FEMALE SPEAKER: Good morning. Were going to be starting this session very shortly. Were pleased that so many people are here for this special session with Bill Gates and Bill Clinton. So if we could have everybody take their seats, they should be coming momentarily. People in front, make sure that you stay seated so that the cameras are able to get the best shots of the session. Thank you.
Okay, all right, thank you. Welcome to this special session. As you know, this is going to be a session, a conversation with Bill Clinton and Bill Gates, two men who have made the fight against HIV/AIDS their highest priority for the work of their respected foundations.
The moderator for
this session will be Charlayne Hunter-Gault. Charlayne Hunter-Gault is
a pioneer, awardwinning journalist who has worked in every medium over
the last 40 years - print, broadcast, radio and television - for The New
Yorker, New York Times, PBS, McNeil-Lehrer, and NPR and was
a CNN Bureau Chief in Johannesburg, where she
I continue to be astounded each time I go on the road and see, up close and personal, the toll AIDS is taking, especially on women, as Bill Gates pointed out yesterday. Women are the face of poverty. Women are the face of AIDS in Africa.
And as I look at the reports on AIDS around the world, while Subsaharan Africa have the largest number of people living with HIV and AIDS, the continent is not alone in this near-unimaginable misery. So unimaginable that it seems clear to me that it would take the greatest imagination and ingenuity to chart a course for the road ahead.
With us today are two men who have both the imagination and the ingenuity. Before I introduce them, let me take care of a couple of procedural details. If you have questions for either or both of them during this session, please write them on a piece of paper. There are supposed to be ushers, ubiquitous, who will receive those papers and get them to us on the stage and I will ask the questions on your behalf. We will get to as many as time allows.
Now to two men who need no introduction. Therefore, their introduction will be brief.
Bill Gates, chairman of Microsoft Corporation and cochair of the $62 billion Bill & Melinda Gates Foundation, has made AIDS a key focus of the foundation and focuses on a favorite theme of mine, both he and Melinda do this, and that is that you have to go there to know there. He has been to where the problems are and he has not hung his head or wrung his hands, as many of you know or may have read about in his opening address to this gathering on Sunday. Moreover, he has pledged to devote most of his time to this and other good causes by 2008 when he will relinquish his hands-on position at Microsoft and apply them to helping the worlds people help themselves.
Since leaving office as the 42nd president of the United States, Bill Clinton has also been there to know there the world over. Through the Clinton Foundation, the President is focusing, as they say, big-time on HIV and AIDS with an initiative that aims to make AIDS treatment more affordable, especially in developing countries, concentrating also on treatment and prevention. The foundation has programs in more than 1,500 countries. Gentlemen, first of all, thank you for being here.
Given all of the problems in the world today, starting with you, President Clinton, why have you chosen AIDS to spend so much time and energy on?
Everybodys got that. Lets give them a hand.
Thank you, thank you. I think we got that. You got it? We got it. President?
We do need a lot more nurses and [applause] our foundation actually is hiring quite a number in Kenya, working with the government for that.
To go back to the
question you asked, it is difficult to imagine how the world can grow
together and overcome the instabilities and inequalities of global interdependence
unless something serious is done to turn the tide on AIDS,
Two, its a breathtaking human tragedy. Most people dont die of it in rich countries anymore and most people who get it in poor countries do, and its unacceptable.
The third reason I got involved in it is that I believed that there were things that I could do because of the life experiences that I had had. Even though I didnt have a lot of money, I had some bilateral donors who were helping me. And now we have, of course, the Global Fund and the PEPFAR Program, Bill and Melinda Gates and their foundation, and all these wonderful people involved in this.
A lot of these countries didnt have organized responses. The market for medicine wasnt organized. We got the price of the first-line drugs down now to as low as $120 per person, per year. The market for the initial test wasnt organized. The market for the testing equipment and evaluating whether the medicine was there or not, not organized. The cost of the pediatric medicine was prohibitive and nobody had done anything yet about the second-line drugs, which we are negotiating lower prices for.
So I thought I could help do all this stuff and help people set up systems that would work and treat more people. We can talk later about what needs to be done on prevention and all that and Bill and Melinda and what theyve done with microbicides is, I think, unbelievable. But what I wanted to do is just try to stop people from dying that didnt have to die and to give these countries a chance to have a future. I thought we could do something nobody else was doing and so I did it [laughter] as best I could. I cared about it when I was president. I cared about it when I left. But it seemed to me that we could never really bring the world together with all these things dividing it unless we could get ahead of this AIDS epidemic, and I still believe that.
As we learned about that, we found out that the healthier the environment, the more it promotes the idea that you dont have to have a huge number of children to be sure that youre going to have support in old age. So we moved in to help and were stunned to find that things like diarrheal diseases and respiratory diseases really werent getting the R&D focus, that despite the wonderful advances in biology that were giving us opportunities to do great medicines, that that wasnt being exploited for these infectious diseases which, in fact, account for the big disparity between developing world and rich world.
So once we got into that, of course, AIDS got onto the agenda. In an epidemic like AIDS, the sooner you act, the more the impact is unbelievable because for every case you stop today, it literally stops dozens of cases that will take place later. So the sooner you can get in with new tools, the better. In some ways, AIDS is the most cruel disease of all, because between the time you get sick and the time you die, youre suffering, youre using up economic resources, youre in the prime of your life and, in many cases, the chance of infecting your partner is extremely high and that has a huge impact on your children. So we really can't achieve goals of giving these countries a chance to share in the great largess that rich countries have gotten used to unless we address this epidemic. It is one where organizing things It doesnt happen naturally. The people in need dont have money to cause the normal sort of capitalistic response that you would expect, and so it takes people like the Clinton Foundation to come in and look at the testing costs and drugs costs, or perhaps us coming in on some of the research issues around microbicide or vaccine. It takes that kind of actor to come and get involved.
Secondly, in the United States, the infection rate is going up among certain discrete populations, I think because we acted like the problem was whipped. Like women of color, for example, are particularly at risk for a lot of reasons that are self-evident to people that are working in that area, but I think that is just a question of our tuning into it again and going after it.
By far, the biggest problem is in all the developing countries of the world. Ninety-percent of the people who are HIV-positive dont know it. Bill made a point yesterday in his presentation here that in spite of the fact that weve gone from 200,000 to over 1.3 million people, getting treatment, getting the ARVs since 2003, since the AIDS Conference in Barcelona in mid-2002 and then later. That is, only 20-percent of the total people who need the medicine to stay alive. With regard to children, were less than 20-percent, were less than 10-percent of the people who need it to stay alive. Even though the treatment is scaling up exponentially as we build the infrastructure, which is something I think we have to do, were still behind the eight ball.
I think weve got to continue to fight stigma. Weve got to continue to stop people from being scared of knowing their status and stop them from being afraid of being tested. If there is an aggressive effort against stigma and an absolute guarantee youll have the medicine, the cure you need, then we could have more people know their status and I think more people would be willing to do whatever isnecessary not to infect others. I dont see how were ever going to catch unless people are at least aware that they could be giving the virus to other people.
And were seeing a bit of data from Botswana, which was one of the earliest places in Africa that treatment got going, that you start to change the dynamic. There has always been the fear that as you get treatment to be broader, it could actually work against us. The fear of giving the disease goes down, so you see behavioral changes that actually work to spread the disease even more than it already has.
AIDS is not a field where weve turned the corner yet or solved the toughest problems. We have in rich countries, but that is not where the epidemic really is. In fact, if you look at some countries like India or Nigeria, there is this huge question of how big the epidemic could become there. Probably more people would get infected with AIDS in the future than have in the past. How could we change that? How could we prevent that from being true? Probably it is impossible without some new tools. Yes, condom use should cause the epidemic to go down, but we havent succeeded in that, except in very few cases - Thailand really being the only one that is clear-cut on that. If we had a tool for a woman to use, that we dont today [interposing] or the microbicide, I think that would change the course of the disease and that we would finally start to have years where we would see total less people infected.
Even once you get to that milestone, you still have more people that are going to be infected and you have all the people that you need to provide lifelong treatment to. So there is nothing simple about cause. It is not one people pick because they think theyll be solving things in any short time frame. It has to be a lifelong endeavor.
Melinda was better at asking about some aspects, perhaps. Wed say, well, how many do you use? But thats kind of a personal question. Anyway.
So there are trials going on. These are so-called first generation. There is a good chance that the first generation will not provide the impact that we want. There is a second generation behind that, but if we have to wait for that, were talking about four to five years before we have it. Oral prevention has also not gone as fast as it should, and we blame ourselves for not pushing that more. We need more trials. Some trials got started, got shut down, because all the understanding about getting people to understand how it was being done, wasnt done.
The second thing I
want to say about stigma is what were trying to do is to find people
who are recognized and respected who are HIV-positive and let them help
us fight stigma. In [inaudible] we have a former boxing coach who was
On the coordination thing, I would just only make two points briefly and Bill can maybe speak to this more than me. One of the most exciting things about having the Gates Foundation fund all this research and then get the gift from Warren Buffett is that it will increase their leverage to demand that anybody that gets the benefit of their investment share their findings and work together and coordinate and not waste money building empires when they could be saving lives.
One of the things that we try to do when we go into a country, about 60 countries can now buy medicine off our lowcost contracts, but we work in 25 where we try to build these kind of cooperative networks. We only go where the government asks and then were only interested in working with whoever else is there, if its PEPFAR, the Global Fund, if its the development offices of Ireland or Canada or whoever. I think one of the things we try to do is make sure that we are all working together because any other option is crazy, its ego over peoples lives. I mean, people will die insofar as we waste money rowing our own boat when we could be working together. People will stay alive, more likely, if we squeeze every last impact out of every last dollar we spend. But I think thats something that has to be done literally country by country and, in big urban areas, area by area.
But the point is I couldnt have done any of that and it wouldnt have been possible if there wasnt leadership. So it is really, really important that leaders are invested in this, but the leaders dont necessarily have to be the reigning head of government if you have a critical mass enough to create a cultural drift and, at least, the government doesnt undermine you with counterproductive policies. But a lot of this stuff has to take place in peoples heads and for that, you have to have leadership.
PEPFAR is a very measurable thing and it has had to get going very quickly. People had a lot of doubt about whether they would be willing to buy these generic drugs. Well, Ive sat there and seen cabinets full of drugs from India and South Africa that were bought by PEPFAR at these low costs that the Clinton Foundation has been so key in driving forward.
So on the treatment front PEPFAR is a great success and we need to get that story out there because there isnt the kind of grassroots support that would necessarily keep the U.S. donating at not only that level, but the increasing level thats needed unless we get that story out, that lives are being saved and that this thing is being run very well. On the prevention front, things are far more complicated because everything that weve tried. For example, education, education does not change behavior as much as wed like. Its a first step and its important, but it does not.
Country-by-country prevention has worked better in some places than others. It has worked in Uganda much better than, say, its worked in South Africa.
So I agree with what
Bill Gates said. I think PEPFAR, on balance, has done a terrific amount
of good. We work with them in many countries. The same kind of people
do that work for PEPFAR that would do that work for anybody else. By and
large, in most countries, theyve done really well. The big breakthrough
was when the president agreed to submit the
Now, on the abstinence education, I think we have to ask ourselves, What does the research show? Its not conclusive, but it seems to show that if you have an aggressive abstinence education program, it delays young peoples initial sexual encounters, but then when they have it, theyre less likely to be protected and therefore more likely to be infected. So its like everything else in this crazy field were working in. Theres a little good news and a little bad news.
What it argues for is that it is a good thing for young people particularly to have education and to promote abstinence, but an abstinence-only program is going to fail and in the end, youre going to wind up being in a cruel fix.
On the other hand, I think if you want to get the benefit of the American money and also if you want to get the benefit of the research and common sense, it is a mistake to walk away from that message altogether because it can help young people stay alive and have a longer period of time when theyre not infected. It is just that you cant do abstinence only, so we need a little bit of humility here, but I also believe that it is a mistake not to acknowledge that, on balance, this program has done way more good than harm, and I am personally very grateful for it.
But then again, when you go out and actually meet with the patients that are on treatment and hear about how theyre still teaching and raising their kids and spreading the message and things like that, it makes one very optimistic. Some countries have turned around the epidemic. Theres a variety of factors that tend to go into that. Just this male circumcision thing, a couple more trials have to complete, but its very likely that will be a helpful tool - not a magic bullet, but a thing that will drop the numbers down in a pretty big way.
India is a place where we got involved early in creating community in order to help influence behavior. It wasnt enough to just get the message out about condom use, you literally had to create community centers where people could go into and talk with each and meet with other people whod had similar experiences. Only when you had created that foundation, which meant starting from scratch to build a whole place to get together, then you had the context to talk about behavior change. That looks like it is having a real impact.
WILLIAM CLINTON: I agree with that, I completely agree that most of what works will work anywhere, but we do know that there is a different sort of psychology in the culture once you get beyond denial. I agree with Bill. We have denial most everywhere and we know that the systems that work will work most anywhere. But it is surprising, for example, if you look at that New York Times story or magazine story on the LoveLife Program in South Africa, it is interesting how messages that work in even one African country on the prevention side dont necessarily work in another. So we do have to be somewhat sensitive to that.
The second thing I wanted to say was that I dont know that I was surprised by this, but I think you can never repeat it enough. There was yet another study last week which showed that in the poorest African villages, people take their medicine at a stunningly high percentage.
The first time we found this, the first time we saw this was in Brazil where people didnt speak Portuguese. In all these little Indian villages up in the Amazon Valley, theyre all taking it. So one more time, we have driven a nail in the coffin of those that want to patronize the poor. Theyll live if you will give them the tools to live. Theyll do just fine.
Okay, can we address AIDS without addressing poverty in Africa, forgiving debt? Bill?
Certainly, debt relief has been a great thing - were involved in that and agricultural productivity - so the foundation looks at it in that holistic way, even though youve got to have tactics that are disease-specific.
America had certainly one of the biggest AIDS problems in the world when I was president. The death rate went down 70-percent. We turned it around, spent a massive amount of money. We did the ground work on creating the Global Fund, we established The Millenium Vaccine Initiative and we contributed 25-percent of all the funds contributed to international AIDS work when I was president. I didnt compare much when you compare what is being spent now to what was spent then. Thats called living backwards; we live forward. The person who controlled the foreign policy purses of the United States Senate wouldnt pay our UN dues. How can you say I didnt do enough when I tripled overseas investment and aid to HIV and AIDS? I think I did do a good job.
So we can look backwards, but we all have to live forward. I think its a great thing. Also, the Christian Evangelical community, which is the base of the Republican party, changed from anti to pro. They supported the Millenium Debt Relief Initiative, a lot of which went to AIDS care in my last year as president, and then they supported this new PEPFAR program and President Bushs initiative, and I think its wonderful. I think we should all just keep working together and do more and put one foot in front of the other and talk about what were going to do tomorrow. I did make a lot of mistakes when I was president, but that wasnt one of them.
So I think it is imperative,
to answer your question properly, that every country has a plan, that
its based on both the real needs and the realistic possibilities,
and then that some combination of funding be allocated to carry that out.
But we find ourselves doing more and more of this because you can't just
take these ARVs and go out in the country and drop them on a parachute
into a clearing. You have to have a health infrastructure. When you build
a health infrastructure, you also I will say it again improve
what can be done for TB, for malaria, for maternal and child health and
the whole range of other health care needs. So I think its important,
but it will really vary from country to country and region by region within
We have to work on second-line therapies as well, but the big thing is the personnel issues. How much of a doctors time or a nurses time? There are some special roles in terms of dispensing medicine, taking blood tests and things like that where you may not need a full-blown nurse to do some of these things. The actual operational approaches are probably different in the urban areas than in the rural areas. These community outreach workers, who know not just AIDS, but other diseases like TB, are very important in terms of how it can be done effectively in the rural area.
Were working with the Clinton Foundation on taking best practices and trying to find out if long-term cost is $500 when you combine everything together. Could it be $300? Could it be $100? That is really a very big question. The training capacity has got to be increased in these different countries, for both the broad roles and the specialized roles so that that doesnt become the bottleneck. So money is going to have to go into that.
Thats what we always try to do. The government has to ask us in and then we say, Okay, now lets come up with an AIDS plan. Then the government adopts the AIDS plan and then everybody is out there working together. I completely agree with what Bill said. I think these system issues are the most important issues in health care and, parenthetically, in development. If you look around this room, there is no shortage of intelligence and effort in the developing countries of the world, but there is a crying shortage of not only resources, but systems that reward effort. So to me, I think this is the number-one thing that needs to be done.
I hope Im pronouncing
the name correctly, S-H-A-M-W. As a youth today hes from
Canada I have learned that HIV
So making sure there is a broad base of support for that and were not dependent on just a few politicians thinking, Hey, this is a good thing. But rather, they know theyve got the backing to take those dollars and spend them that way versus the other budgetary priorities. That, I would say, is number one. So if youre in a developed country, you can make sure there is that broad understanding. In terms of changing African youth, if there is a chance where theyre visiting or if youre really willing to go spend large amounts of your time in those countries, there are lots of volunteer programs that let people get out and do that.
I would say that, in terms of reaching people in other countries, he just needs to remember that kids everywhere are really smart and theyre full of dreams until theyre crushed out. If he could build a sense of solidarity across continental, racial, religious and other lines and income lines so that young people could work together, be together, get to know one another and advocate for adequate funding and also systems that work, I think it would make a big difference. I think if the young people of the world spoke across the income divide that is yawning greater and greater as the days go by and said, We have the same dreams.Therefore, we deserve the same chances, that would be something really worth doing.
But thats okay; you dont have to go there.
I dont think I could be a politician here, but I should probably do more to support the government since theyve been so nice to me over here for the last five years.
So we, together with the Rockefeller Foundation, have a big new initiative to take the ideas of Green Revolution, which are better crops, advice to farmers about how to use those things and get those out there, that were initiating because we want the food to be grown in country. We want that farm sector to do very well.
Were actually talking to the Clinton Foundation about some of the possible inputs like fertilizer and could they take some of the same approaches they used on AIDS medicine and go after some of these farming inputs and as the volume goes up, make sure the full benefit of that goes into great price reductions and broad distribution. So, agricultural productivity is very important. That will drive these nutrition levels up. These different regimes of asking people to take their medicines will do better as you get rid of those problems. Even so, as the president said, it is amazing how good the compliance has been, despite people dealing with those problems.
Now, having said that, there is a lot more than we can discuss here about that; weve got to be very careful that we dont further deplete the top soils, erode the water supply, and undermine Africas sustainable development. But I think that if we can do this is the right way, improving nutrition will increase our capacity to deal with HIV and AIDS, as long as its not a smokescreen of denial, but another part of what it takes to give people a healthy life. Its a very, very important thing to do.
We have great partnerships with a number of the NGOs that specialize in getting into those environments and making sure that health care and the health issues are something theyve got the expertise and resources for.
In other countries in the world, outside of Africa, I think what Bill and Melinda Gates said yesterday is really true. The more you empower women, the more likely you are to have prevention programs that work, education programs that work and turn your infection rate back around. To the extent that women are underpowered, devalued, objectified and worked over, youre going to have higher AIDS infection rates. I think that is true outside of Asia, as well as within.
Now, we are having a very interesting time now in Papua New Guinea, which has half of all the languages still existent on Earth and an infection rate of 2-percent, perhaps the highest in Asia. There, you have traditional tribal, cultural societies in a rainforest environment that may be very different but, in most places, wherever women are devalued and not empowered, youre going to have greater AIDS problems.
But I will say again, the source of optimism is the human materials. There is no shortage of intelligence, effort, dreams or desires in any country in the world, none.
There is a shortage of investment, opportunity and systems that work. Look here, we can have thousands of people in this room because the sound system, the lights and the air conditioning work. These systems would be totally alien to half the people in the world. Thats what you have to keep in mind. If people can be rewarded for their efforts with systems that work, with investments, with opportunity, theyll do fine everywhere and that should be a source of hope for people everywhere.
And I think that its silly for people to be cynical when they ought to be hopeful.
Source: Transcript provided by kaisernetwork.org -- a free service of the Kaiser Family Foundation
Speakers for this session: