[Auto-generated transcript. Edits may have been applied for clarity.] I need to say welcome to this day, to all of our students that are in class.
And then secondly, to everybody has decided to join us today online after this guest lecture.
So just to orientate our online participants, uh,
we are in the middle of our global health module as part of the Translational Health Sciences master's degree.
Um, we've been looking at ways in which different pieces of evidence can be used and translated across different contexts within global health.
Um, and we are delighted that you can join us for today's guest lecture.
Um, and Michal Warren is sadly not with us in person, but is joining us online.
Um, just to give you a bit of a background, um, on him.
So he's has over 30 years of experience working in the field of HIV prevention, working with researchers,
with advocates, um activists, and translating evidence between these different groups.
Um, I think that one of the biggest disruptions and most abrupt disruptions that we've ever seen, and it has recently happened with the funding cuts.
Um, to us, you have aid, um, and Mitchell's organisation, um,
which he's executive director of a buck eating one of the cold cases against the Trump administration.
So we are we are honoured and really excited to hear your perspective.
Thank you so much for joining us. Uh, we have a Q&A function on the chat.
So inviting all of our online participants throughout the talk.
You're welcome to submit your questions there. Um, we'll be presenting about 20 minutes to the session for responding to the Q&A.
Um, Mitchell, over to you. Thank you so much for joining us. Great.
Thank you. And just to confirm, you can hear me. All right. Thank you.
All right. I would so much prefer to be in Oxford right now for a number of reasons,
not least in which you are a couple of hours ahead of me for getting to the pub
would be a little inappropriate for me to go to the pub after this lecture at 1130.
Not unheard of, but probably not appropriate for my day. Um, so I'm a little jealous about that.
And honestly, right now, given and that. Thank you for that kind introduction.
Um, to be perfectly honest. And I'll just say it up front, I'd rather be pretty much anywhere than in the United States right now.
Uh, you are in the midst of studying what is arguably the most important topic,
I think, in, in general, which is translating science into people's lives.
And it has never been more important, nor, frankly, ever been harder than what has happened in the last 100.
And I think it's now 102 days. If you had told me that, I'd be sitting here,
standing here talking to you all 102 days into a U.S. presidential administration, which I knew would be terrible.
I'll just be honest, going to probably give you a bit of, uh, I'm not a particularly objective presenter.
I'll just put it out there at the outset. Um, if you had told me what would be the worst case in 102 days,
I would have described a pretty harrowing reality for public health, for HIV, Aids, for democracy.
But even I and I have a pretty good imagination.
Even I would not have imagined the speed and scale and cruelty that this administration has unleashed.
Uh, and and the idea that I'm even saying that is, is staggering to me.
Um, uh, I really thought we were ready for what would be a very hard for years,
and we knew there was a blueprint for what would happen, um, in that administration over four years, uh, called project 2025.
And it's very clear that that's what is the playbook for this administration.
But, um, I don't think anyone imagined that they would get this far this fast.
Uh, and, um, and somewhat unstoppable.
And, um, I'm I am not a scientist.
I'm not a political scientist. Um, I studied English, history, and women's studies, so I put that out there as a bunch of caveats.
And I'm an advocate. I'm opinionated. Um, I really want to encourage you, and I'll try not to speak too long.
I want to encourage you to challenge and ask any questions.
Um, one of the things about advocates is that advocates tell you the way things are from their perspective, as if they are absolutely certain.
Um, they're my opinions. I do believe I'm pretty evidence based in our advocacy.
I'm very proud of that a day back. Uh, but I do.
I'll probably say some things in the course of the talk that, um, may sound like, um, I know, or they are fact and they may actually be opinions.
I really want to encourage you all to to interrogate that and challenge it.
Um, I'll also say my work for and I'm kind of alarmed when I heard the introduction 30 plus years because that obviously ages me a tad.
Um, it's been primarily in HIV and Aids, so I'm going to use the HIV experience as kind of a lens in.
But I could do this about vaccination programs, about maternal child health programs, about contraceptive programs.
Uh, pretty much any of these issues are happening across our entire ecosystem of global health and development.
Um, I'll use HIV because it's the one I know to the degree I know anything.
And, um, but I think it is illustrative in terms of some writers.
So all of those caveats aside, I'm going to show some slides and jump right in.
Um. And I'm also in amongst all the things I'm not.
I'm also not an architect. But I am going to, you know, really focus on this idea of what the future looks like.
And I want to put that out there. I hope I get to the future,
because I think focusing on what's happened for the last 102 days of the last 44 years of the HIV response is is hugely important and informative.
Um, but it's only what we choose to do with that information that matters.
So I don't want to to only dwell on how bad things are.
Quick outline. I'm going to talk about what was what could have been the HIV response.
I got to talk about what, frankly, is the most. And this is the craziest thing of all.
We're in a moment of, I think, the most exciting opportunity in HIV prevention ever in 44 years.
And the idea that that's the big idea because of this new surreality, because the reality is pretty surreal right now.
Um, I'm going to argue what still could be and then and what we want to do going forward.
So it's a bit of time travel. Back in 2014, a lifetime ago, 11 years ago, the UN, uh agency, the Joint Agency for Aids,
UNAids, working with member states, put out these very ambitious targets for 2020.
And and in the blue box, that's what was modelled.
And the idea was that if we could reach 90% of these key populations, gay men, transgender individuals,
people who use drugs, sex workers reach 90% of adolescent girls, and young women deliver epic numbers of condoms.
3 million people on prep, all of these voluntary medical male circumcision procedures and funded it at a higher level than we were in 2014.
We could imagine the end of the epidemic. Models are wonderful models.
Tell you what could be. Models are not reality and what ended up happening in the course of six years from 2014,
when those models were set and what was actually implemented showed that we were really good at setting ambitious targets.
And we're really good in global health at missing the targets.
And you can see in HIV how how much we missed the most dramatic one of the lines at the bottom, this is about HIV prevention,
particularly the idea of trying to get from 1.7 million new infections down to fewer than 500,000 by 2020.
That was the target. And in fact, the world got to about 1.6 million.
So we had three times the number of people we hoped.
Well, we all know we hope no one gets infected. But the target to really get to what we think of as epidemic control.
And in classic, um, uh, political speak, when you miss a target so epically and so terribly, what do you do?
You set an even more ambitious target. So we went from failing in 2020 and the 2025 targets in 2030 targets.
Talk about even more ambitious scale up. Um, although this time this is an updated version from um after 2020,
a greater reflection that it's not just about condoms in treatment and prep and circumcision.
It's about the social and behavioural issues. It's about, um, laws and policies and human rights.
And so targets were set for that. Um, but again, this was established in 2019 and I don't need to tell you what happened in
2020 where everything went off track because of course of the Covid pandemic.
So this is what actually happened and where things landed in a really bad way.
Um, rather than getting down to that one point or that 500,000.
And the new target for 2025 is 370,000.
And you can see we're kind of stuck up here at 1.3 million, still far too high to have epidemic control.
What's on this side. And you can't really see the small print perhaps, is the number of people on treatment.
And you can see that the treatment target getting, um,
the vast majority of people living with HIV onto treatment was getting pretty close to the target.
But message number one in all of this is that no epidemic is defeated with treatment alone.
You have to prevent infections if you're going to look for sustainable, durable end of an epidemic.
So while the treatment target was getting close, we are far off on prevention.
And that was post-Covid world. Coming back to something, I don't want to think of it as normal because nothing's normal, but it was getting close.
And we were excited because this is the pipeline of HIV prevention.
Here are things currently available. Um, hopefully things you all know about in terms of primary HIV prevention as well as we know the treatment,
getting people on antiretroviral treatment who are living with HIV is also remarkable prevention because they won't transmit the virus.
And then, of course, clean needle programs, something that we've known for over 30 years.
And most political leaders around the world are too afraid to talk about.
Clean needle is prevention.
So we have these, you know, tools at the beginning or at the end of of available two products over the last three years that have been introduced,
a vaginal ring with an antiretroviral that is um, uh, um, uh, used every month and it kind of emits an antiretroviral to prevent infection.
And then injectable cabotegravir an injection that people can get every two months.
And the idea was those would scale up as we prepared for this next wave of products in development, another injectable called Lens Cap of Year.
And I'll talk more about that in a minute. And every six month injection, um, a different form of daily oral prep and a combination pill linking,
um, oral prep as we know it with combined oral contraceptives.
That's important because we know in pretty much every report, every study,
women talk about wanting both, um, contraception and HIV prevention in a single product.
And this would be the first new product since a product approved in 1993 that used to be made not far from Oxford in the United Kingdom,
uh, called the female condom. Hopefully some of you have heard of that.
Um, I promise I spent a lot of my career focussed on it, um, and got made fun of a lot for.
But that's a whole other story, a whole other presentation. And then behind it, um, are all of these products in product development?
Because one of the most important messages in all of this is that no one product, just like no one contraceptive, is perfect for all women and men.
No one HIV prevention option is right for everybody.
So we need a range of options. The more options we have, the more protection we get.
We know that quantitatively there's evidence to support that in both contraception and now in HIV prevention.
But um, other than this monthly pill, a single tablet that's going into a large efficacy trial this year,
pretty much everything else on this graphic over on this side in development,
almost all of these other products were being funded by the US government and have now been discontinued in the last 100 days.
So and I'm going to really I will get off of HIV and talk about some of the politics,
but the the implications of not having pepp far to deliver this on the,
on the far right and to not have robust research and development funding on the far left, um,
shows that we not only kit in the epidemic in the short term, but likely will get as fast as we could have and should have to longer term options.
So this zooms in a bit on these new infections. And you can see that the world was was beginning to make progress over the last 30 years.
But this is you know, all of that progress was since 2004, in the last 20 years.
And it began to slow,
but we began to have all of these new options that theoretically should put us a step closer to providing people things that would work for them.
And perhaps the most exciting opportunity.
And I actually I realise none of these headlines have the year. This all.
It seems like a lifetime ago, but beginning last year.
In June and September, we got results of what is quite remarkable this twice yearly product called lens cap of urine injection,
you get in the abdomen. In the trial in South Africa and Uganda amongst cisgender women.
There wasn't a single infection amongst those participants who were getting
let a cap of here that has never been seen before in an HIV prevention trial.
There were no infections in a in a sibling study amongst men in gender diverse,
gender diverse populations twice a year and then a cap of your same exact product.
There were two infections amongst thousands of participants.
Still the most effective prevention method we've seen.
Um, and and so a lot of last year was spent.
Other than worrying about the US election in November, a lot of the year was spent.
How do we translate this efficacy into effectiveness?
Because what happens in a clinical trial is wonderful.
It makes a great journal article in the New England Journal, but it doesn't prevent infections at scale.
It doesn't end epidemics. It's only when we translate that, and there are a number of issues about the challenge of translating it,
because our ability to deliver with equity and with scale, uh, to have impact, has been very limited in HIV prevention for 20 years.
We have squandered, frankly, every opportunity.
Circumcision, oral prep, the vaginal ring, injectable cabotegravir, all terrific prevention methods.
But we have not mustered the political and financial will from governments around the world, uh, to actually deliver on the promise.
But these trials last year really got people excited. We thought we finally were going to do it.
And then the end of the world as we know it.
One of my favourite R.E.M. songs, just for the record, um, uh, I think, you know, uh, R.E.M. says it's the end of the world as we know it.
Um, but that's okay. And I think I would rewrite those those lyrics today.
It's not okay. Because on January 20th, the very first day of, uh, the new presidential administration, um, amongst the very first executive orders,
and I realise I'm talking to an audience in the UK, our system, you know,
250 years, we broke from you all and we were doing pretty well until January 20th.
Executive orders are not meant to be the way you run a country.
We have a constitution. That's what we fought for 250 years ago.
And executive orders are meant to be the exception, not the rule.
But amongst the very first actions of the president was to, quote unquote, re-evaluate and realign United States foreign assistance.
As someone who's worked in this field for a long time, I believe every program should be constantly re-evaluated.
And we expect that, frankly, every political leader is going to want programs to realign.
But, um, not in the way that has happened. So that came out on January 20th.
And then basically, um, four days later, pretty much every program getting funded by USAID was given a stop work order,
told you should stop now, if they had said we're going to.
And the idea behind the the freeze was we're going to spend 90 days evaluating foreign assistance and decide what's in scope, what's not.
Is there waste? Is there fraud? How do we do it better?
And if they had said, then keep working for those 90 days, but know that we're evaluating everything.
People would have said, wow, this is going to be rough. Things are going to get cut.
But you know, we'll keep going.
But instead, on January 24th, four days later, the administration began to issue stop work orders on pretty much every USAID funded project.
And again, you probably know about that far. That's the largest HIV response.
Again, this is about foreign assistance. This is not HIV only.
This is vaccination. This is contraception. This is humanitarian assistance.
This is food relief. This is everything we think of as foreign assistance.
And um, a couple weeks later,
we joined in a lawsuit against the Department of State and an organisation called the Global Health Council joined an additional,
um, parallel lawsuit that was filed the day after ours.
So and this is a very jumbled slide with lots of headlines, but basically, we filed a lawsuit that said,
we understand that you can re-evaluate and assess foreign assistance, but the blanket freeze we said was unconstitutional.
And one of the reasons for that is in our country, Congress actually gets to decide how money is spent.
They have what's called the power of the purse. They then tell the executive branch that you have to spend money in these broad categories.
The executive branch, the president and the departments under him have a lot of latitude.
What to spend. But you can't just not spend the money because Congress said you should spend the money.
And that was the basis of our lawsuit. And we very quickly, three days later, got what's called a temporary restraining order,
which basically told the government, you have to, um, restart foreign assistance and release foreign aid.
Um, is what they said a couple of days later, and then we have at least we're and I am, uh, and this is a whole presentation of what Mitchell is not.
I'm also not a constitutional lawyer. I'm not a lawyer of any kind.
Um, but I personally will declare a constitutional crisis because in the midst of this,
Congress has either abdicated their authority because they haven't acted back and said,
Mr. President, you can't do that, or it's been usurped by the president, in either case, abdication or usurpation.
I would argue the constitutional crisis in this country, um, thousands of awards from USAID and State Department were cut.
Um, even after the temporary restraining order, which was a bit of a an end run around,
um, the the court order because the court said, go back to work.
And with the what the what the State Department did the next day was cancel almost all the programs that they had previously paused.
It basically told you that this idea of evaluating foreign assistance, a legitimate thing that should be done all the time, was really a fabrication.
It was there's no process behind this.
And one of the things about our court case that's still ongoing is that we've surfaced a lot of documents that show, and we've had now, I think,
nine whistleblowers from USAID who come forward anonymously to give testimony
that basically showed that there was never an intention to do this properly.
There was never an intention to actually assess and and evaluate programs.
It was a sense of just stopping everything.
And then, um, happily, um, after a month of back and forth and lots of lawyer documents and motions and replies,
the judge ruled that the 10th that the administration had to pay the USAID partners.
For January and February, at least for past work done up until the restraining order was in place.
And after a week or two in March of then dragging their feet, they did begin to pay at least some money some of the time.
And there's a link, and I'm happy to share these slides.
Um, we tracked kind of the the lawsuit on online, um, that um, they and this was kind of it and some of this,
if it weren't so tragic, it would actually be comical in the court.
The judge told the government to go back to paying, and the lawyer for the State Department said,
oh, well, we don't know how because we don't have any staff to do that.
And the judge said, that's not my problem, that's your problem.
And they ended up bringing back hundreds of staff on the admin side to process payments.
Now, what USAID used to be able to process in a day or a week has taken them now, two months since that order was made.
So they are clearly dragging their feet. And then, although they have begun to pay past bills, which seems like a pretty basic,
um, um, service of government to pay, they pay the bills that you've incurred.
Um, they did three weeks ago, uh, actually appeal, um, to a higher court.
We're in what's called the district court. There's a circuit court above us.
Um, they've appealed to that to throw the case out.
We are waiting to hear if that court's going to review it, and then we think it will go to the Supreme Court.
And this just shows you the appeal. They have made payments, they've made thousands of payments.
And we're very proud that we did do the lawsuit. I will tell you, it took longer than it should have.
We were ready to fight the lawsuit the day after it all happened at the end of January.
But we ideally wanted other plaintiffs to join us to make the case stronger.
And it took several weeks. And I think people have been very kind, you know, aback that you stepped up.
That's so great. Um, I'm really disappointed in a lot of my peer organisations.
Many of them are much larger than ever. Um, and, um, but it took us all three weeks to find the plaintiffs to join us in these cases.
And. For Avicii was actually pretty simple calculus, to be perfectly honest.
We're a small organisation. We do advocacy.
We believe that people have the right to choose prevention products, but the word choice is now politicised in this country to be about abortion.
And we do a lot of work with transgender communities. And then this new US administration is saying transgender people don't even exist.
They're being erased. So we knew that our work was going to be discontinued at some point.
There was no way this administration was going to fund a VAC to talk about choice and transgender rights.
So we didn't really have much to lose because we kind of assumed we were never going to get the money.
Um, and we didn't get the money. We did get paid a little bit for January in February.
But we've laid off staff. We've reorganised to be a much smaller organisation.
Um, but I believe we can still do things. And, and so people say to me, well, why did you say if you don't think you're going to get the money?
Well, we did it because we believed it was not about the money.
Our lawsuit is about constitutional rights of Congress to appropriate funds that the president can't just deny and say,
I don't believe in foreign assistance anymore, and it's not necessarily changing anything.
And as you may have seen in the news over the last couple of weeks,
the administration has informed Congress that they want to dissolve USAID and move it into the State Department.
For those of you in the UK, this is not a novel concept.
Them, as you know, the Department for International Development in the UK was merged into the Foreign and Commonwealth Office to become Fcdo.
That in and of itself is not a bad thing. In fact, President Clinton, a Democrat, tried to do the same thing many years ago.
So that's not the problem. The problem is not funding what Congress tells you to do, including a robust HIV response.
Why does it matter? So in the midst of all of this, within a week there was lots of outcry.
And Secretary Rubio, our Secretary of state, same thing, is kind of the foreign, you know, the, uh,
Minister of Foreign affairs in the UK basically said, oh, you know what, pep us continuing, I'm going to give it a waiver for life saving work.
Oh, but oh, life saving in his mind,
only treatment for some people and preventing mother to child transmission because everybody loves to help mothers and babies.
That's like mom and apple pie. That's not a robust, comprehensive, integrated, sustainable HIV response that leads to epidemic control.
And this is a slide from the HIV Modelling consortium that tells you why in orange,
if we don't have Prep or condoms or voluntary medical male circumcision,
not only will we not reach the target of reduced infections, but we're going to see us go back by 2036 to levels last seen in 2000.
Epidemics don't end unless they're ending like smallpox epidemics bounce back if they're not control.
We saw that with malaria. There's a whole history of malaria research that showed that people thought we succeeded.
They stopped doing certain things in malaria bounces back, TB comes back, HIV will come back.
And the the so-called waiver that Secretary Rubio signed excluded prevention except for pregnant and breastfeeding women.
And and that's not the lion's share of prep circumcision and condom users to state the obvious.
So you could imagine in the next decade, we will be back to things last seen in 2000.
Think about where you were in 2000, what you were doing.
Um, and is that really where you want to go back?
And maybe some of you were having your greatest years in 2000, but this is not where we want to go back to in the epidemic.
This is an example. So over the last, you know, we had pre-exposure prophylaxis or Prep a pill a day.
We have known since 2012 for 13 years.
We actually we found the first data in 2010. 15 years ago, we saw the first evidence that oral prep was safe and effective in preventing HIV.
And it was approved in 2012. And in 13 years, this just shows, um, uh, prep initiations globally since 2016.
And you can see that already five years after prep was approved, hardly anybody was using Prep anywhere in the world.
What happened here?
Well, 2021, of course, was in the middle of Covid, but this was when Pep FA's leadership said, oh my God, we've got to invest in Prep.
Took them a decade to realise it, but they did it finally. And all that.
Orange is Pep FA supported prep. And as of January 24th, Pep four supported prep.
No longer exists. Now we believe, and we think we know that, um, that, um, uh, Pep FA won't do it, but Global Fund,
the Global Fund to Fight Aids, TB, malaria and Ministries of health are actively looking at how to keep this momentum.
And there was already conversation even had Kamala Harris been our president.
There was conversation about moving funding, um, from Pep four funding to governments funding their own responses over the next five years.
It's the right thing to do in terms of sustainability, in terms of transitioning ownership, leadership, and we need to do more of that.
But you don't do that in in 100 days.
You do it in three, 4 or 5 years in a thoughtful, strategic way.
We should be re-evaluating and transitioning. You don't do it because these programs don't have on off switches.
And a lot of these prep programs in 2024, the switch was turned off in January at the most critical moment because again,
um, we're talking about planning for like half of year. So online you can find we have a website called Prep Watch that keeps things.
We think. We hope all things prep. There is now a downloadable resource on the impact of all of this stop work in these countries.
The countries listed here in Africa were countries that were beginning to deliver cabotegravir as every two month injection.
That's very safe and effective. The yellow these are countries that were partially disrupted, um, red totally stopped.
And um, and Zambia, the only country where that work is continuing with some similarity to what it looked like.
And you can click online to any country to see what's happening. And you can see the documentation here.
This is a disaster in the best of times with, um, with prep programming,
but it's happening at a moment of, as I said, of our greatest opportunity in history.
And I've been working in this epidemic for too long. I want to stop, um, when the epidemic stops.
This was our greatest moment. So Cabotegravir is up here. Small supplies, kind of expensive.
$160 per year in low and middle income countries. But along comes Lynnette Kapp of here.
This product again, in the trials that we've never seen anything more effective,
we believe it's going to be priced at under $100 per person per year at launch.
It will be approved by the U.S. Food and Drug Administration by June 19th,
assuming the Food and Drug Administration still exists in the next two months, and we don't have a guarantee of that because of Secretary Kennedy.
Um, but we expect that that will continue. It will likely get approved.
It's sitting also with the European Medicines Agency,
and the World Health Organisation is going to be releasing guidelines in July and in December, which again, lifetime ago in December,
Foreign Global Fund committed after a lot of advocacy from us and many others to commit to the largest,
most ambitious prevention program in the history of HIV to get millions of people access clinic out of here in the first couple of years.
And that that statement was made in December. Um, and a month later, of course, Pepp far it's not gone, but it's very different.
And we don't know. Global fund has said they're going to continue to support it,
but we should be we should be ready in the next 60 days to roll it out to people who want and need it and can benefit from it.
And now we're scrambling in a way that's unconscionable. Um, in addition, I mentioned before the monthly pill coming from a company called Merck.
Very exciting, because as great as Lynn is, I will tell you, at a health systems level, it's hard.
We need to bring millions of people who are otherwise completely healthy.
They need HIV testing and they need to get this injection in their abdomen, which is not without its pain and challenge.
Um, every, every six months. Imagine if you could giving people one pill every month, bringing people together for,
you know, the proverbial book club and giving everybody a single pill.
That's a study. We don't know if the product is going to work, but if it does, it may be a more feasible program and, uh, product to deliver.
And then, of course, for women of reproductive age, this idea of the dual prevention pill hugely opportune.
Not since condoms have we had something that does both things. And that's also likely to get a recommendation this year.
Um, and so the question really becomes, are we going to squander yet another opportunity?
This is what the world was looking like. We we struggled and squandered opportunities for oral prep in the vaginal ring.
We were doing a little better as a global community with cabotegravir.
But things were are still and I'm I'm an optimist.
And I'll tell you, if you're going to work in global health, if you're not an optimist, you probably should find another line of work.
Um, you've got to be optimistic because if you're not, it's soul destroying.
Um, and I've been challenged, I will tell you the last 100 days more than I've ever been.
But I'm still an optimist that we will do the right things and be able to to convince other funders,
other governments, that this is too important an opportunity to miss out on.
This just gives you a bit more of the detail of what's happened.
And it just tells you that in seven months, um, from the height of optimism to, um, uh, obviously January 20th, which I didn't put on this timeline.
Um, and going forward, we have an opportunity.
And the question is, can we still rally, um, uh, all the stakeholders to do the right thing?
So I want to end with just a couple of thoughts on the way forward. This may sound really depressing.
Um, um, and and I this is not a consensus view.
This is my view. I do not believe that we will ever go back to the way things were on January 19th.
I think those of us advocates and others who are fighting for things to go back.
Um, I think we need to really question it. Um, this actually is a picture from the.
I don't know if any of you remember, this is a guy named Timothy Geithner.
He was the, um, secretary of finance, basically the treasury secretary in the United States, um, uh, under President Obama, uh, in 2009.
And when they came into office following a what we thought was a really bad time of Republican leadership,
we now look at that as maybe not so bad after all, compared to where we are now.
Um, he was dealing with all of these challenges, and this is him trying to plug.
All the holes of the [INAUDIBLE] in global health right now.
And if I were cleverer with computer, or maybe if I asked,
I would have done this with with Pep FA and Gavi and Global Fund and, you know, nutrition and everything else.
We've spent a lot of the last 100 days trying to plug the [INAUDIBLE], and this was six weeks in.
Has it been that long already? Rather fortuitous. This was drawn 16 years ago.
Um, we do have to fill the essential gaps right now,
and clearly keeping people on treatment for HIV and many other things is is lifesaving and critical.
But I don't believe that we are ever going to rebuild the [INAUDIBLE], so to speak, of global health and development.
Um, we're not going to rebuild what was, I don't believe. Um, I think we have to build for the future.
Um, and this is an article in science magazine just came out a couple of weeks ago.
Um, this massive hole in global health and and to switch from, from a [INAUDIBLE] analogy, I think we have to go upstream and build a new [INAUDIBLE].
Something very different, something far more resilient. And I'll give you some my early thoughts on what that needs to look like.
Um, this is a different analogy. Earthquakes. You know, after an earthquake, you don't go back and build the same building.
You know what doesn't stand the earthquake? So you have to build a more resilient architecture.
That's what we need to do. That's why I'm so glad that you all have an abandon your studies,
because I can imagine early in one's career thinking, why am I going to work on global health?
It's never going to, you know, achieve the impact that we wanted.
I believe it can, but it's not going to be because of USAID, and it's going to be because we think together advocates,
policymakers, funders, researchers, um, what it needs to look like in a very different way.
And here are a few things that I think are priorities for the future.
Now we've always said you need to prioritise. I think we need to prioritise in a way we've never prioritised before.
There are things that every organisation, my own included,
that have done because that's just the way things were done as global health, not just the Aids response.
But if you look back on the last 25 years,
the Garvey's the Global Fund's the more recent pandemic fund coming out of Covid, a rising tide was lifting all boats.
That tide is going way out, way fast. So we need to start looking, every one of us what's mission critical, what's essential.
And there's a lot that we've done that we need to hold up to scrutiny,
not because Elon Musk tells us to hold it up to scrutiny, that he wants to cut it with a chainsaw.
We need to be the ones to decide what's really critical and what was a nice to have that we're going to have to let go.
And I think every one of us has to decide on a few things that we're going to stop doing.
Second, don't miss out on innovation. It's not just about minute cap of here.
Just this week, we saw that the world's largest TB vaccine trial product called M 72.
It enrolled its trial participants a year early.
So we're a year ahead of schedule to find out if we have the first new TB vaccine in in a century.
Um, and it may work. And if it does, are we going to roll it out? We have two malaria vaccines recommended by there.
They're all sorts of innovations. And if we get stuck trying to build back what was, I fear we're going to miss out on the innovation.
And and it's not just those technologies in different disease areas. It's things like AI.
It's things like health systems thought of differently.
Because my third point is we have and I spent almost all my time on HIV and Aids for 32 many years.
I don't think diseases don't think products.
We have got to think. Health systems.
And that's what governments are going to be doing, because a government might have been very open to Pep for telling them to do this in global fun,
giving them money for that, and God be giving them money for that. That's all going to change.
And I'll go to the very last bullet. Local ownership and leadership.
We talk a lot about, um, whether you talk about the term decolonising global health or,
or, um, uh, you know, we use the term in the back of that recentering.
We want to centre it where it needs to be.
Um, and whether you call it localising or decolonising or recentering, local ownership and leadership has to happen even faster than we thought.
The and those leaders are going to be thinking about health systems, are going to be thinking about their citizens.
They're not going to think about HIV or TB. They're going to be thinking about the systems to deliver.
Doesn't mean we don't have programs still focussed on HIV or online, a cap of your.
But they have to fit in and integrate in a way that we don't do currently.
And it means we need to think differently. Um, and we need to collaborate differently.
We live in a bubble. I live in a bubble. I listen to the New York, I read the New York Times, I listen to National Public Radio.
It tells me what I know. It tells me what I believe. I know I just can't listen to anything else because I just, I can't.
But we do need to collaborate differently when it comes to the future of global health.
And we need to think in very different ways, not only within other health sectors.
But again, I think about some of the newer technology. There's a lot of talk about AI.
How can we harness that for good? And how do we make sure that it's not going to just own us,
but that we're going to deploy it as an efficiency gain, not as a way to, to to to become subservient to it.
Um, and that's just one example. I think part of the next six months or a year needs to be conversations where every meeting probably needs
to uninvite half of the usual suspects and invite in unusual suspects to replace their seats at the table.
And that means each of us is going to have to give up something. And that gets back to my first point.
Prioritise prioritise, prioritise. And that means some of us have to step away.
Um, if we're going to make space for these newer ideas. Um, one of the things that's not just in HIV, but this sustained.
I spent a lot of time in the last three years, people have talked about sustainability and sustainability,
became code word for getting governments to fund their own Aids responses.
What is more, what is fundamentally more sustainable?
You know, is Kenya funding their Aids response more sustainable than the US funding it?
I think we know that no government is particularly sustainable when it comes to global health and development.
So part of this new resilient system needs to be, um, sustainability led locally, but also no reliance on any single entity.
And we need to make sure that it's not about we're not trying to sustain money.
Um, obviously we need money. I think we could probably have impact with less money. Um, and we're all going to have to think about that.
The World Health Organisation is thinking about it. Um, every agency has to think about it.
But remember, as you go into wherever you work, when people say sustainability,
for me the first most important question is what are you trying to sustain?
Too often implicitly, what people really are trying to sustain is either a budget line or their acronym.
What we're trying to sustain is impact. I love VAC, I've been running it for 21 years.
I'd hate for it to disappear because I like what I do, but I'm not here to sustain.
We need to sustain the Aids response and make sure that people get access to a cap of year.
And and we should figure out how we do that. I don't really care who does it.
Um, and that's hard to say because I like doing it.
And then finally, by building for the future, I've kind of repeated myself probably more than a few times already in the last 40 minutes.
Um, we got to snap out of it. I, I believe there's a it's it's kind of like, um, you know, there's the, the,
um, and Elizabeth Kubler Ross, the the cycles of grief, the stages of grief.
I believe we're in a bit of stages at now. We went from, like, head in the sand paralysis to a lot of disbelief and shock.
And there's still a lot of now, um, inward looking, save my, you know, self-protection.
We have got to stop. We've got to stop as a global community and get out of this paralysis, the disbelief.
And we've got to decide what we want the future to be. And it may be that we need to say, you know what?
We only want we we believe we can do this with 75% of the money.
And I've had meetings with leading people, leading researchers, leading policymakers who say, you, Mitchell, you're giving up.
Don't give in and pre-emptively say, you can do it for less.
Well, I get it. I don't want to declare failure. I don't want to. I don't want to lose.
But if we don't give the world a narrative that says we can still do it in this way, with this much money,
then that narrative is going to be written by people who not only don't understand what we understand, um, they're going to do it.
By people who don't care about these issues.
I'd be okay if they didn't understand science and health. If at least they cared.
And I don't believe after 102 days of this that I've seen evidence.
So I'll come back to the introduction. The evidence for policy making, the evidence for decision making.
I get to see any evidence that there's care and empathy.
So we've got to write that narrative, and I have no idea what that's going to look like.
But luckily, you all are doing programs to join this workforce and you'll figure it out.
Um, don't let it be done by people who aren't in your seats.
So I'll stop there. I'm happy to take any questions. Comments.