATOR SHAH: Thank you on both fronts. On the collaboration point, I would just say that I think one of the reasons I was so excited to come here and deliver this address here is that I think this collaboration is the most one we can build on behalf of the poorest communities in the world. I think linking the inventors and the scientists to the nature of the problem and turning USAID into a platform that can scale new interventions faster is the strategic direction we want to go.

And in each of our areas – in each of our strategies, we've invited NIH staff to come to our strategy reviews that we're conducting between now and May. We want to hear your ideas. We want to build those partnerships. And we, frankly, want to push ourselves and the community of people we work with harder to get their – to get them to be a little bit more open to – a lot more open to rapidly scaling new interventions and new technologies.

Looking at it from where I sit, the global public health space is relatively conservative and risk-averse, often for good reason – that the new things are a little bit less proven and sometimes more costly. But if we don't scale introduction quickly, we're never going to get the costs down and learn enough to overcome that. And you have a chicken-and-egg problem. So I appreciate your point.

MR. COLLINS: We'll take two more questions. Over here.

Q: Hi, my name is Mandy Slutsker. I'm with ACTION – it's Advocacy to Control Tuberculosis Internationally. Very excited to hear you talk about the new diagnostics available in TB and I was wondering if you could describe in a little more detail how USAID is going to make GeneXpert available at field sites.

ADMINISTRATOR SHAH: Well, that's what our team is working through right now. I had a chance to visit a number of our multilateral partners in Geneva. Part of the answer is we need support from the Global Fund and we need support from the Stop TB Partnership and the international procurement facility.

But part of the answer is, we can be an advocate for that. I've had the chance to be in this field from the position of a private foundation – the Gates Foundation – and I noted that it often felt like the public partners were not the most vocal advocates for getting the newest interventions and technologies into the system, even though the public partners often funded and had relative control over a bigger piece of that system.

So I don't think it'll happen right away. But I think we can use that as a test case and see if we can drive it through a number of different vehicles and be more aggressive about it.

Q: Thank you very much, Dr. Shah. That is a very inspirational lecture. I really enjoyed it right from the maternal and child health all the way. And I was quite pleased at the way – when you'd come to the issue of the non-communicable disease. And while it is important to address issues of HIV/AIDS and infectious disease and when we are conquering this, we are going to have people living with these (endangering ?) diseases and with appropriate timing, coming up with a U.N. summit in the next few months.

Now, you also touched upon an important fact which I really appreciated it – that is on the community health workers, to empower them. I think if you want to make the change in global health, I think that's a route that we all need to look into it.

And in this regard, how can NIH as a whole work with USAID to empower community health workers, not only to deal with the communicable disease but disease as a whole, including communicable and non-communicable disease?

ADMINISTRATOR SHAH: That's an excellent point. And we have a lunch, I think, after this and we're going to dig into that. What I think partners like USAID should take more responsibility for is defining the targets and saying look, we have thousands of community health workers trained and working with us around the world. But we need your capacity to invent solutions, to do research, to understand what's feasible to increase their level of capability and capacity.

And part of that is this mindset shift, that if we're – if our mindset is based on kind of in-facility, Western models of care, we're going to be less inclined to think about how do we invent around community health workers as the solution as opposed to replace community health workers as the problem.

And then one other thing about that is we actually have some history here. We have decades of research of working in this space. And a common mistake has been just layering on community health workers more and more responsibility without giving them the tools that make them more capable.

So that's why I'm so focused on what are the tools and technologies? How can you leverage the fact that they are now connected to the Internet and have mobile phones to make them more effective? What are the literal technologies you can put in their backpack that allow them to be more powerful at the point of childbirth or at the point of interaction with a young child?

And that's what's changing. And so if we can invent solutions around that and if this massive engine of research and innovation can focus on that with the same intensity with which you might focus on a laboratory diagnostic test, that's a huge, huge, huge win for the world.

MR. COLLINS: So, Dr. Shah, I think we all really have been inspired by your view and are grateful to you for the public service that you're carrying out. Having a scientist at the head of USAID with the vision and the optimism that you've shared is truly something that we can embrace and look forward to working even more closely with you.

It's been said that hope in every sphere of life is a privilege that attaches to action. You've given us hope but you've also given us a lot of action. We want to thank you. Please join me in thanking Dr. Shah. (Applause.)

National Institutes of Health, Bethesda, MD

Last updated: September 26, 2017

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