Transcript: Priorities in Ending the AIDS Epidemic

Female Speaker: Good morning. We’re going to be starting this session very shortly. We’re 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.

Credit: Lise Beaudry, IAS President Clinton and Bill Gates at World AIDS Conference 2006 Forum

Charlayne Hunter-Gault: But let me ask you this. Despite the fact that AIDS is stabilizing in some countries, even declining in some countries, including countries in the industrialized west, let alone in Subsaharan Africa where you have the highest incidence of AIDS, it’s on the increase. So given that kind of scenario, our topic today is the “Road Ahead,” but is it a rocky road we’re looking at or do you see any smooth places in that road?

President Clinton: Well, I think it will be a rocky road until we have a vaccine or a cure. But if you look at around the world, the Caribbean is the only region where the infection rates are dropping and there is a reason.

Charlayne Hunter-Gault: And why is that?

President Clinton: I think partly because it is small enough to get a handle on in different population centers, in getting medicine, doing education, doing prevention, doing care, the whole nine yards. I think they’ve really done a good job of that.
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 don’t know it. Bill made a point yesterday in his presentation here that in spite of the fact that we’ve 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, we’re less than 20-percent, we’re 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, we’re still behind the eight ball.

I think we’ve got to continue to fight stigma. We’ve 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 you’ll 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 is necessary not to infect others. I don’t see how we’re ever going to catch up unless people are at least aware that they could be giving the virus to other people.

Charlayne Hunter-Gault: Bill Gates, you have concerns about women and, as we know, the fastest-growing population of AIDS-infected people is women. They have the highest incidence of AIDS in the world. But how do you deal with stigma? I mean, even President Mandela, an icon to everybody in the world and who lost a son to AIDS, came out and said, “This is like any other disease. Come on, people, let’s get our status known.” And nobody is getting their status known. How do you overcome this stigma? Do you see any examples around the world where you go?

William Gates: Certainly having a treatment program in place that is broadly accessible does start to change the dialogue because then you have healthy people out in the community ideally talking about their status and saying, “Hey, if you get tested, you can get the drugs.”

And we’re 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 we’ve 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 haven’t 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 don’t today 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 who 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 they’ll be solving things in any short time frame. It has to be a lifelong endeavor.

Charlayne Hunter-Gault: But how far down the line is a female condom, or is the microbicide? The [inaudible] is already out there. How long do we have to wait for this?

William Gates: There are trials going on today. President Clinton and I were in Durban just in July and got to meet Gita Ramjee, who is running some trials there in Durban that are just unbelievable. We talked with some of the trial participants. It is always interesting to ask them, “How do you like the microbicide?”

Melinda was better at asking about some aspects, perhaps. We’d say, well, how many do you use? But that’s 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, we’re 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, wasn’t done.

Charlayne Hunter-Gault: Who’s to blame for that?

William Gates: Well, a number of people. We could have done a better job. Our partner could have done outreach to the community better. There were some activists who came in from Europe who spread some facts that weren’t correct and that really just really caused a huge problem there. We’ve got to put more energy into standing up to those things and making sure that the design is rock solid.

Charlayne Hunter-Gault: Bill Clinton, do you see enough coordination among AIDS activists and people like yourselves, the two of you and your foundations? Because it seems to me there is a lack of will here or a lack of coordination or something. What is it that isn’t pushing this thing or making sure that everybody’s on the same page so that you do not have these kinds of problems?

President Clinton: Well, I’d like to make just one point about this prevention thing first. I think that prevention programs are constrained for the same reason that CARE programs are, by not having networks in rural areas. Dr. Paul Farmer and others who have been working with us in Rwanda and elsewhere, the work they’re doing in [inaudible] and other places to bring health care out into rural areas brings you both prevention and the antiretroviral care if you do it right. The second thing I want to say about stigma is what we’re 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 his deathbed and is in great shape now. We have a woman who was a rape victim, a young woman, going out into rural areas telling everybody they should know their status. She is not ashamed and she is not going to be a victim for the rest of her life. I think we need to do that everywhere.

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 low-cost 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 we’re only interested in working with whoever else is there, if it’s PEPFAR, the Global Fund, if it’s 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, it’s ego over people’s 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 that’s something that has to be done literally country by country and, in big urban areas, area by area.

Charlayne Hunter-Gault: How important is leadership, governmental leadership, for example?

President Clinton: It’s real important, but it can come in different ways. I’ll give you an example. The Chinese were in denial about AIDS and then they decided they wouldn’t be and they turned on a dime. We had this big conference at Tsinghua University in Beijing and these government ministers came and shook hands with an AIDS activist for the first time. Ten days later the premier had AIDS activists in his office, and six weeks later the president of China was visiting people on their deathbeds in hospitals. They turned on a dime like that but, last year, the government called and said, “Would you please go out into these rural capitals and be on television seen playing with children and having lunch with people, because we still have all this stigma in rural areas?”

But the point is I couldn’t have done any of that and it wouldn’t have been possible if there wasn’t leadership. So it is really, really important that leaders are invested in this, but the leaders don’t 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 doesn’t undermine you with counterproductive policies. But a lot of this stuff has to take place in people’s heads and for that, you have to have leadership.

Charlayne Hunter-Gault: Now Bill Gates, you mentioned earlier condom use and you also mentioned PEPFAR. There is a lot of confusion, particularly in the developing world, about the conditionality, as they see it, on this money. Is PEPFAR and its conditionality a good thing or a bad thing? This whole issue of emphasizing abstinence and being faithful over condom use, is that helping or hurting the cause?

William Gates: Well, PEPFAR is overwhelmingly an incredible program, incredible in its scale. It’s now up at over $3 billion a year, and incredible in its impact. When we were in South Africa at the microbicide trial site, one fantastic thing that had happened was PEPFAR had funded a treatment center that was literally next door. So anybody who was the trial who contracted AIDS during the trial would immediately be sent over and put onto the treatment regime. That really helps drive research forward and the numbers there are pretty phenomenal.

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, I’ve 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 isn’t the kind of grassroots support that would necessarily keep the U.S. donating at not only that level, but the increasing level that’s 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 we’ve tried. For example, education, education does not change behavior as much as we’d like. It’s a first step and it’s 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, it’s worked in South Africa.

Charlayne Hunter-Gault: But, of course, in Uganda now there is a real de-emphasis on condom use and I understand it is having a negative impact on the incidence of AIDS.

William Gates: Most of those stories about those changes are overblown. PEPFAR comes in with money to do things. There is money from the local government as well that can take whatever the gaps are deal with those things. The increase in treatment that Global Fund and PEPFAR have caused — It’s great to have lots of ideas about how to improve those things, but the basic story of success there and how well that has gone should not be covered up. We need voters in Europe, voters in Japan, voters in all these different countries to feel good about what they’ve done because these are serious amounts of money and we need maybe three or four times as much before we get to the real levels.

Charlayne Hunter-Gault: President Clinton, the conditionalities that say you can't counsel abortion or you can't get money if you do abortions, or that you cannot put condom use on the same level as the other two of the ABCs - you said things have to happen in people’s head. Is that going to be a negative impact?

President Clinton: Well, first of all, let’s disaggregate this a little bit. As I understand the law, and I think I understand it, 30-percent of the money appropriated by the United States Congress for PEPFAR has to be spent in some form or fashion on abstinence programs. Now, 70-percent of what they appropriate is still a whole lot of money and still is more than most other countries appropriate. I think that is really, really important to emphasize. Thank you.

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, they’ve done really well. The big breakthrough was when the president agreed to submit the generic drugs to the FDA for approval and if the FDA approved them, then American taxpayer money could be used to buy them. That was a huge breakthrough and it has enabled all of us to save a lot more lives.

Now, on the abstinence education, I think we have to ask ourselves, “What does the research show?” It’s not conclusive, but it seems to show that if you have an aggressive abstinence education program, it delays young people’s initial sexual encounters, but then when they have it, they’re less likely to be protected and therefore more likely to be infected. So it’s like everything else in this crazy field we’re working in. There’s 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, you’re 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 they’re not infected. It is just that you can’t 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.

Charlayne Hunter-Gault: All right, I want to get to audience questions in a moment because I’ve looked at them and they’re fabulous. But I want to ask you one more question quickly, both of you, and maybe you could answer briefly. Have you seen anything out there that has surprised you, either in a good way or in a bad way? Bill Gates?

William Gates: As President Clinton said, this is a field where every day you find good things that are going on that make you optimistic, and then you’ll see where things have turned around and gone the wrong way. The fact that we haven’t been able to conquer mother-to-child because of stigma, because of the lack of getting things out there, the fact that we still have mother-to-child transmission is disappointing. We should be doing better on that. The fact that these drug trials, microbicides and oral prevention, haven’t moved further is very disappointing.

But then again, when you go out and actually meet with the patients that are on treatment and hear about how they’re 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. There’s a variety of factors that tend to go into that. Just this male circumcision thing, a couple more trials have to complete, but it’s 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 wasn’t 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 who’d 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.

Charlayne Hunter-Gault: I want to have Bill Clinton answer that question about surprise in a minute, but I just want to pursue one thing with you. Do you find a difference in culture — Of course, all countries have different cultures, but do you find that something might work in one country that doesn’t work in another because of culture? Do you have to have a multifaceted approach because countries differ in their cultural practices, their cultural attitudes?

William Gates: Not really. I haven’t come to a country where injecting drug use is easily discussed or men having sex with men or commercial sex workers. I hope to go to that country some day where none of those things are controversial or [laughter, applause] or hard to discuss, but we don’t really have that. So no country can really give themselves an A in terms of who they’ve pursued things. Even Thailand, which is probably at the top of the list, has had some recurrence-type issues and things that they need to stay engaged in. So these problems are pretty universal.

Charlayne Hunter-Gault: So in other words, back to the other question, if you have a greater coordination among the AIDS groups and the governments and everybody involved in this thing, you can have a general set of principles that would apply across the board. That seems to be what you’re saying.

William Gates: That’s right. The solutions that work and most of the tools are going to work on a global basis. If we can come up with breakthroughs, most of them will be helpful everywhere, even though it has to be people in the community that get word out.

Charlayne Hunter-Gault: Bill Clinton, surprises?

President Clinton: Well, first, let me answer the second one. I agree with that.

Charlayne Hunter-Gault: I love being on a panel with you and being the moderator.

President 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 don’t necessarily work in another. So we do have to be somewhat sensitive to that.

The second thing I wanted to say was that I don’t 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 didn’t speak Portuguese. In all these little Indian villages up in the Amazon Valley, they’re all taking it. So one more time, we have driven a nail in the coffin of those that want to patronize the poor. They’ll live if you will give them the tools to live. They’ll do just fine.

Charlayne Hunter-Gault: In the few minutes that we have left, I’m going to try and ask some of the questions from the audience. Here we have one from Ethiopia addressed to Bill.

Okay, can we address AIDS without addressing poverty in Africa, forgiving debt? Bill?

William Gates: Well, in the long run, what you want is all the things that we take for granted in developed countries to be available globally. That will deal with many of these problems. We can't wait until we have the solution to poverty to go in and take care of these health issues. In fact, by solving these health issues, we do change things and let that positive cycle get going. But in the long run, we should be measured more broadly, not just by the health measures.

Certainly, debt relief has been a great thing - we’re involved in that and agricultural productivity - so the foundation looks at it in that holistic way, even though you’ve got to have tactics that are disease-specific.

Charlayne Hunter-Gault: Do you want to add?

President Clinton: Yeah, I just think that if you first develop the health infrastructure throughout a whole country, particularly in Africa, to deal with AIDS, you will increase the infrastructure of dealing with maternal and child health, malaria and TB. Then I think you have to look at nutrition, water and sanitation. All these things, when you build it up, you’ll be helping to promote the economic development and to alleviate poverty. I think that you’ve got to have healthy people to grow and economy, so I’m with Bill on this.

Charlayne Hunter-Gault: This one is for Bill Clinton specifically and it’s asked by Victor Sierra [misspelled?] from Ecuador. You did not do much for HIV/AIDS during your presidency. Were the interests of powerful groups too strong? What are the lessons learned from that time for moving ahead with the AIDS fight?

President Clinton: First of all, that ain’t so.

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 didn’t compare much when you compare what is being spent now to what was spent then. That’s called living backwards; we live forward. The person who controlled the foreign policy purses of the United States Senate wouldn’t pay our UN dues. How can you say I didn’t 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 it’s 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 Bush’s initiative, and I think it’s 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 we’re going to do tomorrow. I did make a lot of mistakes when I was president, but that wasn’t one of them.

Charlayne Hunter-Gault: Thank you, thank you. This one is specifically for Bill Gates from Dr. Michael Sinclair from the United States of America. We all know his name. In your enthusiasm for new prevention technology, you do not see to give much priority to public media education and the behavior modification associated with HIV risk reduction. Would you like to comment on that?

William Gates: Yeah, I think the foundation is the biggest funder of media-based activities. Kaiser Foundation is a grantee that has done fantastic work reaching out to various media group. I was actually at the UN when we did a global media launch. We had all the big world media companies come in, politicians come in and talk about how, well beyond just sort of public service advertising, if you can get the story lines and the soap operas or whatever shows there are, radio and TV, if you can get the news people to understand the issues and report on them and really get people to see the scale of the epidemic in the country, you can make a very big difference. So part of the advocacy is that kind of media influence. It is a tool that is very, very important. I think in India, for example, we’ve got to have more reporting about the disease in order for things to change there. So it’s a very important element and one that, indirectly, we’ve put a lot into.

Charlayne Hunter-Gault: And, of course, you mentioned Kaiser; Dr. Michael Sinclair is with Kaiser. This next question is one I have seen up close and personal. The question is for both/either Bill. In LuSutu [misspelled?] and in Malawi and in Zambia, everywhere I went on my poverty series looking at AIDS, the doctors complained that they cannot keep nurses and doctors for that matter, but especially nurses. We’ve got this crowd over here. Just be quiet. We’re recognizing you. This is you issue. They can’t keep them — we got the point; we got the message. This is your question. How do you keep — and this is well phrased — how do we ensure that many more health workers are hired, paid and trained sufficiently and given the proper tools to do their jobs so that they can stay in their countries where patients need them? They’re immigrating to America, to England, everywhere [applause] and leaving almost no healthcare workers to take care of this AIDS thing, which is buckling the hospitals and health care facilities.

President Clinton: First of all, this really is one thing where there are country-by-country differences. For example, in India, where we both work, there is still a huge number of doctors in little rural areas because it has a unique place in India’s culture, but they don’t necessarily know very much about HIV and AIDS, so we’re trying to train, over a period of time, 150,000 of them. In other places, you have to get some doctors in. In Kenya, we have a big nursing shortage and the government has certain budgetary constraints, so we’re hiring nurses and training them. In Rwanda, Dr. Farmer’s group, Partners in Health, is training paramedical personnel, community leaders, because we know as a practical matter, there are places where we need a health presence and we’re not going to have a doctor or a nurse.

So I think it is imperative, to answer your question properly, that every country has a plan, that it’s 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 it’s important, but it will really vary from country to country and region by region within countries.

Charlayne Hunter-Gault: Okay, we got it. That was a very good answer and that’s your issue. Let’s hear from Bill Gates on the question of your issue.

William Gates: Yeah, I think it’s great that there’s recognition that the world’s capacity to treat people is not as much gated by the drug price now as it is by the personnel issues. Yes, the Clinton Foundation has helped get the cost down to $130 per person, per year, but it would help a lot if we could get that down to $80, or even $50, which would be heroic, but can probably be done.

We have to work on second-line therapies as well, but the big thing is the personnel issues. How much of a doctor’s time or a nurse’s 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.

We’re 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 doesn’t become the bottleneck. So money is going to have to go into that.

Charlayne Hunter-Gault: It’s like the microbicide question. What kind of time frame are we talking about, how urgently are people looking at these questions, and how soon can you see more personnel be made to stay in place?

William Gates: Well, a lot of the Global Fund and PEPFAR money is going into those training issues of creating the capacity. They run into that as a bottleneck. When we went into Botswana as long ago as ’99, the first two years I was very impatient with our treatment effort there, called ASHA [misspelled?] was slow to start up. It was all personnel-related, making sure that they understood how to deal with the special issues that come up in AIDS. So as these treatment programs roll out and smart people are involved in those things, they see that putting their money into those training activities and thinking about it holistically, not just AIDS by itself, is the way to create the best sustainability.

Charlayne Hunter-Gault: In the short term, Bill Clinton, is there a space for people outside of those countries who are experts, who have the training, et cetera, to go in while the homegrown, indigenous people are being trained?

President Clinton: Absolutely, but I think it works better if they go in with the local people, pursuant to a national and regional plan.

That’s what we always try to do. The government has to ask us in and then we say, “Okay, now let’s 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.

Charlayne Hunter-Gault: Okay, this is a question from what appears to be a wonderful young citizen, 15-year-
old Shamw Mohammed, Jr. [misspelled?] who is 15 and the founder of LetsStopAIDS.org. Let’s hear it for him. How about that?

I hope I’m pronouncing the name correctly, S-H-A-M-W. As a youth today — he’s from Canada — I have learned that HIV and AIDS play a key role in my lifestyle. I would like to know what would be your message to young activists, like myself, for commencing the inspiration and leadership to other children in the world. Bill Gates?

William Gates: I think it is a very tough problem, when you go to the townships in South Africa or some of these countries, to get AIDS to be the top issue that young people think about. They’re dealing with so much in terms of their education, will they have a job and the social environment that they live in, so the idea that it is simply, “Gosh, if they would just hear this one thing, that would change their behavior,” unfortunately, that doesn’t really get there. In rich countries, I will say that providing the dollar resources for things like Global Fund is probably the biggest contribution that rich countries need to make.

So making sure there is a broad base of support for that and we’re not dependent on just a few politicians thinking, “Hey, this is a good thing.” But rather, they know they’ve 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 you’re 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 they’re visiting or if you’re 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.

Charlayne Hunter-Gault: Bill Clinton?

President Clinton: First, I would say to that young leader, to his fellow Canadians and other young people that he might reach over the net in the developed world, he should tell them that they should care about this, they should lobby their governments to spend more money and that they should consider volunteering because it is hard to imagine that the world that he will grow up into and that he will bring children into will be the world he wants unless we do something about AIDS.
I would say that, in terms of reaching people in other countries, he just needs to remember that kids everywhere are really smart and they’re full of dreams until they’re 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.

Charlayne Hunter-Gault: I don’t know why this question is included and I really don’t want you to answer it, but I’m going to ask it because it’s cute. Would you consider being prime minister of Canada, Bill Clinton?

But that’s okay; you don’t have to go there.

President Clinton: I’ve come to Canada, I think, almost 25 or 30 times since I’ve been out of office, so probably what I should consider doing is checking with my accountant to see if I owe income taxes in Canada.

I don’t think I could be a politician here, but I should probably do more to support the government since they’ve been so nice to me over here for the last five years.

Charlayne Hunter-Gault: We have just three or four more questions and they’re really good, so I want to get to them. This one is for both Bills from Imad Osmann Scali [misspelled?] from Sudan. How can treatment be successful when people are malnourished and don’t have enough to eat? Why is nutritional/food support not financed?

Bill Gates?

William Gates: Certainly there is a need to improve agricultural productivity. The so-called Green Revolution caused in large parts of Asia, including India and China, the nutrition per person to go up very substantially. That was a big breakthrough in terms of wheat, rice and corn production and productivity. Africa didn’t get that benefit because of the variety of crops they have and the different weather environments there.

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 we’re initiating because we want the food to be grown in country. We want that farm sector to do very well.

We’re 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.

Charlayne Hunter-Gault: President Clinton, you must be aware that in Africa, South Africa, the minister of health has been particularly keen on nutrition, encouraging olive oil and African potato and things like that to boost the immune system. It has become the butt of the joke. Is this serious? Do you think that’s serious?

President Clinton: Well, I think nutrition has gotten a bum rep because some people have offered it as a substitute for antiretrovirals and care. But it doesn’t mean that it’s not important. It is important. If you can get a decent diet and have a basically healthier lifestyle and environment, than the medicine is likely to work far better. I think, to go back to what Bill said, that’s why we’re working in a couple of countries to try to increase agricultural productivity and increase the nutritional and caloric intake of people in the country. I think it will increase the overall health, as well as the income of the farmers.
Now, having said that, there is a lot more than we can discuss here about that; we’ve got to be very careful that we don’t further deplete the top soils, erode the water supply, and undermine Africa’s 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 it’s not a smokescreen of denial, but another part of what it takes to give people a healthy life. It’s a very, very important thing to do.

Charlayne Hunter-Gault: I apologize to the person who asked this question because I can’t read the middle name, but it looks like Mary Hower Night [misspelled?] from the International Organization for Migration. What can the major donors and leaders do to bring attention to population groups left out of national efforts for both prevention and care, such as migrants, refugees and other mobile populations?

William Gates: Whenever you get displacement, whether it’s from war or whatever it is, the health issues that come up are very dramatic. That’s where you’ll see epidemics of things like cholera that really, in normal conditions, don’t exist. So being able to jump in, in those conditions and having the capacity is very important.

A lot of the generosity generally comes after the disaster, but the best thing is to have the generosity before the disaster so that people are in place with resources and expertise and they can come in right away in the first week, say, after there has been a problem. Hopefully, we’ll have less of these conflict events that create migration in large numbers, but we’re still dealing with that, whether it’s natural disaster that you’ve been involved in or a war-type situation.

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 they’ve got the expertise and resources for.

Charlayne Hunter-Gault: Bill Clinton, unless you have something to add to that, let me ask you this other question. It comes from S. Carter of the USA. We’ve heard a lot already regarding HIV and women in Africa. Can you also address what needs to be done for African-American women and poor women in other developed countries? Separate out those two because in the African-American population, the thing is rising as fast as it is in Africa, it seems.

President Clinton: Let me just say that with regard to African-American women, I sort of alluded to that earlier. We know that the infection rates are going back up. We know that a lot of it is a result of it of African-American women being, ironically, in positions similar to that that women in some developing countries find themselves in, in terms of being infected by partners who themselves are HIV-positive, who may have gotten it from IV drug use, from other women, from being in prison, from all kinds of things and that they really are facing the same sorts of empowerment issues that a lot of women in developing countries are. And I think we have to go back and try to change that, as well as make a renewed effort on all the fronts we did back in the 1980s in America with the discrete populations. We’ve got to go back at all the things we did before that worked and try again.

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, you’re 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, you’re going to have greater AIDS problems.

Charlayne Hunter-Gault: I see the president and the convener of this conference about to hit the stage, so it means that our time is almost up, but I want a concluding statement. I have spent the better part of this summer talking about what I call the four Ds of the African apocalypse: death, disease, disaster and despair and how that influences the prism through which most people, especially in America, see Africa. When you talk about AIDS, that seems to fall right into that formulation, so if we talk about AIDS, are there any words that you can leave this audience with that says it is important to be involved in this, that there is an endpoint, that it isn’t all just gloom and doom? How do you motivate the public when all they hear about is the downside of despair in Africa and these developing countries or anywhere where AIDS is prevalent and rising? What’s the hope here and how do you mobilize people to be involved?

President Clinton: First of all, I would say that if anybody had ever been to Africa with us or India or Southeast Asia, they wouldn’t feel that way. I was just in Liberia, which was totally wrecked, totally wrecked by 14 years of the most abusive circumstances you can imagine and the lights don’t come on in the buildings in most places in the capital at night. But after we signed our AIDS agreement, I did a little town hall meeting with the President Ellen Johnson-Sirleaf and 100 of their college students. They were just as bright and informed and inquisitive and insistent as any group, anywhere in the world.
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. That’s what you have to keep in mind. If people can be rewarded for their efforts with systems that work, with investments, with opportunity, they’ll do fine everywhere and that should be a source of hope for people everywhere.

Charlayne Hunter-Gault: Assuming you agree with that, Bill Gates, how do you get that message out? How do you inspire people to be engaged in this fight that has so engaged the two of you and Melinda?

William Gates: Well, I think get-togethers like this one are critical, where you get the people who care the most and let them share what’s going right, what’s not going well, and let them after they leave this meeting go and get the word out. Go and get the word out to voters, to people going through medical schools that should want to get involved more in these world health issues, go to governments in the developing world and talk about how other governments have been doing things right. This meeting is a symptom of how people have decided that this is the worst medical disaster ever in history and we’re going to change those things. We’re not yet at the mid-point of the thing, but I get very optimistic with the side meetings with the scientists, the side meetings with the advocates here. There is a lot of energy here and time is on our side. Science will give us
these new tools - not as fast as we’d like - and we need to keep giving ourselves a hard time about that, but overall, this is a story that will have a happy ending because of the energy of the people at this event.

President Clinton: Let me just say one other thing. Bill Gates made a fair amount of money [laughter] by being able to imagine the future and helping to create a big part of it that we all accessed. Do you really believe that he and his wife would be giving all their money away and that naïve Warren Buffett would give all his money to them to give away if they didn’t believe not only that people’s lives were worth saving, but that they could be saved? That’s the best evidence, I know. He’s got pretty good judgment here. He’s not known for making bad investments.

And I think that it’s silly for people to be cynical when they ought to be hopeful.

Charlayne Hunter-Gault: Thank you, Bill and Bill.

President Clinton: Thank you.

Charlayne Hunter-Gault: Thank you.

Female Speaker: Let’s thank our moderator, Charlayne Hunter-Gault, Bill Gates, Bill Clinton — Thank you so much for this incredible session. Thank you.