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[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.

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And then secondly, to everybody has decided to join us today online after this guest lecture.

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So just to orientate our online participants, uh,

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we are in the middle of our global health module as part of the Translational Health Sciences master's degree.

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Um, we've been looking at ways in which different pieces of evidence can be used and translated across different contexts within global health.

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Um, and we are delighted that you can join us for today's guest lecture.

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Um, and Michal Warren is sadly not with us in person, but is joining us online.

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Um, just to give you a bit of a background, um, on him.

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So he's has over 30 years of experience working in the field of HIV prevention, working with researchers,

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with advocates, um activists, and translating evidence between these different groups.

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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.

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Um, to us, you have aid, um, and Mitchell's organisation, um,

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which he's executive director of a buck eating one of the cold cases against the Trump administration.

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So we are we are honoured and really excited to hear your perspective.

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Thank you so much for joining us. Uh, we have a Q&A function on the chat.

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So inviting all of our online participants throughout the talk.

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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.

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Um, Mitchell, over to you. Thank you so much for joining us. Great.

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Thank you. And just to confirm, you can hear me. All right. Thank you.

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All right. I would so much prefer to be in Oxford right now for a number of reasons,

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not least in which you are a couple of hours ahead of me for getting to the pub

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would be a little inappropriate for me to go to the pub after this lecture at 1130.

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Not unheard of, but probably not appropriate for my day. Um, so I'm a little jealous about that.

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And honestly, right now, given and that. Thank you for that kind introduction.

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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.

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Uh, you are in the midst of studying what is arguably the most important topic,

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I think, in, in general, which is translating science into people's lives.

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And it has never been more important, nor, frankly, ever been harder than what has happened in the last 100.

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And I think it's now 102 days. If you had told me that, I'd be sitting here,

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standing here talking to you all 102 days into a U.S. presidential administration, which I knew would be terrible.

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I'll just be honest, going to probably give you a bit of, uh, I'm not a particularly objective presenter.

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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,

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I would have described a pretty harrowing reality for public health, for HIV, Aids, for democracy.

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But even I and I have a pretty good imagination.

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Even I would not have imagined the speed and scale and cruelty that this administration has unleashed.

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Uh, and and the idea that I'm even saying that is, is staggering to me.

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Um, uh, I really thought we were ready for what would be a very hard for years,

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and we knew there was a blueprint for what would happen, um, in that administration over four years, uh, called project 2025.

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And it's very clear that that's what is the playbook for this administration.

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But, um, I don't think anyone imagined that they would get this far this fast.

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Uh, and, um, and somewhat unstoppable.

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And, um, I'm I am not a scientist.

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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.

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And I'm an advocate. I'm opinionated. Um, I really want to encourage you, and I'll try not to speak too long.

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I want to encourage you to challenge and ask any questions.

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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.

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Um, they're my opinions. I do believe I'm pretty evidence based in our advocacy.

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I'm very proud of that a day back. Uh, but I do.

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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.

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I really want to encourage you all to to interrogate that and challenge it.

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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.

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Um, it's been primarily in HIV and Aids, so I'm going to use the HIV experience as kind of a lens in.

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But I could do this about vaccination programs, about maternal child health programs, about contraceptive programs.

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Uh, pretty much any of these issues are happening across our entire ecosystem of global health and development.

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Um, I'll use HIV because it's the one I know to the degree I know anything.

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And, um, but I think it is illustrative in terms of some writers.

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So all of those caveats aside, I'm going to show some slides and jump right in.

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Um. And I'm also in amongst all the things I'm not.

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I'm also not an architect. But I am going to, you know, really focus on this idea of what the future looks like.

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And I want to put that out there. I hope I get to the future,

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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.

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Um, but it's only what we choose to do with that information that matters.

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So I don't want to to only dwell on how bad things are.

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Quick outline. I'm going to talk about what was what could have been the HIV response.

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I got to talk about what, frankly, is the most. And this is the craziest thing of all.

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We're in a moment of, I think, the most exciting opportunity in HIV prevention ever in 44 years.

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And the idea that that's the big idea because of this new surreality, because the reality is pretty surreal right now.

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Um, I'm going to argue what still could be and then and what we want to do going forward.

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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,

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UNAids, working with member states, put out these very ambitious targets for 2020.

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And and in the blue box, that's what was modelled.

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And the idea was that if we could reach 90% of these key populations, gay men, transgender individuals,

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people who use drugs, sex workers reach 90% of adolescent girls, and young women deliver epic numbers of condoms.

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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.

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We could imagine the end of the epidemic. Models are wonderful models.

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Tell you what could be. Models are not reality and what ended up happening in the course of six years from 2014,

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when those models were set and what was actually implemented showed that we were really good at setting ambitious targets.

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And we're really good in global health at missing the targets.

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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,

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particularly the idea of trying to get from 1.7 million new infections down to fewer than 500,000 by 2020.

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That was the target. And in fact, the world got to about 1.6 million.

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So we had three times the number of people we hoped.

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Well, we all know we hope no one gets infected. But the target to really get to what we think of as epidemic control.

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And in classic, um, uh, political speak, when you miss a target so epically and so terribly, what do you do?

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You set an even more ambitious target. So we went from failing in 2020 and the 2025 targets in 2030 targets.

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Talk about even more ambitious scale up. Um, although this time this is an updated version from um after 2020,

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a greater reflection that it's not just about condoms in treatment and prep and circumcision.

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It's about the social and behavioural issues. It's about, um, laws and policies and human rights.

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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

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2020 where everything went off track because of course of the Covid pandemic.

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So this is what actually happened and where things landed in a really bad way.

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Um, rather than getting down to that one point or that 500,000.

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And the new target for 2025 is 370,000.

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And you can see we're kind of stuck up here at 1.3 million, still far too high to have epidemic control.

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What's on this side. And you can't really see the small print perhaps, is the number of people on treatment.

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And you can see that the treatment target getting, um,

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the vast majority of people living with HIV onto treatment was getting pretty close to the target.

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But message number one in all of this is that no epidemic is defeated with treatment alone.

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You have to prevent infections if you're going to look for sustainable, durable end of an epidemic.

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So while the treatment target was getting close, we are far off on prevention.

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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.

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And we were excited because this is the pipeline of HIV prevention.

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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,

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getting people on antiretroviral treatment who are living with HIV is also remarkable prevention because they won't transmit the virus.

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And then, of course, clean needle programs, something that we've known for over 30 years.

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And most political leaders around the world are too afraid to talk about.

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Clean needle is prevention.

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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,

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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.

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And then injectable cabotegravir an injection that people can get every two months.

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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.

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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,

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um, oral prep as we know it with combined oral contraceptives.

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That's important because we know in pretty much every report, every study,

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women talk about wanting both, um, contraception and HIV prevention in a single product.

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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,

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uh, called the female condom. Hopefully some of you have heard of that.

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Um, I promise I spent a lot of my career focussed on it, um, and got made fun of a lot for.

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But that's a whole other story, a whole other presentation. And then behind it, um, are all of these products in product development?

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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.

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No one HIV prevention option is right for everybody.

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So we need a range of options. The more options we have, the more protection we get.

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We know that quantitatively there's evidence to support that in both contraception and now in HIV prevention.

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But um, other than this monthly pill, a single tablet that's going into a large efficacy trial this year,

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pretty much everything else on this graphic over on this side in development,

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almost all of these other products were being funded by the US government and have now been discontinued in the last 100 days.

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So and I'm going to really I will get off of HIV and talk about some of the politics,

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but the the implications of not having pepp far to deliver this on the,

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on the far right and to not have robust research and development funding on the far left, um,

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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.

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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.

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But this is you know, all of that progress was since 2004, in the last 20 years.

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And it began to slow,

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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.

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And perhaps the most exciting opportunity.

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And I actually I realise none of these headlines have the year. This all.

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It seems like a lifetime ago, but beginning last year.

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In June and September, we got results of what is quite remarkable this twice yearly product called lens cap of urine injection,

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you get in the abdomen. In the trial in South Africa and Uganda amongst cisgender women.

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There wasn't a single infection amongst those participants who were getting

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let a cap of here that has never been seen before in an HIV prevention trial.

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There were no infections in a in a sibling study amongst men in gender diverse,

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gender diverse populations twice a year and then a cap of your same exact product.

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There were two infections amongst thousands of participants.

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Still the most effective prevention method we've seen.

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Um, and and so a lot of last year was spent.

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Other than worrying about the US election in November, a lot of the year was spent.

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How do we translate this efficacy into effectiveness?

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Because what happens in a clinical trial is wonderful.

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It makes a great journal article in the New England Journal, but it doesn't prevent infections at scale.

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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,

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because our ability to deliver with equity and with scale, uh, to have impact, has been very limited in HIV prevention for 20 years.

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We have squandered, frankly, every opportunity.

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Circumcision, oral prep, the vaginal ring, injectable cabotegravir, all terrific prevention methods.

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But we have not mustered the political and financial will from governments around the world, uh, to actually deliver on the promise.

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But these trials last year really got people excited. We thought we finally were going to do it.

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And then the end of the world as we know it.

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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.

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Um, but that's okay. And I think I would rewrite those those lyrics today.

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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,

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and I realise I'm talking to an audience in the UK, our system, you know,

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250 years, we broke from you all and we were doing pretty well until January 20th.

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Executive orders are not meant to be the way you run a country.

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We have a constitution. That's what we fought for 250 years ago.

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And executive orders are meant to be the exception, not the rule.

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But amongst the very first actions of the president was to, quote unquote, re-evaluate and realign United States foreign assistance.

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As someone who's worked in this field for a long time, I believe every program should be constantly re-evaluated.

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And we expect that, frankly, every political leader is going to want programs to realign.

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But, um, not in the way that has happened. So that came out on January 20th.

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And then basically, um, four days later, pretty much every program getting funded by USAID was given a stop work order,

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told you should stop now, if they had said we're going to.

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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.

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Is there waste? Is there fraud? How do we do it better?

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And if they had said, then keep working for those 90 days, but know that we're evaluating everything.

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People would have said, wow, this is going to be rough. Things are going to get cut.

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But you know, we'll keep going.

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But instead, on January 24th, four days later, the administration began to issue stop work orders on pretty much every USAID funded project.

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And again, you probably know about that far. That's the largest HIV response.

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Again, this is about foreign assistance. This is not HIV only.

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This is vaccination. This is contraception. This is humanitarian assistance.

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This is food relief. This is everything we think of as foreign assistance.

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And um, a couple weeks later,

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we joined in a lawsuit against the Department of State and an organisation called the Global Health Council joined an additional,

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um, parallel lawsuit that was filed the day after ours.

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So and this is a very jumbled slide with lots of headlines, but basically, we filed a lawsuit that said,

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we understand that you can re-evaluate and assess foreign assistance, but the blanket freeze we said was unconstitutional.

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And one of the reasons for that is in our country, Congress actually gets to decide how money is spent.

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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.

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The executive branch, the president and the departments under him have a lot of latitude.

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What to spend. But you can't just not spend the money because Congress said you should spend the money.

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And that was the basis of our lawsuit. And we very quickly, three days later, got what's called a temporary restraining order,

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which basically told the government, you have to, um, restart foreign assistance and release foreign aid.

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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.

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I'm also not a constitutional lawyer. I'm not a lawyer of any kind.

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Um, but I personally will declare a constitutional crisis because in the midst of this,

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Congress has either abdicated their authority because they haven't acted back and said,

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Mr. President, you can't do that, or it's been usurped by the president, in either case, abdication or usurpation.

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I would argue the constitutional crisis in this country, um, thousands of awards from USAID and State Department were cut.

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Um, even after the temporary restraining order, which was a bit of a an end run around,

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um, the the court order because the court said, go back to work.

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And with the what the what the State Department did the next day was cancel almost all the programs that they had previously paused.

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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.

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It was there's no process behind this.

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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,

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nine whistleblowers from USAID who come forward anonymously to give testimony

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that basically showed that there was never an intention to do this properly.

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There was never an intention to actually assess and and evaluate programs.

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It was a sense of just stopping everything.

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And then, um, happily, um, after a month of back and forth and lots of lawyer documents and motions and replies,

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the judge ruled that the 10th that the administration had to pay the USAID partners.

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For January and February, at least for past work done up until the restraining order was in place.

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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.

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And there's a link, and I'm happy to share these slides.

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Um, we tracked kind of the the lawsuit on online, um, that um, they and this was kind of it and some of this,

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if it weren't so tragic, it would actually be comical in the court.

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The judge told the government to go back to paying, and the lawyer for the State Department said,

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oh, well, we don't know how because we don't have any staff to do that.

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And the judge said, that's not my problem, that's your problem.

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And they ended up bringing back hundreds of staff on the admin side to process payments.

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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.

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So they are clearly dragging their feet. And then, although they have begun to pay past bills, which seems like a pretty basic,

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um, um, service of government to pay, they pay the bills that you've incurred.

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Um, they did three weeks ago, uh, actually appeal, um, to a higher court.

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We're in what's called the district court. There's a circuit court above us.

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Um, they've appealed to that to throw the case out.

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We are waiting to hear if that court's going to review it, and then we think it will go to the Supreme Court.

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And this just shows you the appeal. They have made payments, they've made thousands of payments.

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And we're very proud that we did do the lawsuit. I will tell you, it took longer than it should have.

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We were ready to fight the lawsuit the day after it all happened at the end of January.

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But we ideally wanted other plaintiffs to join us to make the case stronger.

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And it took several weeks. And I think people have been very kind, you know, aback that you stepped up.

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That's so great. Um, I'm really disappointed in a lot of my peer organisations.

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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.

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And. For Avicii was actually pretty simple calculus, to be perfectly honest.

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We're a small organisation. We do advocacy.

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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.

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And we do a lot of work with transgender communities. And then this new US administration is saying transgender people don't even exist.

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They're being erased. So we knew that our work was going to be discontinued at some point.

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There was no way this administration was going to fund a VAC to talk about choice and transgender rights.

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So we didn't really have much to lose because we kind of assumed we were never going to get the money.

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Um, and we didn't get the money. We did get paid a little bit for January in February.

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But we've laid off staff. We've reorganised to be a much smaller organisation.

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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?

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Well, we did it because we believed it was not about the money.

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Our lawsuit is about constitutional rights of Congress to appropriate funds that the president can't just deny and say,

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I don't believe in foreign assistance anymore, and it's not necessarily changing anything.

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And as you may have seen in the news over the last couple of weeks,

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the administration has informed Congress that they want to dissolve USAID and move it into the State Department.

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For those of you in the UK, this is not a novel concept.

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Them, as you know, the Department for International Development in the UK was merged into the Foreign and Commonwealth Office to become Fcdo.

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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.

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So that's not the problem. The problem is not funding what Congress tells you to do, including a robust HIV response.

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Why does it matter? So in the midst of all of this, within a week there was lots of outcry.

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And Secretary Rubio, our Secretary of state, same thing, is kind of the foreign, you know, the, uh,

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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.

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Oh, but oh, life saving in his mind,

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only treatment for some people and preventing mother to child transmission because everybody loves to help mothers and babies.

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That's like mom and apple pie. That's not a robust, comprehensive, integrated, sustainable HIV response that leads to epidemic control.

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And this is a slide from the HIV Modelling consortium that tells you why in orange,

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if we don't have Prep or condoms or voluntary medical male circumcision,

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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.

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Epidemics don't end unless they're ending like smallpox epidemics bounce back if they're not control.

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We saw that with malaria. There's a whole history of malaria research that showed that people thought we succeeded.

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They stopped doing certain things in malaria bounces back, TB comes back, HIV will come back.

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And the the so-called waiver that Secretary Rubio signed excluded prevention except for pregnant and breastfeeding women.

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And and that's not the lion's share of prep circumcision and condom users to state the obvious.

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So you could imagine in the next decade, we will be back to things last seen in 2000.

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Think about where you were in 2000, what you were doing.

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Um, and is that really where you want to go back?

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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.

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This is an example. So over the last, you know, we had pre-exposure prophylaxis or Prep a pill a day.

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We have known since 2012 for 13 years.

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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.

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And it was approved in 2012. And in 13 years, this just shows, um, uh, prep initiations globally since 2016.

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And you can see that already five years after prep was approved, hardly anybody was using Prep anywhere in the world.

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What happened here?

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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.

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Took them a decade to realise it, but they did it finally. And all that.

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Orange is Pep FA supported prep. And as of January 24th, Pep four supported prep.

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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,

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the Global Fund to Fight Aids, TB, malaria and Ministries of health are actively looking at how to keep this momentum.

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And there was already conversation even had Kamala Harris been our president.

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There was conversation about moving funding, um, from Pep four funding to governments funding their own responses over the next five years.

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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.

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But you don't do that in in 100 days.

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You do it in three, 4 or 5 years in a thoughtful, strategic way.

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We should be re-evaluating and transitioning. You don't do it because these programs don't have on off switches.

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And a lot of these prep programs in 2024, the switch was turned off in January at the most critical moment because again,

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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.

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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.

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The countries listed here in Africa were countries that were beginning to deliver cabotegravir as every two month injection.

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That's very safe and effective. The yellow these are countries that were partially disrupted, um, red totally stopped.

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And um, and Zambia, the only country where that work is continuing with some similarity to what it looked like.

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And you can click online to any country to see what's happening. And you can see the documentation here.

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This is a disaster in the best of times with, um, with prep programming,

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but it's happening at a moment of, as I said, of our greatest opportunity in history.

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And I've been working in this epidemic for too long. I want to stop, um, when the epidemic stops.

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This was our greatest moment. So Cabotegravir is up here. Small supplies, kind of expensive.

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$160 per year in low and middle income countries. But along comes Lynnette Kapp of here.

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This product again, in the trials that we've never seen anything more effective,

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we believe it's going to be priced at under $100 per person per year at launch.

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It will be approved by the U.S. Food and Drug Administration by June 19th,

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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.

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Um, but we expect that that will continue. It will likely get approved.

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It's sitting also with the European Medicines Agency,

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and the World Health Organisation is going to be releasing guidelines in July and in December, which again, lifetime ago in December,

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Foreign Global Fund committed after a lot of advocacy from us and many others to commit to the largest,

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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.

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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.

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And we don't know. Global fund has said they're going to continue to support it,

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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.

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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.

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Very exciting, because as great as Lynn is, I will tell you, at a health systems level, it's hard.

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We need to bring millions of people who are otherwise completely healthy.

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They need HIV testing and they need to get this injection in their abdomen, which is not without its pain and challenge.

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Um, every, every six months. Imagine if you could giving people one pill every month, bringing people together for,

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you know, the proverbial book club and giving everybody a single pill.

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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.

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And then, of course, for women of reproductive age, this idea of the dual prevention pill hugely opportune.

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Not since condoms have we had something that does both things. And that's also likely to get a recommendation this year.

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Um, and so the question really becomes, are we going to squander yet another opportunity?

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This is what the world was looking like. We we struggled and squandered opportunities for oral prep in the vaginal ring.

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We were doing a little better as a global community with cabotegravir.

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But things were are still and I'm I'm an optimist.

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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.

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Um, you've got to be optimistic because if you're not, it's soul destroying.

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Um, and I've been challenged, I will tell you the last 100 days more than I've ever been.

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But I'm still an optimist that we will do the right things and be able to to convince other funders,

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other governments, that this is too important an opportunity to miss out on.

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This just gives you a bit more of the detail of what's happened.

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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.

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Um, and going forward, we have an opportunity.

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And the question is, can we still rally, um, uh, all the stakeholders to do the right thing?

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So I want to end with just a couple of thoughts on the way forward. This may sound really depressing.

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Um, um, and and I this is not a consensus view.

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This is my view. I do not believe that we will ever go back to the way things were on January 19th.

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I think those of us advocates and others who are fighting for things to go back.

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Um, I think we need to really question it. Um, this actually is a picture from the.

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I don't know if any of you remember, this is a guy named Timothy Geithner.

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He was the, um, secretary of finance, basically the treasury secretary in the United States, um, uh, under President Obama, uh, in 2009.

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And when they came into office following a what we thought was a really bad time of Republican leadership,

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we now look at that as maybe not so bad after all, compared to where we are now.

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Um, he was dealing with all of these challenges, and this is him trying to plug.

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All the holes of the [INAUDIBLE] in global health right now.

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And if I were cleverer with computer, or maybe if I asked,

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I would have done this with with Pep FA and Gavi and Global Fund and, you know, nutrition and everything else.

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We've spent a lot of the last 100 days trying to plug the [INAUDIBLE], and this was six weeks in.

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Has it been that long already? Rather fortuitous. This was drawn 16 years ago.

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Um, we do have to fill the essential gaps right now,

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and clearly keeping people on treatment for HIV and many other things is is lifesaving and critical.

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But I don't believe that we are ever going to rebuild the [INAUDIBLE], so to speak, of global health and development.

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Um, we're not going to rebuild what was, I don't believe. Um, I think we have to build for the future.

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Um, and this is an article in science magazine just came out a couple of weeks ago.

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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].

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Something very different, something far more resilient. And I'll give you some my early thoughts on what that needs to look like.

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Um, this is a different analogy. Earthquakes. You know, after an earthquake, you don't go back and build the same building.

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You know what doesn't stand the earthquake? So you have to build a more resilient architecture.

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That's what we need to do. That's why I'm so glad that you all have an abandon your studies,

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because I can imagine early in one's career thinking, why am I going to work on global health?

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It's never going to, you know, achieve the impact that we wanted.

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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,

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policymakers, funders, researchers, um, what it needs to look like in a very different way.

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And here are a few things that I think are priorities for the future.

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Now we've always said you need to prioritise. I think we need to prioritise in a way we've never prioritised before.

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There are things that every organisation, my own included,

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that have done because that's just the way things were done as global health, not just the Aids response.

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But if you look back on the last 25 years,

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the Garvey's the Global Fund's the more recent pandemic fund coming out of Covid, a rising tide was lifting all boats.

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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.

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And there's a lot that we've done that we need to hold up to scrutiny,

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not because Elon Musk tells us to hold it up to scrutiny, that he wants to cut it with a chainsaw.

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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.

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And I think every one of us has to decide on a few things that we're going to stop doing.

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Second, don't miss out on innovation. It's not just about minute cap of here.

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Just this week, we saw that the world's largest TB vaccine trial product called M 72.

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It enrolled its trial participants a year early.

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So we're a year ahead of schedule to find out if we have the first new TB vaccine in in a century.

378
00:35:58,600 --> 00:36:05,210
Um, and it may work. And if it does, are we going to roll it out? We have two malaria vaccines recommended by there.

379
00:36:05,450 --> 00:36:14,110
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.

380
00:36:14,230 --> 00:36:18,400
And and it's not just those technologies in different disease areas. It's things like AI.

381
00:36:18,610 --> 00:36:21,519
It's things like health systems thought of differently.

382
00:36:21,520 --> 00:36:28,390
Because my third point is we have and I spent almost all my time on HIV and Aids for 32 many years.

383
00:36:29,200 --> 00:36:32,710
I don't think diseases don't think products.

384
00:36:33,830 --> 00:36:36,920
We have got to think. Health systems.

385
00:36:38,290 --> 00:36:45,579
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,

386
00:36:45,580 --> 00:36:50,620
giving them money for that, and God be giving them money for that. That's all going to change.

387
00:36:50,980 --> 00:36:54,610
And I'll go to the very last bullet. Local ownership and leadership.

388
00:36:54,940 --> 00:37:00,340
We talk a lot about, um, whether you talk about the term decolonising global health or,

389
00:37:00,610 --> 00:37:04,630
or, um, uh, you know, we use the term in the back of that recentering.

390
00:37:04,810 --> 00:37:07,060
We want to centre it where it needs to be.

391
00:37:07,600 --> 00:37:16,360
Um, and whether you call it localising or decolonising or recentering, local ownership and leadership has to happen even faster than we thought.

392
00:37:16,630 --> 00:37:21,100
The and those leaders are going to be thinking about health systems, are going to be thinking about their citizens.

393
00:37:21,280 --> 00:37:26,110
They're not going to think about HIV or TB. They're going to be thinking about the systems to deliver.

394
00:37:26,510 --> 00:37:30,280
Doesn't mean we don't have programs still focussed on HIV or online, a cap of your.

395
00:37:30,460 --> 00:37:34,180
But they have to fit in and integrate in a way that we don't do currently.

396
00:37:34,540 --> 00:37:38,350
And it means we need to think differently. Um, and we need to collaborate differently.

397
00:37:38,650 --> 00:37:44,410
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.

398
00:37:44,770 --> 00:37:51,130
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.

399
00:37:51,610 --> 00:37:55,780
But we do need to collaborate differently when it comes to the future of global health.

400
00:37:56,380 --> 00:38:02,110
And we need to think in very different ways, not only within other health sectors.

401
00:38:02,290 --> 00:38:06,490
But again, I think about some of the newer technology. There's a lot of talk about AI.

402
00:38:07,150 --> 00:38:11,830
How can we harness that for good? And how do we make sure that it's not going to just own us,

403
00:38:11,830 --> 00:38:18,430
but that we're going to deploy it as an efficiency gain, not as a way to, to to to become subservient to it.

404
00:38:18,760 --> 00:38:26,319
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

405
00:38:26,320 --> 00:38:33,250
to uninvite half of the usual suspects and invite in unusual suspects to replace their seats at the table.

406
00:38:33,430 --> 00:38:37,270
And that means each of us is going to have to give up something. And that gets back to my first point.

407
00:38:37,420 --> 00:38:40,840
Prioritise prioritise, prioritise. And that means some of us have to step away.

408
00:38:41,410 --> 00:38:47,380
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.

409
00:38:47,450 --> 00:38:52,540
I spent a lot of time in the last three years, people have talked about sustainability and sustainability,

410
00:38:52,540 --> 00:38:56,110
became code word for getting governments to fund their own Aids responses.

411
00:38:56,710 --> 00:39:00,130
What is more, what is fundamentally more sustainable?

412
00:39:00,850 --> 00:39:04,870
You know, is Kenya funding their Aids response more sustainable than the US funding it?

413
00:39:05,260 --> 00:39:09,490
I think we know that no government is particularly sustainable when it comes to global health and development.

414
00:39:09,730 --> 00:39:17,470
So part of this new resilient system needs to be, um, sustainability led locally, but also no reliance on any single entity.

415
00:39:17,800 --> 00:39:21,940
And we need to make sure that it's not about we're not trying to sustain money.

416
00:39:22,450 --> 00:39:27,860
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.

417
00:39:27,880 --> 00:39:31,960
The World Health Organisation is thinking about it. Um, every agency has to think about it.

418
00:39:32,440 --> 00:39:37,570
But remember, as you go into wherever you work, when people say sustainability,

419
00:39:37,750 --> 00:39:41,560
for me the first most important question is what are you trying to sustain?

420
00:39:42,490 --> 00:39:48,430
Too often implicitly, what people really are trying to sustain is either a budget line or their acronym.

421
00:39:49,240 --> 00:39:53,980
What we're trying to sustain is impact. I love VAC, I've been running it for 21 years.

422
00:39:54,250 --> 00:39:58,150
I'd hate for it to disappear because I like what I do, but I'm not here to sustain.

423
00:39:58,480 --> 00:40:02,200
We need to sustain the Aids response and make sure that people get access to a cap of year.

424
00:40:02,620 --> 00:40:05,680
And and we should figure out how we do that. I don't really care who does it.

425
00:40:06,100 --> 00:40:08,530
Um, and that's hard to say because I like doing it.

426
00:40:09,310 --> 00:40:15,100
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.

427
00:40:15,400 --> 00:40:22,809
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,

428
00:40:22,810 --> 00:40:27,310
um, and Elizabeth Kubler Ross, the the cycles of grief, the stages of grief.

429
00:40:27,550 --> 00:40:34,390
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.

430
00:40:34,390 --> 00:40:39,310
And there's still a lot of now, um, inward looking, save my, you know, self-protection.

431
00:40:39,880 --> 00:40:46,090
We have got to stop. We've got to stop as a global community and get out of this paralysis, the disbelief.

432
00:40:46,090 --> 00:40:50,800
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?

433
00:40:51,040 --> 00:40:55,030
We only want we we believe we can do this with 75% of the money.

434
00:40:55,330 --> 00:41:00,460
And I've had meetings with leading people, leading researchers, leading policymakers who say, you, Mitchell, you're giving up.

435
00:41:01,120 --> 00:41:04,690
Don't give in and pre-emptively say, you can do it for less.

436
00:41:05,410 --> 00:41:08,830
Well, I get it. I don't want to declare failure. I don't want to. I don't want to lose.

437
00:41:09,100 --> 00:41:16,210
But if we don't give the world a narrative that says we can still do it in this way, with this much money,

438
00:41:16,930 --> 00:41:24,940
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.

439
00:41:26,120 --> 00:41:29,150
By people who don't care about these issues.

440
00:41:30,430 --> 00:41:36,190
I'd be okay if they didn't understand science and health. If at least they cared.

441
00:41:36,760 --> 00:41:41,330
And I don't believe after 102 days of this that I've seen evidence.

442
00:41:41,350 --> 00:41:46,420
So I'll come back to the introduction. The evidence for policy making, the evidence for decision making.

443
00:41:46,600 --> 00:41:49,780
I get to see any evidence that there's care and empathy.

444
00:41:51,070 --> 00:41:55,750
So we've got to write that narrative, and I have no idea what that's going to look like.

445
00:41:56,770 --> 00:42:02,170
But luckily, you all are doing programs to join this workforce and you'll figure it out.

446
00:42:02,500 --> 00:42:05,500
Um, don't let it be done by people who aren't in your seats.

447
00:42:06,160 --> 00:42:08,830
So I'll stop there. I'm happy to take any questions. Comments.