Special report, six months onHaitiFrom sustaining lives .docx

Special report, six months on
Haiti
From sustaining lives to sustainable solutions:
the challenge of sanitation
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P.O. Box 372
CH-1211 Geneva 19
Switzerland
Telephone: +41 22 730 4222
Telefax: +41 22 733 0395
E-mail: [email protected]
Web site: http://www.ifrc.org
International Federation of Red Cross
and Red Crescent Societies, Geneva, 2010

Copies of all or part of this document may be made for non-
commercial use, providing the source is acknowledged. The
International Federation would appreciate receiving details
of its use. Requests for commercial reproduction should be
directed to the International Federation at [email protected]
Strategy 2020 voices the collective determination
of the International Federation of Red Cross and Red
Crescent Societies (IFRC) in tackling the major challenges
that confront humanity in the next decade. Informed by
the needs and vulnerabilities of the diverse communities
where we work, as well as the basic rights and freedoms
to which all are entitled, this strategy seeks to benefit all
who look to Red Cross Red Crescent to help to build a
more humane, dignified, and peaceful world.
Over the next ten years, the collective focus of the IFRC
will be on achieving the following strategic aims:
1. Save lives, protect livelihoods, and
strengthen
recovery from disasters and crises
2. Enable healthy and safe living
3. Promote social inclusion and a culture
of non-violence and peace
strategy2020
Notable
achievements,
but substitution
is not the
answer

The IFRC wishes to acknowledge the input and support of the
following:
The Haitian Red Cross, its remarkable volunteers and staff
The British Red Cross
The IFRC’s Haiti delegation, particularly the water and
sanitation team
The IFRC’s Water, Sanitation, and Emergency Health Unit
Oxfam GB in Haiti
DINEPA and the WASH cluster’s sanitation technical working
group in Haiti
The World Bank
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Top line messages
Before the earthquake
Tentative steps in the face of chronic under-development
Six months on:
notable achievements, but substitution is not the answer
The challenges of the next 6–12 months
Taking the first steps towards sustainable sanitation solutions
The next ten years
Innovation is the key

Haiti earthquake operation in figures
P.15 P.22P.20
Contents
P.O. Box 372
CH-1211 Geneva 19
Switzerland
Telephone: +41 22 730 4222
Telefax: +41 22 733 0395
E-mail: [email protected]
Web site: http://www.ifrc.org
The challenges
of the next 6–12
months
Haiti
earthquake
operation in
figures
The next
ten years:
innovation is
the key
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International Federation of Red Cross and Red
Crescent Societies
From sustaining lives to sustainable solutions: the challenge of
sanitation in Haiti • Special report, six months on • July 2010
Sanitation services can be defined as safe excreta disposal, solid
waste disposal, medical waste disposal, control of vectors such
as
flies, mosquitoes and rats, provision of handwashing and
bathing
and laundry facilities, promotion of good hygiene practices and
management of dead bodies. Safe excreta disposal entails both
ensuring that facilities including toilets are constructed, and
that
men, women and children use them correctly.
Mass Sanitation Module Guidelines, IFRC (2010)
© JOSE MaNUEl JIMENEZ/IFRC
5

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Today, six months on, the effects of the magnitude 7.0
earthquake that struck
Haiti on 12 January remain horrifyingly visible. Large parts of
Port-au-Prince,
Léogâne and Jacmel are in ruins. Rubble and rubbish lie piled in
the streets.
Hundreds of thousands of people are living under tents and
tarpaulins, huddled
together on street corners, vacant lots, parks and public squares,
anywhere that
offers space for families to shelter.
• Sanitation saves lives. Without it, there is a risk of a
secondary
disaster, in which the people who have survived the earthquake
could succumb to preventable disease.
• The IFRC is calling on the international community to
recognize sanitation as one of the absolute priorities in Haiti’s
reconstruction, and to ensure that sufficient resources are
devoted to it.
• The current situation is not sustainable. The IFRC and other
agencies providing water and sanitation services on behalf
of the Haitian authorities are currently stretched beyond their
capacity and mandate.
• Haitian authorities must receive funding and support to build
their capacities to provide the improved sanitation services the
Haitian population needs and deserves.

• access to appropriate sanitation is also a dignity and
protection
issue, particularly for women and children. Community
participation is essential to identify ways to ensure that people
feel safe when using sanitation facilities – toilets and showers –
both at night and in the day.
• Innovative solutions for future sanitation provision are
needed.
For example research is needed into potential solutions such
as small bore sewerage, large-scale composting of waste, or
establishing biogas production.
Top line messages
6
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Six months on, a large proportion of sanitation services (and
two-thirds of the
water trucking) continue to be provided by international
partners. This is not
sustainable. The IFRC calls upon the international community
to recognize
sanitation as one of the absolute priorities in Haiti’s
reconstruction and ensure
that sufficient resources are devoted to it. Initial planning is
underway, and
this needs to be supported.

We also call upon those allocating funds to ensure that Haitian
authorities
receive the funding and support they need to provide the
improved sanitation
services the Haitian population needs and deserves.
Generally after a natural disaster, talk is about helping the
country build back
to pre-disaster levels of service. Given the poor water and
sanitation coverage
in Haiti before the earthquake, there now exists a real
opportunity to build back
much better. The Haitian authorities must be supported to
provide innovative
and sustainable systems that will enable large numbers of
Haitian people to
have safe and reliable sanitation, in some cases for the very first
time.
Eritrea 3 5 143
Niger 3 7 714
Chad 5 9 640
Ghana 6 10 1,465
Ethiopia 4 11 6,858
Sierra Leone - 11 147
Madagascar 8 12 1,353
Togo 13 12 222

Burkina Faso 5 13 1,365
Guinea 13 19 991
Haiti 29 19 -162
Congo - 20 -
Rwanda 29 23 38
Somalia - 23 605
Côte d’Ivoire 20 24 1,905
Improved sanitation
coverage (%)
Number of people who
gained access to improved
sanitation (thousands)
1990 2006 1990 – 2006
Table 1: Countries with low improved
sanitation coverage
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With the government and local authorities as devastated as the
country – ministries
and their offices collapsed, employees killed, documentation
and equipment
lost – international organizations have been working together to
support the
government to provide survivors with the bare essentials:
tarpaulins and tents
to keep out the rain, healthcare, access to clean water and
sanitation services.
In Haiti, providing clean water and sanitation services is an
enormous task.
Before the earthquake, safe water access was amongst the
lowest in Latin
America and the Caribbean,2 whilst access to sanitation was
amongst the lowest
in the world (see table 1).3 The earthquake has made a bad
situation so much worse.
This report focuses on one area of work; the provision of
sanitation services.
Sanitation demonstrates all the challenges and opportunities of
responding to
this catastrophic disaster in terms of health services, shelter etc.
So often the
neglected twin of water provision – which generally receives
more attention
and most of the available funding – effective sanitation is vital.
A key call of this report is that equal emphasis must be given
both now and in
the future to improving sanitation facilities. This will be
instrumental in
reducing disease, ensuring a healthy future and assuring the

dignity of those
whose lives have been affected by the tragedy of the
earthquake.
ACF 824
ACTED 871
CARE 698
HAVEN 1,072
Oxfam 1,373
Red Cross Red Crescent 2,671
Save the Children 900
Top seven organizations
providing sanitation services1
Approx. number of
latrines constructed
Table 2: largest providers of sanitation services
in post-earthquake Haiti
1 Taken from DINEPa statistics June 14, 2010, amended with
up-to-date figures from IFRC, Haiti. DINEPa points out that the
figures
are very approximate and many organizations are under-
reporting construction. The DINEPa report suggests that 11,234
latrines
were reported to have been constructed, although there were no
details as to how many were still serviceable.

2 Mcleod, C, Haiti: Exploring Water & Sanitation, University of
Pennsylvania (2009)
http://www.pgwi.org/. This report further points out that Haiti
is in the region of the world with the highest available average
water per person.
3 Progress in Drinking Water and Sanitation: special focus on
sanitation, WHO/UNICEF (2008)
http://www.who.int/water_sanitation_health/monitoring/jmp200
8/en/index.html
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Before the earthquake
Tentative steps in the face of chronic
under-development
In 2008, Haiti was “the only country in which access to
improved
sanitation4(had) significantly decreased over the past decade.”5
Its improved
sanitation coverage rate was ranked 11th worst in the world –
on a par with
DR Congo and Somalia.6 The existing water regulatory
agencies had no
responsibility for sanitation, resulting in the absence of any
sewage systems

and individual families arranged their own sanitation according
to their economic
means. Those households with toilets or latrines would, when
they could afford
it, pay for emptying services, including employing bayacou
(night soil collectors
who emptied tanks by hand), although many latrine pits were
extremely deep
and could go for years without being emptied.
Fewer than 70 per cent of people living in urban environments
had regular
access to safe water, so it is no surprise that the incidence of
diarrhoeal disease
was high. Haitian children commonly had four to six episodes
of diarrhoea
per year (several times higher than the expected annual
incidence among young
children in industrialized countries) and watery diarrhoea
caused between five
and 16 per cent of child deaths.7
The situation was similarly bleak when it came to garbage
collection. Many
older Haitians speak of Port-au-Prince as once being a relatively
clean city,
with regular rubbish collections and street cleaning services.
However, 30
years of chronic under-resourcing saw these services diminish
and piles of
rotting rubbish became a familiar sight all around the capital
city.
There were hopeful signs when, in 2009, a new water and
sanitation regulatory
authority was created. DINEPA’s8 mandate was to reform the

drinking water
and sanitation sector, starting by harmonizing the existing
organizations that
had responsibility for water and sanitation services. This
process had only just
begun when the earthquake struck.
4 i.e. facilities of a safe standard
5 Mcleod, ibid, p.11
6 WHO/UNICEF (2008), ibid, see table above
7 CDC:
http://www.bt.cdc.gov/disasters/earthquakes/haiti/waterydiarrhe
a_pre-decision_brief.asp
8 Direction National de l’Eau Potable et de l’assainissement
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The earthquake devastated already fragile water and sanitation
systems near the
epicentre and left more than 1.5 million9 vulnerable people
without access to
safe drinking water or a toilet, and at risk of water- and
sanitation-related
diseases. Further from the epicentre there was less direct
damage to these systems,
but people fled Port-au-Prince to virtually all corners of Haiti,
compromising
already poorly functioning water and sanitation systems in

outlying areas and
making poor hygiene practices unavoidable for many people.
Despite being badly affected by the earthquake, losing
employees, assets and
documentation, DINEPA took the leadership of the WASH
cluster – the
mechanism put in place to harmonize water, sanitation and
hygiene interventions
throughout Haiti following the earthquake.10 For the first six
months DINEPA
trucked approximately one-third of all the subsidized water to
camps in the
affected areas.
The sanitation programmes of the International Red Cross and
Red Crescent
Movement have made a significant contribution to improving
the living conditions
of those affected by the earthquake. In collaboration with the
Haitian Red
Cross Society, the Austrian, British, French and Spanish Red
Cross societies
have so far provided sanitation facilities (toilets and showers)
to 85,000 people
across a number of different camps, in Port-au-Prince, Jacmel,
Léogâne, Petit-
Goâve and Grand-Goâve.
9 Taken from OCHa’s Humanitarian Bulletin, 19 June 2010
10 For more information see
http://www.humanitarianreform.org/humanitarianreform/Default
.aspx?tabid=76
“Minimum water supply needs are being met for 1.2 million
people, with the Cluster having reached its Phase One target of

distributing 5 litres of safe drinking water per person per day…
and (is) providing enough latrines with access to about 200
people
per facility. With 16,500 more latrines either under construction
or in the pipeline, this figure is projected to reduce to 100 per
latrine by October.” The Bulletin notes that construction rates
are
severely under-reported and use is overestimated, which “may
imply that user ratios may have already reached acceptable
bounds of 50 to 100 users per toilet.”
OCHa, Humanitarian Bulletin, June 19 2010
http://www.reliefweb.int/rw/rwb.nsf/db900sid/
MINE-86kR32?OpenDocument&RSS20&RSS20=FS
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Elie Michel balances gingerly on narrow planks of
wood as he fills up the tank with water. The 22-year-old
explains, “We’re waiting for a truck to come and pump
the faeces out of these tanks. We add water to make
the waste more liquid so it’ll be easier to drain out of
the tank. Then another truck will move the empty tanks
and we can put in new ones.”
Elie works with the Spanish Red Cross, which provides
water and sanitation services in 32 camps across
Port-au-Prince. He has a three-month contract that he

hopes will be renewed. Together with his mother, who
has a small trading business, he is able to provide for
the basic needs of his younger brother and sister. The
four of them live together in a tent in Portail Léogâne,
downtown Port-au-Prince.
When asked about the risks of becoming ill through his
work, Elie says, “We have equipment and protective
gear. I’m not worried. It’s a dirty job but somebody has
to do it. I’d like to have a better job but I’m happy doing
this for the time being. My dream is to be a policeman
but there are no opportunities right now, so I’ll stick
with the Red Cross.”
He is proud of the work that he and his colleagues are
doing. “We’re a team – the driver, the technician and
me. We install toilets in the camps and we maintain
them.” Despite Elie’s enthusiasm, the job can be
frustrating. He explains, “We’re repairing this one
because people wrecked it. It’s upsetting after all the
work we put into constructing them.”
In some camps, sanitation committees have been set
up to encourage residents to maintain the facilities
installed by the Red Cross Red Crescent. Hygiene
promotion activities are also organized to ensure
people know how to use the toilets properly.
Even so, Elie finds people’s attitudes can be
demoralizing. “People complain about the smell
coming from the toilets. Depending on the wind, the
smell can be really strong, but then you have to ask
why people are throwing all kinds of waste into them
that shouldn’t be there in the first place.”
“It’s a dirty job,

but somebody has to do it.”
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Six months on:
notable achievements, but
substitution is not the answer
Six months after the earthquake, and despite intensive efforts by
DINEPA and
humanitarian agencies, the IFRC estimates that around half the
directly affected
population (and particularly those living in smaller, informal
and hard-to-reach
locations) has not seen any improvement in their sanitation and
water situation.
The authorities, together with the international aid community,
are still months
away from meeting these overwhelming needs.

In the last month or so, some encouraging improvements in the
environmental
health of Port-au-Prince have been spotted. Large bins provided
by SMCRS11
– the metropolitan authority responsible for garbage collection
– are appearing
on street corners and teams of SMCRS street cleaners have
started clearing
gullies and drains of rubbish. Anecdotal evidence suggests that
some streets
are cleaner now than before the earthquake, with fewer piles of
garbage in evidence.
At the same, time it is clear that the provision of safe water and
appropriate
sanitation has done much to secure the situation of many
vulnerable people.
Although the numbers of toilets come nowhere near meeting
SPHERE standards
(an internationally recognized set of universal minimum
standards for disaster
response), there are signs of improved sanitation. Camp
residents no longer need
to queue to use a toilet and there have been no major outbreaks
of diarrhoeal
disease. Organizations working in sanitation in Haiti suggest
that some of the
SPHERE indicator target figures need to be put into context,
taking into account
the daily comings and goings of significant numbers of
residents, many of
whom return home to use the toilet, whilst the numbers of
permanent camp
residents is unclear.

However, it is no exaggeration to say that the sanitation
situation for most
Haitians affected by the earthquake is considerably worse now
than it was
before the quake.
For the humanitarian community, the first phase of response
focused on numbers
of toilets being constructed. The emphasis now also includes
guaranteeing
usability of the facilities provided, as well as upgrading and
replacing existing
facilities. In this, hygiene promotion to ensure that toilets are
properly used
and kept clean is key, together with carrying out regular
inspections and swiftly
carrying out repairs when needed.12 Efforts in hygiene
promotion (particularly
focused on children) must be accompanied by the reliable
provision of clean
water and soap; increasing awareness of the importance of
washing hands after
visiting the toilet or preparing food will be futile if water and
soap are not available.
Reinforcing hygiene promotion activities through the school
curriculum should
be encouraged where possible.
“The IFRC estimates that
around half the directly
affected population has
not seen any improvement
in their sanitation and
water situation.”
11 le Service Métropolitain de Collecte des Résidus Solides

12 In mid-June, DINEPa started conducting twice-weekly
inspections of sanitation facilities in all 1,300 camps.
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Ensuring access to appropriate sanitation is also a protection
and dignity issue,
particularly for women and children. Even in camps that have
adequate toilet
coverage, women are often afraid to use the toilets at night,
given the distance
they may need to walk and the absence of lighting. Instead, they
prefer to use
plastic bags or other receptacles in the privacy of their shelters.
Some camp
committees have put in place volunteer camp security systems
to try to reduce
the opportunities for violence. Anecdotal evidence suggests that
despite this,
women do not feel confident to leave their homes at night to
visit the toilet.
Organizations providing toilets and showers must consult with
camp residents
to identify ways to ensure that people feel safe to use the
facilities night and day.
Substitution cannot continue long term. Substitution cannot
continue long

term. The IFRC and other agencies providing water and
sanitation services are
currently supplying services on behalf of the Haitian authorities
and are
stretched beyond their collective capacity and mandate. The
current approach
is one of containment; buying time whilst longer-term decisions
are made.
This situation cannot continue forever. Whilst the government
and WASH
cluster are developing plans for the transition of responsibilities
for water
provision, plans for sanitation are still in their infancy. A dual
approach giving
equal prominence to funding both sanitation and water provision
is required
to secure the health of people affected directly and indirectly by
the earthquake.
© JakOB Dall
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Crescent Societies
Jean-David Dieudonné was unemployed before the
earthquake, but he used to help his mother with
her small trading business. His wife left the country
seeking better opportunities in Santo Domingo, capital
of the Dominican Republic. Since the earthquake, he

has been lucky to find work in the camp where he lives.
He works as a hygiene promoter with the British Red
Cross at a camp known as La Piste. He says, “I started
working here two months ago. Before the earthquake
I used to live nearby in Pont Rouge but now I live here
at the camp.”
Jean-David works six days a week and earns 550
Haitian dollars a month. It’s enough to support himself
and his ten year-old son.
“I’m happy to be part of a team that is teaching people
to be healthy. We encourage people to come to the
meetings we organize. We talk to them about how to
keep clean and wash their hands to prevent disease.
We use theatre to show people how to use the toilets
properly,” he says.
According to Jean-David, the hygiene promotion
activities have had an impact on people’s behaviour
already. “I can see a difference. Before we started this
work, we would sometimes find human faeces on the
ground in the camp, but we don’t see that anymore.
People use the toilets now, and use paper to wipe
themselves – before they used cardboard or anything
else they could find. Until the earthquake happened,
many people had never really learnt about sanitation.
Now, as a result of our hygiene promotion activities,
people are changing their behaviour.”
As a resident in La Piste, Jean-David is not only a
promoter of good hygiene but also benefits from the
services provided by the British Red Cross. “I used to
have a toilet in my house, but the ones we have here
in the camp are better. People used to complain about

the pit latrines we had at first in the camp because
there were lots of flies and the rain got into them, but
now they’ve been replaced with the elevated toilets,
they’re much better.”
Hygiene promotion
at Camp La Piste
CASe STudy
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Every morning at 8am, Jasmin Herline and fellow
Automeca camp resident Lucia Toussaint clean the
toilets in block 2. Much to their dismay, the toilets are
always in a mess again the following morning.
“I ask myself, ‘Would people take better care of the
toilets if they were in their own homes?’ Maybe it’s
because the toilets are provided for free that people
think it’s OK to treat them badly.”
Jasmin moved to the camp with her extended family,
including her parents, brother, sister, husband and her
two children in the aftermath of the earthquake. Previously
her home was on the road that leads to the airport.
“I lived near the toilets when they were first installed and
I volunteered to help take care of them because it’s a
service that the Red Cross provides us with.” Soon the
British Red Cross began paying a salary of 250 Haitian
gourdes per day to the hard-working teams who clean

the toilets. Part of their job is to inform the Red Cross
when the tanks are full so that they can be emptied.
In her old home, Jasmin cleaned her own toilet with the
same attention to detail that she does now. “I use this
toilet so I make sure it’s clean,” she says.
In some camps, residents return to their abandoned
homes to use the toilets rather than use the ones
installed for communal use. Jasmin thinks this might
be due to security issues. “There are no security
patrols in the evening so it’s dangerous to go out to
the toilet. Even the men don’t feel safe going out in
the dark. I use a vase in my tent and throw it out the
next morning.”
The Automeca camp has a committee and organizes
volunteer security patrols during the day, but it’s
difficult to get volunteers to work at night as they fear
for their safety.
Sanitation technicians –
doing the work that nobody
else wants to do
CASe STudy
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The challenges
of the next 6–12 months

Taking the first stepstowards
sustainable sanitation solutions
The focus of the first six months has been on assuring a
minimum level of human
and solid waste management in the camps. During the next 6–12
months,
DINEPA and organizations such as the IFRC will increasingly
focus attention
on addressing the health and hygiene issues of people moving to
transitional
shelters and those returning to their homes. This will include
repairing usable
toilets in homes that have been classified as structurally sound
or reparable, as
well as improving existing services in the camps.
It is clear that finding sustainable solutions in sanitation, in the
short and
longer term, can only follow once solutions are found to shelter
issues such
as rubble clearance and making resettlement options available
to homeless people.
Working in an integrated manner and increasing the scale and
speed of
interventions will be essential. It is worth noting that the
current delays being
experienced by agencies bringing vital equipment into Haiti are
impacting
their abilities to deliver sanitation, as well as other services.
Waiting for vehicles
such as de-sludging pumps to clear customs and be registered is
significantly
holding up some operations. Speeding up the registration and
import of essential

equipment should be prioritized.
One of the key lessons learned in the first months of the
earthquake response
operation was the need for flexibility regarding the individual
context of
each camp and neighbourhood; determining the most
appropriate solution
to residents’ sanitation needs. Each camp has different
characteristics and
may need a different approach; agencies must build their
approaches on what
will work in that context.
Improving the sanitation habits of people, whether they are
living in camps
or returning home, is an approach being advocated by the
WASH cluster, of
which IFRC is a part. If, for example, people were using a
sludge collection
system at home before the earthquake, then ensuring this is
done regularly,
hygienically and that the sludge is dumped appropriately may be
a good solution
once they return home.
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Nicolette Bernard is a 30-year-old qualified nurse who
leads a team of 10 Red Cross hygiene promoters at
the Automeca camp. “I love what I do. It’s about giving
information, education and encouraging behaviour
change. I love the contact with the people. My job now
is more rewarding than my previous job, as I see a
change in people’s behaviour,” she says.
Before the earthquake, Nicolette worked at the
maternity ward of the St. Croix hospital in Léogâne. At
the time of the earthquake she was at home in Port-
au-Prince and ran to safety in a nearby field. At first,
she helped at a local hospital, but then made contact
with the Haitian Red Cross through her sister, who has
been a volunteer for many years.
“The Red Cross needed help so I volunteered as
a translator with the health team. Then one day
Mrs Ferna Victor, Branch Director of the Haitian Red
Cross, told me the British Red Cross was looking for
nurses for hygiene promotion.”

Nicolette manages a team of hygiene promoters, toilet
cleaners and inspectors who work together to ensure
that camp hygiene is maintained at an acceptable level.
The hygiene promoters use lively songs and interactive
practical demonstrations to spread their message and
focus particularly on the children. Camp residents
are encouraged to form sanitation committees to
clean their toilets on a regular basis. Toilet inspectors
make daily rounds to ensure the structures are well
maintained and that doors and roofs don’t disappear.
This is easier said than done; in some camps such as
La Piste, toilet doors have disappeared only days after
being installed.
Nicolette laments the breakdown in the provision
of sanitation services over the years: “In the 1980s,
the capital was a lot cleaner. But overpopulation
and reduced public spending led to poorer levels of
hygiene.”
Nicolette and her team are working to change poor
hygiene habits and improve the landscape. “People
used to leave their garbage all over the place even
though there were bins around. Now they use the bins.”
Making it fun
to learn about hygiene
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Whilst the IFRC works mainly in larger camps and
neighbourhoods, other
agencies and NGOs are working in small camps that are not
accessible to
larger de-sludging machines. They have also taken this
“improve on what exists”
approach, consulting with camp dwellers to learn and build
upon their own
practices. They are currently piloting a number of different
options. These
include field-testing the distribution and safe collection of
biodegradable
bags13 in locations where there appears to be no other viable
solution (for
example, no space for more conventional toilets), installing
toilets that use
little or no water,14 and investigating options to introduce
manual de-sludging
pumps that would improve upon the bayacou system of toilet
clearance used
prior to the earthquake.
In camps where several agencies have responsibility for
sanitation provision, a

common approach on the ground must be adopted. In some
cases, different
agencies have differing means of responding (for example, some
pay for toilet
cleaning whilst others prefer a community support approach).
This can lead to
difficulties and tensions, which must be avoided. A unified
approach should be
taken, led by the needs on the ground.
City-wide solid waste management, such as collecting garbage
from bins and
transporting it to the dump site, is clearly not the responsibility
of those agencies
currently providing sanitation services. Key to moving forward
here will be
the leadership and commitment of the appropriate authorities,
together with
the capacity-building support of the international community so
that they can
manage this task effectively. SMCRS is increasing its capacity
to manage solid
waste and keep streets clean, but it needs the resources to
sustain these
improvements, increasing the regularity of garbage collection,
maintaining
infrastructure and equipment, training and retaining staff for the
long term.
Support for an initial large-scale, cash-for-work scheme to clear
all ravines,
gullies and drainage ditches would enable SMCRS to maintain a
cleaner
environment, as well as reducing Port-au-Prince’s vulnerability
to flooding in
the event of heavy rains or hurricanes.

Support should also be given to SMCRS to improve the existing
waste disposal
site for Port-au-Prince. Currently, both solid and human waste –
including
faeces in plastic bags, a commonly used option in Haiti – is
indiscriminately
dumped at Truitier, just outside the city. Those who have
visited the site describe
it as “worse than hell”: a huge area of stinking and slowly
smoking garbage,
picked over for recyclable material by people who live nearby.
Enabling the
separation of solid and human waste will be vital.
In the next six to 12 months, DINEPA and the agencies working
in the provision
of sanitation services will need to confront a number of
dilemmas:
How to stabilize the sanitation services in the short term in
camps that are
precariously located and absolutely unsustainable in the long
term without
inadvertently giving messages that it is appropriate and
acceptable for people
to live in these locations. In larger camps, agencies are
preoccupied with how
to avoid inadvertently contributing to the creation of long-term
slum areas.
13 Including the use of PeePoo bags which speed up the
decomposition of faeces –
http://www.peepoople.com/showpage.php?page=5_0
14 For more information on Ecosan toilets, see WaSHlink –
http://washlink.wordpress.com/category/toilet/ecosan/

18
Crescent Societies
How to put in place a coherent and coordinated strategy for
more sustainable,
lower-cost15 medium- and longer-term options for excreta
disposal for urban
earthquake-affected populations, displaced populations, and
returnees. Using
de-sludgable toilets is a suitable solution for the emergency and
recovery phases
of the emergency, however, it may not be a sustainable option
because of cost
and logistical considerations.
How to accurately measure the coverage of sanitation facilities
in camps given the
difficulties in ascertaining exactly how many people are living
permanently in
any given camp and lack full access to toilets. Methods to
determine appropriate
toilet coverage per location, including observation and
surveying, are required,
focusing on toilet usability rather than the number of toilets
originally built
– which may not be serviceable due to theft or misuse.
How to build community engagement in camps that are not
established communities,

which is a particular challenge for agencies more used to
working in rural
settings. Whilst some smaller neighbourhood camps (groups of
neighbours
occupying space near their homes) may be tight-knit
communities, many of
the larger camps are not communities but collections of
displaced people. In
the months to come, including those people living in the camps
will be critical.
In La Piste camp, for example, both the Spanish and British Red
Cross societies
are developing ways of engaging women in the camps. Other
organizations
have had some success creating mothers’ groups in the camps.
Each camp
requires an individual approach.
How to interact with camp committees that may be self-
appointed rather than
representative. Whilst some committees are genuinely working
hard for the
best interests of camp residents, others may be motivated by
self-interest, which
agencies cannot support. Working through the women’s groups
mentioned above
may be an approach to avoid unwittingly supporting
undemocratic committees.
After six months of intensive work on the ground, some of the
48 WASH agencies’
plans to increase sanitation work are being severely hampered
by difficulties in
finding staff. In mid-June, Relief Web16 was advertising 21
vacant positions for
senior water and sanitation professionals for Haiti, (four for

IFRC programmes),
whilst IFRC had 11 positions advertized on its own internal job
vacancy site
JobNet. Engaging camp dwellers where possible in community
mobilization
and non-technical roles will free up senior staff, but unless the
staffing shortages
are urgently met, the water and sanitation situation of many
Haitian people
will be adversely affected. Identifying new sources for
personnel is a priority; the
funds are there to do a good job, but little can be achieved
without the staff in place.
15 after the earthquake, private de-sludging companies were
charging 40 USD per de-sludge per cubicle. Currently, rates are
around
14 USD per de-sludge per cubicle. It is estimated that over 800
m3 of excreta sludge is being transported out of Port-au-Prince
each day.
16 amongst other things, ReliefWeb advertises job vacancies:
http://www.reliefweb.int/rw/res.nsf/doc212?OpenForm
19
Crescent Societies
Paul Ladouceur has been a Haitian Red Cross
volunteer for 14 years. He started working with the
French Red Cross as a hygiene promoter in 2003.

Since the earthquake, teams of volunteers like Paul
have been working in camps across Port-au-Prince
encouraging communities to keep their environment
clean and healthy.
Every Saturday, Red Cross volunteers organize a
“clean-up day” in the camps, providing residents with
forks and spades to shovel up the waste that litters the
camps. The plastic bags, bottles and human waste are
then taken in wheelbarrows to a truck that dumps it at
the main garbage disposal site in Port-au-Prince.
An earnest and studious man, Paul joins the families in
raking up the dirt in the burning midday sun.
“It is vital that the residents take responsibility for the
cleanliness of the camp and for their health. Disease
prevention is better than cure.”
The volunteers also encourage the communities to dig
ditches for the water to run off after the rains. The camp
is not low-lying, so there is no great risk of flooding, but
Paul says people are concerned about the impact of
heavy rains that fall during the hurricane season. He
gives them advice about not seeking shelter under
trees, but in strong buildings such as schools and
churches instead.
The volunteers run competitions between the different
blocks in the camps and at the end of the day the
residents organize festivities such as theatre, dance or
music. It helps to foster a sense of community for a
group of people who have been brought together by a
force of nature.
Cleaning up the camps

CASe STudy
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Crescent Societies
The next ten years
Innovation is the key
There are huge challenges in meeting the long-term sanitation
needs for Haiti,
but at the same time great opportunities exist to make
substantial improvements
to the sanitary environment of Port-au-Prince and beyond. The
key is to support
the Haitian authorities in investigating and putting in place
pioneering sanitation
solutions. The crucial starting point is to ensure that equal
importance, support
and funding is channelled to sanitation as well as the provision
of water
in tackling the long-term rebuilding of Haiti.
Sustainable sanitation depends upon sustainable housing plans.
Developing
a comprehensive resettlement plan, together with urban
planning for Port-
au-Prince, are vital steps to finding durable and integrated
shelter and sanitation
solutions. As plans are put in place to upgrade different
neighbourhoods, there
is an opportunity to integrate sanitation together with plans for
houses, roads,
water, electricity and communications – substantially improving

life for many
of Haiti’s citizens.
Valuable lessons can be learned from other cities affected by
devastating
earthquakes, including Managua, Nicaragua in 1972 and
Arequipa, Peru in
2001. The Managua earthquake left more than half the
population homeless
and 70 per cent of buildings destroyed or severely damaged.17
Some sources
estimate that rebuilding the capital took 38 years and misguided
urban planning
decisions were said to have resulted in major social upheaval in
the years following
the disaster. Looking at sanitation, there are valuable lessons to
be learned
from countries such as India, Tanzania and Brazil where
innovative approaches
to providing sanitation in crowded urban environments are
being developed
and implemented.
Transporting and dumping human waste is costly. Given the
high water table
throughout low-lying areas of Port-au-Prince, putting in a
conventional sewage
system may be out of the question. But specialists suggest that
more innovative
solutions, including small-bore sewerage, make more sense in
Haiti. There
may also be opportunities for sanitation systems to provide
sustainable livelihoods,
converting the health risks that excreta represent today into jobs
tomorrow.
Large-scale composting of waste for agricultural use or

production of biogas
are two options that require investigation for viability in Haiti,
given that
transporting and dumping human waste is costly.
An absolute priority in solid waste management is clearing the
rubble. Apart
from impeding the flow of traffic and the reconstruction of
homes and permanent
buildings, piles of rubble are becoming part of the scenery, with
people learning
17 Mallin, J, The Great Managua Earthquake,
http://www.ineter.gob.ni/geofisica/sis/managua72/mallin/great0
1.htm.
See also http://www.mcclatchydc.com/2010/02/15/85144/haiti-
quake-fear-what-if-recovery.html
comparing Managua and Port-au-Prince.
21
Crescent Societies
to live around them, attracting yet more garbage. Developing
Haiti’s capacity
to manage the solid waste it produces – through, perhaps, large-
scale recycling –
rather than continuing to dump it represents an enormous
opportunity to
improve the environmental health of Haiti.

As plans are made for the allocation and distribution of funds
pledged towards
rebuilding Haiti, the WASH cluster’s sanitation working group
has started to
identify the key components for a long-term sanitation strategy
for Haiti. A
number of the following elements will form part of this
strategy.
The long-term institutional support and funding to the Haitian
authorities
responsible for the provision of sanitation services throughout
the country is
essential, so that sanitation policy can be reviewed, staff
capacity expanded
and equipment provided. A key step is to support DINEPA’s top
priority of
identifying an appropriate site for sludge treatment, as well as
investigating the
most appropriate technologies to do this. DINEPA also needs to
develop its
capacity to deliver sanitation services; currently, it has many
staff focusing on
water, but only one focusing on excreta disposal.
Supporting the development of a thriving private sector will
also be important,
particularly in stimulating the local production of septic tanks,
toilets and other
hardware, and providing support to bayacou. Agencies are
currently discussing
different approaches to repairing individual toilets in homes –
such as giving
cash grants or vouchers together with technical advice and
follow-up.

Investment in formative research is needed now in areas such as
the barriers
and motivational factors to achieving improved sanitation
within Haitian society,
the ability and willingness to pay for it, and whether there is an
openness to
adopt innovations such as the agricultural use of human-derived
fertiliser or
the conversion of excreta into energy through biogas
production. All these issues
must be properly researched, together with a better
understanding in how to
carry out urban mass sanitation, given that most experience to
date stems from
rural and peri-urban situations.
Haiti is still in the first phase of recovering from the
devastating effects of the
12 January earthquake, but now is the time to look forward – to
the next six
months and also to the next 10 or 20 years. The decisions made
now will have
the most profound influence in helping the country deliver a
prosperous future
for its citizens. Making sure that sanitation is given equal
priority and funding
to the provision of water – and seizing opportunities to put in
place innovative
long-term approaches to solid and human waste management in
Haiti requires
immediate action, research and planning.
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Crescent Societies
Haiti earthquake
operation in figures
(Figures accurate to 30 June 2010)
Health
95,000 people have received treatment at Red Cross
Red Crescent healthcarefacilities.
1,000 to 2,000 patients seen each day.
152,342 people vaccinated against measles, diphtheria and
rubella.

More than 16 million community health awareness
text messages have been sent.
Water, sanitation and hygiene promotion
300,000 men, women, and children reached by hygiene
promotion activities.
Everyday, the Red Cross Red Crescent trucks 2.4 million
litresof water to 94 water points in camps
in Port-au-Prince
– enough for 280,000 people.
2,671 latrines have been built.
Shelter
120,000 families – or 597,000 people – have
received Red Cross Red Crescent emergency
shelter materials.
The Red Cross Red Crescent is committed to building
30,000 transitional shelters.
Relief
955,000 relief items – hygiene kits, kitchen sets, jerry
cans, buckets, blankets and mosquito nets – have been
distributed.
disaster preparedness
With the hurricane season looming, the IFRC is prepositioning
relief items in ten high-risk regions for 25,000
families
(125,000 people) across Haiti.
Tens of thousands of SMS messages in Creole are being sent
asking people if they want information on how to be
prepared during the peak of the hurricane season.

Logistics
Over the course of the operation, more than 11,000 tons of
Red Cross Red Crescent aid has arrived in Haiti.
23
The Fundamental Principles
of the International Red Cross
and Red Crescent Movement
Humanity
The International Red Cross and Red Crescent Movement,
born of a desire to bring assistance without discrimination
to the wounded on the battlefield, endeavours, in its
international and national capacity, to prevent and alleviate
human suffering wherever it may be found. Its purpose
is to protect life and health and to ensure respect for the
human being. It promotes mutual understanding, friendship,
cooperation and lasting peace amongst all peoples.
Impartiality
It makes no discrimination as to nationality, race, religious
beliefs, class or political opinions. It endeavours to
relieve the suffering of individuals, being guided solely by
their needs, and to give priority to the most urgent cases
of distress.
Neutrality
In order to enjoy the confidence of all, the Movement
may not take sides in hostilities or engage at any time in
controversies of a political, racial, religious or ideological
nature.

Independence
The Movement is independent. The National Societies,
while auxiliaries in the humanitarian services of their
governments and subject to the laws of their respective
countries, must always maintain their autonomy so that
they may be able at all times to act in accordance with the
principles of the Movement.
Voluntary service
It is a voluntary relief movement not prompted in any
manner by desire for gain.
unity
There can be only one Red Cross or Red Crescent Society
in any one country. It must be open to all. It must carry on
its humanitarian work throughout its territory.
universality
The International Red Cross and Red Crescent Movement,
in which all societies have equal status and share equal
responsibilities and duties in helping each other, is worldwide.
19
9
6
0
0
0
7
/2

0
1
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0
The International Federation of
Red Cross and Red Crescent
Societies promotes the
humanitarian activities of National
Societies among vulnerable
people.
By coordinating international
disaster relief and encouraging
development support it seeks
to prevent and alleviate human
suffering.
The International Federation,
the National Societies and the
International Committee of
the Red Cross together constitute
the International Red Cross and
Red Crescent Movement.
Haiti: From sustaining lives to sustainable solutions –
the challenge of sanitation
A publication from the International Federation
of Red Cross and Red Crescent Societies (IFRC)

For more information, please contact:
IFRC Americas Zone
Tel: + 507 380 0250
IFRC Geneva Secretariat
Media service duty phone
Tel: + 41 79 416 38 81
Email: [email protected]
www.ifrc.org/haiti
IFRC Water, Sanitation and Emergency Health Unit
Tel: + 41 22 730 42 18
REPORT OF THE CSIS COMMISSION ON
Smart Global Health Policy
A HEAlTHIER,
SAFER, ANd
MORE PROSPEROuS
WORld
COCHAIRS
William J. Fallon & Helene D. Gayle
1800 k STREET NW, WASHINgTON dC 20006
P. 202.887.0200 F. 202.775.3199 | WWW.CSIS.ORg
Ë|xHSKITCy065974zv*:+:!:+:!
ISBN 978-0-89206-597-4

REPORT OF THE CSIS COMMISSION ON
Smart Global Health Policy
A HEAlTHIER,
SAFER, ANd
MORE PROSPEROuS
WORld
COCHAIRS
William J. Fallon & Helene D. Gayle
About CSIS At a time of new global opportunities and
challenges, the Center for Strategic and International
Studies (CSIS) provides strategic insights and
policy solutions to decisionmakers in government,
international institutions, the private sector, and
civil society. A bipartisan, nonprofit organization
headquartered in Washington, DC, CSIS conducts
research and analysis and develops policy initiatives
that look into the future and anticipate change.
Founded by David M. Abshire and Admiral Arleigh
Burke at the height of the Cold War, CSIS was
dedicated to finding ways for America to sustain its
prominence and prosperity as a force for good in
the world. Since 1962, CSIS has grown to become
one of the world’s preeminent international policy
institutions, with more than 220 full-time staff
and a large network of affiliated scholars focused

on defense and security, regional stability, and
transnational challenges ranging from energy and
climate to global development and economic
integration.
Former U.S. senator Sam Nunn became chairman
of the CSIS Board of Trustees in 1999, and John
J. Hamre has led CSIS as its president and chief
executive officer since April 2000.
COCHAIRS
William J. Fallon (Cochair), Admiral, U.S. Navy (Retired)
Helene D. Gayle (Cochair), President & CEO, CARE
COMMISSIONERS
Rhona S. Applebaum, Vice President, The Coca-Cola Company
Christopher J. Elias, President & CEO, PATH
Representative Keith Ellison (D-MN)
William H. Frist, former U.S. Senate Majority Leader
Representative Kay Granger (R-TX)
John J. Hamre, President & CEO, CSIS; former U.S. Deputy
Secretary of Defense
Peter Lamptey, President, Public Health Programs, Family
Health International
Margaret G. McGlynn, former President, Global Vaccines &
Infectious Diseases, Merck and Co.
Michael Merson, Director, Global Health Institute, Duke
University
Patricia E. Mitchell, President & CEO, The Paley Center for
Media
Surya N. Mohapatra, Chairman, President & CEO, Quest
Diagnostics, Inc.
Thomas R. Pickering, Vice Chairman, Hills & Company
Peter Piot, Director, Institute for Global Health, Imperial

College London; former Director of UNAIDS
Karen Remley, Commissioner, Virginia Department of Health
Judith Rodin, President, The Rockefeller Foundation
Joe Rospars, Founding Partner, Blue State Digital
Robert E. Rubin, Cochairman, Council on Foreign Relations;
former U.S. Secretary of the Treasury
Senator Jeanne Shaheen (D-NH)
Donna E. Shalala, President, University of Miami; former U.S.
Secretary of Health and Human Services
Senator Olympia Snowe (R-ME)
Debora L. Spar, President, Barnard College
Rex Tillerson, Chairman & CEO, Exxon Mobil Corporation
Rajeev Venkayya, Director, Global Health Delivery, Bill &
Melinda Gates Foundation
CSIS COMMISSION ON SMART GlObAl HEAlTH POlICy
CSIS does not take specific policy positions;
accordingly, all views expressed herein should be
understood to be solely those of the author(s).
© 2010 by the Center for Strategic and
International Studies. All rights reserved.
Library of Congress Cataloguing-in-Publication
Data CIP information available on request.
ISBN 978-0-89206-597-4
Center for Strategic
and International Studies
1800 K Street, NW
Washington, DC 20006
Tel: (202) 775-3119
Fax: (202) 775-3199

Web: www.csis.org
Photo Credits
Cover: Polio Vaccination in Nepal, CSIS Global Health Photo
Contest 1st
Place Winner, Susheel Shrestha, 2008.
Page 3: 159-5 Lagos, Nigeria, Kunle Ajayi, 2006/Daily
Independent,
courtesy of Photoshare, 2010.
Pages 4, 5, 7, 9, 13, 20, 23, 27, 33, 34, 35, 40: Commissioners,
Liz Lynch/
CSIS, 2009.
Pages 8, 12, 16, 23, 26, 32, 33, 38: Commissioners, Kaveh
Sardari/CSIS,
2009.
Page 7: Commission in Kenya, Evelyn Hockstein/CARE, 2009.
Page 9: Mother and Child, CSIS Global Health Photo Contest
Finalist,
Mohammad Rakibul Hasan, 2009.
Page 11: U.S. Navy Petty Officer 2nd Class Timothy Hall, DoD
photo by
U.S. Navy Seaman Apprentice Bradley Evans, Defense.gov,
2009.
Page 17: A girl in primary school, Bandar Abbas, © UNICEF
Iran,
Shehzad Noorani.
Page 18: Epidemia de Pánico, Eneas (CC BY-NC 2.0).

Portrait of Woman and Child, Sri Lanka, Dominic
Sansoni/World
Bank.
Page 24: Malaria Bed Net, Talea Miller, PBS Online NewsHour
(CC BY-
NC 2.0).
Page 28: Commissioners, Daniel Porter/CSIS, 2009.
Page 29: Commissioners, Indra Palmer/CARE 2009.
Page 38: CSIS Essay Contest Submission Locations, © 2009
Google—Map
date © 2009 Google
Page 39: Keith Ellison in Kenya at Ifo Camp Verification
Center, Jennifer
Cooke/CSIS, 2009.
CONTENTS
Opening Letter
Synopsis
Part I: A Quantum Leap Forward
Part II: A U.S. Global Health Strategy
1. Maintain our commitment to the fight
against HIV/AIDS, malaria, and tuberculosis

2. Prioritize women and children in U.S. global
health efforts
3. Strengthen prevention and health emergency
response capabilities
4. Ensure that the United States has the capacity
to match our global health ambitions
5. Make smart investments in multilateral
institutions
Part III: Closing Thoughts
Endnotes
Appendix
Acknowledgments
6
8
14
21
24
24
26

27
38
42
44
45
50
6 RepoRt of the CSIS CommISSIon on SmaRt Global health
polICy
The 25 commissioners who signed this report
joined together in the spring of 2009 with a sense
of optimism, purpose, and engagement. We firmly
believed the United States can better the lives of
the world’s citizens and advance its own interests by
investing strategically in global health—even at a time
of global economic recession and exceptional domestic
challenges. One year later, we remain convinced not
only of this statement’s veracity, but of its urgency. But
truly remarkable gains for global health will only be
achieved through a smart, long-term U.S. approach
that harnesses all of America’s assets and expertise—in
better partnerships with friends and allies.
The Commission was an experiment. At the outset,
we wondered whether two dozen diverse individuals—
accomplished opinion leaders and high-level strategists

of varied political stripes, drawn from backgrounds
in business, finance, Congress, media, philanthropy,
foreign affairs, security, government, and public
health—could reach consensus on a long-term plan
for the United States to save and enhance the lives of
millions of people around the world through global
health. We have not answered all the questions that
emerged, nor have we devised perfect solutions. But
we believe we have put forward a compelling, concrete,
and pragmatic plan of action.
We owe this achievement to the dedicated commitment
of our fellow commissioners, as well as the extensive
and generous support we’ve received from countless
experts. We approached this task humbly, with
gratitude and respect for those who have worked long
hours in hospitals and clinics, laboratories, and in the
field to make this world a healthier place. Our report
builds upon their knowledge and experience.
The Commission convened for full-day deliberations
on June 10 and October 16, 2009. In August, some
of us traveled to Kenya to view first-hand the impact
of U.S. global health investments, as well as our future
challenges. Over 10 months, we held numerous
conference calls and expert consultations, each with
a high level of commissioner participation. We also
benefitted significantly from the willingness of senior
officials in the White House, the U.S. Department of
State, the U.S. Agency for International Development,
and the U.S. Department of Health and Human
Services, including the Centers for Disease Control
and Prevention and National Institutes of Health, to
share their perspectives with us.

Throughout the course of the Commission’s work, we
were determined to connect with the growing numbers
of Americans, particularly students, who are passionate
about global health. With the help of the staff of Blue
State Digital, we created an interactive Web site, www.
smartglobalhealth.org, which allowed us to exchange
ideas with thousands of people who proposed
questions for deliberation, anecdotes and photos from
the field, and most importantly, fresh, critical insights.
Their input is reflected in the report, including the
stunning cover photo! We also traveled to two major
centers of American global health work—the Research
Triangle in North Carolina and the California Bay Area—
for public consultations. These honest and substantive
conversations with the public informed our work as well.
The report that follows represents a majority consensus
among the commissioners. We did not insist that
each commissioner endorse every point contained in
the document. In becoming a signatory to the report,
commissioners signal their broad agreement with its
findings and recommendations.
This is a good moment to pause, set aside our immediate
concerns or diverse views, and reflect on just how much
our nation has achieved, especially in the past decade, in
saving and enhancing the lives of millions of individuals.
As we examine how we can better organize and apply
ourselves, make the best use of our assets, and be more
effective in our actions, let us imagine what the global
health outlook could be in 2025, if only we set clear and
realistic goals and stay on course to achieve them.
Sincerely,
Admiral William J. Fallon (ret.) Dr. Helene D. Gayle

Cochair Cochair
Opening Letter from the Commission Cochairs
7
William J. Fallon Helene D. Gayle
Senator Olympia
Snowe (R-ME)
Debora L. Spar Rex Tillerson Rajeev Venkayya
Joe Rospars Robert E. Rubin Senator Jeanne Shaheen
(D-NH)
Donna E. Shalala
Thomas R. Pickering Peter Piot Karen Remley Judith Rodin
Margaret G. McGlynn Michael Merson Patricia E. Mitchell
Surya N. Mohapatra
William H. Frist Representative Kay
Granger (R-TX)
John J. Hamre Peter Lamptey
Rhona S. Applebaum Christopher J. Elias Representative Keith
Ellison (D-MN)
CSIS Commission on Smart Global Health Policy

polICy
Synopsis
9SynopSIS
As the United States applies smart power
to advance U.S. interests around the world,
it is time to leverage the essential role that
U.S. global health policy can play.
Americans have long understood that promoting
global health advances our basic humanitarian values
in saving and enhancing lives. In recent years, support
for global health has also proven its broader value
in bolstering U.S. national security and building
constructive new partnerships.
A smart, strategic, long-term global health policy will
advance America’s core interests, building on remarkable
recent successes, making better use of the influence
and special capabilities of the United States, motivating
others to do more, and creating lasting collaborations
that could save and lift the lives of millions worldwide.
It will usher in a new era in which partner countries take
ownership of goals and programs, in which evaluation,
cost effectiveness, and accountability assume vital roles,
and in which a focus on the health of girls and women
becomes a strategic means to bring lasting changes.
And it will enhance America’s influence, credibility, and
reservoir of global goodwill.

The CSIS Commission on Smart Global Health Policy
calls on Washington policymakers to embrace a five-
point agenda for global health—a mutually reinforcing
set of goals to achieve U.S. ambitions and partner
country needs.
1. Maintain the commitment to the
fight against HIV/AIDS, malaria, and
tuberculosis
It is critical that the United States keep its HIV/AIDS,
malaria, and tuberculosis programs on a consistent
trajectory, even in the face of a grave fiscal situation
and competition from other worthy priorities. Today,
more than 2.4 million persons living with HIV are
directly supported by the United States with life-
extending antiretroviral treatment (ART). Many others
are ready to begin treatment. If we continue investing
steadily in these programs, the Obama administration
can realize its goal of funding antiretroviral treatment
for more than 4 million people over the next five years;
and our AIDS and malaria platforms can expand
successfully into other health areas, in partnership with
able international alliances like the Global Fund to
Fight AIDS, Tuberculosis and Malaria.
It won’t be easy. Over the past year, the pace of growth
in treatment has slowed. Budgets have tightened.
Concerns have mounted over the long-term cost
of treatment, especially if resistance develops to
current medications. In this difficult climate, tensions
have risen among global health advocates. But
compassionate, realistic, patient U.S. leadership can
transcend fragmentation, ameliorate conflict across

health constituencies, and ensure that immediate
budgetary woes do not derail our efforts. We can
leverage our existing disease-focused investments to
create lasting health systems, with long-term solutions
based on steady growth that reduce mortality and
illness, and build partner country capacities.
2. Prioritize women and children in U.S.
global health efforts
The United States should move swiftly and resolutely
to bring about major gains in maternal and child
health, through proven models of care prior to,
during, and after birth, and through expanded access
to contraceptives and immunizations. A doubling
of U.S. effort—to $2 billion per year—will catalyze
inspiring results. Direct U.S. investments are best
focused on a few core countries in Africa and South
Asia where there is clear need, the United States can
“We have before us the chance to accelerate our recent historic
successes in advancing
global health. If Americans seize this moment, take the long
strategic view, make the
commitment—with our friends and allies—the lives of millions
will be lifted in the coming
decades. The world will be safer and healthier. Our nation will
have shown its best.”
— Helene D. Gayle
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make a distinctive contribution, partner governments

are willingly engaged, and there is a genuine prospect
of concrete health gains and increasing country
capacities. At the same time, renewed emphasis on
U.S. investments through multilateral channels can
enable us to reach a broader population in need.
Closing gaps in the critical services and protections
provided to mothers and children is a smart, concrete,
and effective means to strengthen health systems
and lower maternal and child mortality and illness.
Affordable tools exist to reduce infant deaths in
the first month of life; expanded immunizations
can improve child survival; and expanded access to
contraceptives can bolster women’s health.
U.S. leadership in collaboration with others will lift
the lives of the next generation of girls and women,
strengthen families and communities, and enhance
economic development worldwide. It will also
accelerate progress toward the major Millennium
Development Goal (MDG) of improving maternal
mortality, where efforts during the past two decades
have yielded scant gains.
3. Strengthen prevention and capabilities
to manage health emergencies
Disease prevention offers the best long-run return on
investment. Millions of children die from the effects of
malnutrition; greater investments in nutrition can save
them. Behavior changes can significantly lower the rate
of new HIV infections, curb tobacco use, and reduce
premature death from chronic disorders, which are
rising steeply in developing as well as middle-income
countries. Better lifestyle choices can be advanced
through sustained education. Now is the time for the

United States to share expertise, best practices, and
data, and advance the newly launched Global Alliance
for Chronic Disease.
Meeting emerging threats requires long-range
collaborative investments: building preparedness
among partner countries to prevent, detect, and
respond to the full range of health hazards, including
infectious diseases; and creating reliable opportunities
for poor countries to access affordable vaccines
and medications that will be crucial in combating
pandemics. Strengthening the shared oversight of
food and drug safety is also essential in an increasingly
integrated global marketplace.
4. Ensure the United States has the
capacity to match our global health
ambitions
In an era where much more is possible in global health,
and much more is at stake, the U.S. government needs
greater predictability, order, evaluation, leadership,
partnerships, and dialogue with the American people.
An essential step is to forge a global health strategy,
organized around a forward-looking commitment
of about 15 years, careful planning, and long-term
funding tied to performance targets. Such an approach
could preserve our gains and provide the long-term
predictability and time to achieve substantial progress
in reaching our core goals: improving maternal and
child health, access to contraceptives, preparedness
capacities, control of infectious diseases, and means
to address chronic disorders. Strengthening skilled
workforces and infrastructure around these objectives
typically requires 15 to 25 years. The Commission

recommends that a deputy adviser at the National
Security Council (NSC) be charged with formulating
global health policy; overseeing its strategy, budget, and
planning; and ensuring a strong connection between
the president, the NSC, the Office of Management
and Budget (OMB), and the diverse agencies and
departments responsible for implementation. The
“A smart global health policy can leverage the immense
capabilities and generosity of the
U.S. government and the American people. It can vastly
improve the lives and personal
security of millions of people and in the process, help to
increase worldwide economic
and political stability.” — William J. Fallon
11SynopSIS
Commission further recommends that an Interagency
Council for Global Health be established, reporting
to the NSC deputy adviser. Leadership for this
Interagency Council should be provided by the
Departments of State and Health and Human
Services—the two departments that account for the
overwhelming majority of global health resources
and programs—and should facilitate coordination by
setting benchmarks, reviewing progress, improving
data, and building accountability.
The Commission recommends that a senior global
health coordinator, located in the Office of the
Secretary of State, coordinate day-to-day operations
and implementation of the president’s six-year,
$63-billion Global Health Initiative. The Department

of State has been performing this role to date and has
shown commendable progress in persuading relevant
agencies and departments to work together.
Our in-country ambassadors, as “honest brokers”
at ground level, should lead the integration of our
health, climate change, food security, and other
development programs.
In the face of our current fiscal constraints, we will
need to stay on course to fulfill the president’s Global
Health Initiative (FY2009–FY2014). Over the longer
period, 2010 to 2025, a reasonable growth target is for
U.S. annual commitments to global health to be in the
range of $25 billion (inflation adjusted) by 2025.
There is much to be gained if the administration and
Congress both alter their practices to allow for multiyear
budgeting of long-term global health programs, as well
as for support of innovative financing methods. The
Commission recommends that Congress establish a
House/Senate Global Health Consultative Group for
the next three years to advance long-range budgeting,
promote the implementation of an integrated, long-
term U.S. global health strategy, and improve cross-
committee congressional coordination.
For the first time, the National Institutes of Health
(NIH) has made global health one of its top five
priorities. NIH is now poised to better leverage the
exceptional science and research strengths of our
nation to benefit U.S. global health programs through
operational research, cultivation of the next generation
of scientists in partner countries, and accelerating
the development and delivery of new vaccines and

treatments. These efforts will achieve maximum
benefit if they are closely integrated into a U.S. global
health strategy.
Congress is in the midst of overhauling the
authorities and resources of the U.S. Food and Drug
Administration (FDA), which regulates all U.S. drugs
and 80 percent of the U.S. food supply. Congress
should give the FDA the means to work with our
trading partners, particularly developing countries, to
improve inspection and quality control of food closer
to its place of origin and better coordinate food and
drug safety efforts with regional and multilateral health
and economic institutions.
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Information technology can be applied in several
ways to assess and enhance health programs. A new
measurement paradigm, using proven methods to
document “hard” health outcomes—in terms of lives
saved, diseases and disabilities prevented, and increased
partner government capacities to deliver health
services—will be essential. This step is necessary to
build confidence, generate better data, and strengthen
a culture of measurement and accountability, for
the U.S. and partner governments and other health
organizations. Well-planned evaluations of ongoing
health programs can also provide information
that program managers could use to improve
implementation. The U.S. government can more
systematically tap the special competencies of the
U.S. private sector to strengthen the performance of

U.S. global health programs—for example, through
better utilization of expertise in systems design (supply
chains, workforce training and retention, marketing
campaigns, use of information tools); the placement
of talented business leaders onto boards; and the
development of health insurance in developing
countries. This will build on the results-oriented
approach and private-sector best practices that imbue
the Millennium Challenge Corporation (MCC).
Cabinet officials and other U.S. leaders of global
health programs should more regularly and actively
communicate with—and convey U.S. achievements
with more certainty to—university and faith
communities, philanthropies, leaders in industry and
science, and health implementers. These constituencies
are eager to join a richer and more active two-way
dialogue and to acquire a greater voice and ownership
of U.S. global health approaches. Moreover, they are
fundamental to building an enduring American base of
support for global health.
“When the U.S. devotes resources to global health, we are
establishing global partnerships.
These are not only humanitarian investments; we are ensuring
the security and prosperity
of nations around the world.” — Representative Kay Granger
5. Make smart investments in
multilateral institutions
The Commission recommends that the United States
bolster its collaboration with partner institutions
capable of achieving significant health outcomes: the
World Health Organization (WHO); the World Bank;
the GAVI Alliance; the Global Fund to Fight AIDS,

Tuberculosis and Malaria; and traditional UN agencies
such as UNICEF. The United States will continue
to put a strong focus on its direct investments, since
such a bilateral approach affords greater control and
accountability and strengthens bilateral partnerships
and goodwill, but multilateral approaches offer a vital
and necessary complement. By pooling resources and
efforts with others, the United States is better able
to build health systems, extend the reach of vaccine
and infectious disease programs beyond U.S. partner
countries, devise alliances to meet trans-sovereign
challenges, and mobilize resources and leadership
among our partners. By championing the achievement
of the Millennium Development Goals by 2015, the
United States can demonstrate both its leadership and
the heightened value it places on multilateralism. At
the same time, we need to look realistically beyond
2015 to the considerable additional work that will
likely be required over the following decade to
consolidate and sustain MDG progress.
Enhanced U.S. leadership and engagement
multilaterally will be crucial in three areas: finance,
coordination, and strategic problem solving.
Finance: It is in our long-term interests to make
substantial financial commitments and to make
a stronger diplomatic effort to improve these
organizations’ performance and governance. The
Commission recommends that the United States
increase the share of global health resources dedicated
to multilateral organizations from 15 to at least 20
13SynopSIS

percent, while also enlisting commitments from other
donors, recipient partner governments, and emerging
powers—working bilaterally, through the G-8, and
increasingly through the G-20. The United States
should press the World Bank to significantly step up
its role in building health systems. Finally, the United
States should support, both materially and politically,
promising innovative financing options that could
enable the future mass-scale delivery of life-saving
vaccines or other innovations.
Coordination: The United States’ commitment
to work with others is essential to untangle the
counterproductive proliferation of uncoordinated
donor demands for data. This obstacle to efficiency,
in part exacerbated by U.S. programs, results
in duplicated effort and wasted resources. The
United States could work more closely with other
governments, donors, and organizations in support of
strengthened national health plans aiming for greater
efficiency and streamlined efforts.
Strategic problem solving: The United States can
join with key world leaders, possibly through fresh
global health summits, to seek concrete solutions
to challenges such as the health workforce deficit,
drug resistance to existing therapies, global pricing
of commodities, metrics, and long-term financing.
High-level leadership can pragmatically tie health
investments to improved water, sanitation, and
nutrition. U.S. leadership can also substantially
accelerate efforts to curb global tobacco use: by
ratifying and advancing the Framework Convention
on Tobacco Control; sharing best practices through
the WHO; encouraging partner governments to make

regulatory reform a high priority; and spotlighting
the burdensome long-term health costs of tobacco
use versus the short-term economic gain of increased
production, domestic sales, and exports.
If we pursue these steps, we can accomplish great
things in the next 15 years.
We can cut the rate of new HIV infections by two-
thirds, end the threat of drug-resistant tuberculosis, and
eliminate malaria deaths.
We can significantly expand access to contraceptives,
which will substantially improve the health of mothers
and their families.
We can reduce by three-quarters the 500,000 mothers
who die each year in pregnancy; save over 2.6 million
newborn babies from perishing in their first month of life;
and significantly reduce the more than 2 million deaths
of children under five years of age caused each year by
vaccine-preventable diseases.
Using existing medicines, we can control or eliminate
many neglected diseases that affect billions of people in the
developing world.
We can help build the basic means to detect and respond
to emerging health hazards and build a better system for
ensuring access to essential vaccines and medications when
severe pandemics strike.
And with U.S. assistance, developing and middle-income
countries alike can greatly reduce the premature death and
illness associated with diabetes, cardiovascular disease,

tobacco use, and traffic accidents.
Put simply, we can give global public health an excellent
prognosis for lasting progress.
“Public health conditions in developing countries are critical
not only to those countries
but, in an increasingly inter-connected world, to the industrial
countries as well. Disease
can spread rapidly with modern transportation, trade and travel;
and the industrial
country economies are ever more dependent on developing
country supply chains, with a
corresponding interest in minimizing disruptions or productivity
losses due to disease. The
Commission’s report sets forth a plan for thoughtfully
increasing health care assistance and
for making that assistance more effective.” — Robert E. Rubin
polICy8 CSIS Commission on Smart Global health policy
I | A Quantum Leap Forward
15a Quantum leap foRwaRd
Over the past decade, the United
States has jump-started an historic
health transformation in poor villages,
communities, and countries worldwide.
American engagement, in partnership
with others, has saved and lifted human

lives on a scale never known before. In the
past, such impressive humanitarian gains
might have been seen merely as “soft,” yet
we now understand their benefits include
advancing economic development and
regional stability. More than ever, we
realize that U.S. global health programs are
a vital tool in a smart power approach to
promoting U.S. interests around the world.
We have come a long way. In 2000, Washington
policymakers were debating whether the United States
could muster even a $100-million contribution to the
global fight against HIV/AIDS. Today, the United
States is investing more than $8 billion each year to
protect poor people from HIV, malaria, tuberculosis,
and other threats to a healthy life. If we include U.S.
clean water, sanitation, and other investments, U.S.
commitments exceed $10 billion per year.1
Today, owing to sustained antiretroviral treatment
(ART), more than 4 million mothers, fathers,
daughters, and sons have escaped premature death
from HIV and returned to productive lives. The
United States can proudly and accurately claim that it
directly supports over 2.4 million of these individuals.2
Millions of Zambians, Rwandans, Ethiopians, and
Tanzanians now also live free of the threat of malaria,
thanks to rapidly expanded distribution and use of bed
nets, medications, and insecticidal sprays.
Millions of poor children around the world have been
immunized against measles and polio this decade
with support from the United States. They now
have an opportunity to live full lives, free of these
crippling diseases.

But the United States did not bring about these
changes just by injecting aid dollars. High-level,
persistent U.S. leadership has been indispensable.
Through that leadership, America has rallied global
opinion behind the moral call to reduce the stark
health inequities that divide the world’s rich from its
poor. It has helped the world to confront the reality
that unchecked disease can threaten global stability.
It has catalyzed a new global will for action and
shattered the old conventional wisdom that ART
is too expensive and too difficult to administer in
remote communities. It has sparked unprecedented
investment in the science and research that can lead to
new vaccines and medications for the world’s deadliest
and most costly diseases. And it has helped spur other
donors and international organizations to do far more:
today, the total external investment in global health
exceeds $22 billion per year—still less than needed,
but 20 times more than was available in 2000.3
It has also revealed how U.S. health investments
advance America’s standing and interests in the world.
In the 2007 Pew Global Attitudes Survey, for example,
8 of the 10 countries with the most favorable opinion
of the United States were African states where the
United States has made the greatest health efforts.4
Meanwhile, deaths related to HIV declined by over
10 percent in 12 countries targeted by the President’s
Emergency Plan for AIDS Relief—the majority in
“Smart power is neither hard nor soft—it is the skillful
combination of both. Smart power means developing an
integrated

strategy, resource base, and tool kit to achieve American
objectives, drawing on hard and soft power. It is an approach
that
underscores the necessity of a strong military, but also invests
in alliances, partnerships, and institutions at all levels to expand
influence and establish the legitimacy of American action.
Providing for the global good is central to this effort because it
helps America reconcile its overwhelming power with the rest
of the world’s interests and values.” — CSIS Commission on
Smart Power, 2007
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eastern and southern Africa.5 These health gains have
bolstered regional stability and economic growth,
demonstrating the interdependence of human security
and state stability in fragile regions, and the powerful
impact of “soft” health investments.
The Roots of Success
Recent gains were built on the remarkable
achievements of earlier decades. The
eradication of smallpox in the 1970s,
advances in prevention and treatment
of common childhood illnesses, and the
dramatic progress in controlling polio since
the late 1980s inspired many to ask: why
can’t we do more?
But the tipping point came earlier this decade through
new commitments and financial support from
traditional donor countries and new leadership in the

countries most burdened by ill health and poverty.
Across Africa, Asia, and in many other developing
areas, a new generation of leaders, activists, scientists,
and health experts rose to meet the challenge. Within
the G-8 and the UN General Assembly, among
wealthy donors, across civil society groups and through
new global alliances—most importantly the Global
Fund and the GAVI Alliance—it became possible
to leverage political will and resources, create a new
understanding of the acute burden of infectious
diseases, and open new channels to prevent and
control them.
Most significantly, the American people came to
believe that global health is a worthy, collective good
that must include strong U.S. engagement and that
U.S. leadership on global health is among the best uses
of U.S. smart power—one that can generate dynamic
new partnerships that encompass more than the health
arena. Across presidential administrations and in the
Congress, global health has been largely immune to
political polarization and indeed has become a zone
of exceptional bipartisan consensus. The President’s
Emergency Plan for AIDS Relief (PEPFAR) and the
President’s Malaria Initiative (PMI) are two signature
White House initiatives launched by President George
W. Bush and now sustained by President Barack
Obama through his administration’s emerging six-year,
$63-billion Global Health Initiative. Through these
endeavors, the United States proved that multiyear
plans, geared to achieve concrete results—and
calculated in billions versus millions—create powerful
credibility, momentum, and leverage.
America’s nongovernmental, philanthropic, and faith

communities also embraced the cause of global health.
Many prominent opinion leaders made innovative,
substantive contributions, while also shaping
Americans’ outlook: Bill and Melinda Gates, backed
by their foundation and now supported by Warren
Buffet, have been an especially powerful force, along
with Bono and the One Campaign; the Reverend Rick
Warren and the Saddleback Church; former president
Bill Clinton and the Clinton Global Initiative; former
president Jimmy Carter and the Carter Center; and
Ted Turner and the UN Foundation. Across America,
countless small nonprofit health and development
groups and grassroots activists acquired a new voice,
advocating expanded U.S. engagement in global health
and a two-way dialogue between the U.S. government
and engaged citizens on future strategies.
On American campuses, interest surged among
youth and faculty alike, and promising global health
programs proliferated.6 In the private sector, biotech
firms and pharmaceutical companies forged dynamic
alliances with universities to create knowledge,
innovation, skills, jobs, and long-range global
partnerships. Their impact can be seen in New York
City and Atlanta, North Carolina’s Research Triangle,
California’s Bay area, the Seattle metro area, and the
Boston corridor, to name the most prominent.
In 2008–2009, the prestigious U.S. Institute of
Medicine, with support from diverse U.S. agencies and
private funders, assembled a cross section of the world’s
leading global health experts that critically affirmed

U.S. global health achievements during the past decade
and provided a set of concrete recommendations that
informed the design of President Obama’s Global
Health Initiative.7
The American public applauded these efforts. Surveys
affirmed that in good economic times and bad,
Americans believe U.S. investments in global health
are a worthy use of scarce U.S. dollars and generate
results that enhance human lives. In early 2009, even
as U.S. unemployment was accelerating, a Kaiser
Family Foundation survey showed that two-thirds of
Americans supported maintaining or increasing U.S.
funding to improve health in developing countries.8
Keeping Our Eyes on the Prize
Now, as we look to the next 15 years, the
challenge is to solidify and expand the
progress we have made. If we succeed, we
will see historic gains not just in reducing
mortality and illness but also in building
resilient, competent health systems—as
well as major advances in gender equity,
economic development, and human
security.
Ensuring that women have full access to AIDS
treatments and are empowered—economically, legally,
and politically—can enhance their access to other
health services and enable them to be more successful
mothers and wage earners. Preventing malaria can
unlock economic productivity by liberating parents to
work full days at full strength. The world will continue
to surprise us with threats like H1N1, avian influenza,

“Investing in the health of women and girls around the globe is
one of the most effective, yet
under-utilized, tools for encouraging social stability and
economic prosperity in the developing
world. When women are empowered and healthy, families and
communities will thrive. A
strong commitment to addressing maternal and child health will
save countless lives and is one
of the smartest development investments we can make.” —
Senator Jeanne Shaheen
SARS, extensively drug-resistant tuberculosis, and
more. Yet, creating laboratories and surveillance
systems will help communities and nations shield
themselves against the pathogens of the future, before
these invisible threats do irreparable harm. But taking
the next leap forward will not be easy.
First, disease treatment alone will not create the long-
lasting solutions the world so desperately needs. In the
case of HIV, for example, new infections will continue
to far outpace the numbers of people receiving
treatment unless prevention becomes a true priority
and more effective programs are in place. Prevention is
just as crucial with many other diseases; new vaccines
against diarrheal disease and pneumonia and access to
clean water can avert millions of childhood deaths, and
public education programs can significantly reduce
countless millions of deaths and illness due to smoking
and alcohol abuse. Better safety efforts will reduce
contamination of both food and drugs.
Second, while the past decade has seen tremendous
progress, many gaps and disparities persist. Thanks
to a strong global effort, a mother and her family in
Kenya might now be able to go to a clinic and receive

tests and treatment for HIV. But that same family
might still lack access to bed nets and medications
for malaria or the treatment and care required for
tuberculosis. They might still lack access to basic
prevention and treatments for the parasitic diseases
and diarrhea that so disrupt and limit the lives of the
poor. And while deaths from AIDS and malaria have
gone down, other health issues—maternity care, for
example—have been neglected. To families around the
world, the consequences are all too real: every minute,
one mother dies giving birth, while another 30 suffer
serious complications as a result of their pregnancy.9
Each year, 4 million newborns die in their first month
of life—roughly the number of all babies born in
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the United States. All of these outcomes are largely
preventable with existing tools.
Third, the world will not wait. The earth’s population
is projected to rise faster than ever before, from 6.8
billion today to 8.1 billion in 2025, and possibly
stabilize at 9.1 billion in 2050. Most of that growth
will be in poor, densely populated urban areas that
are prone to infectious disease outbreaks. As we
witnessed in early 2008, when food riots erupted
in over 33 countries, these overburdened cities can
be flashpoints for political violence. And whereas
industrialized countries will see their populations aging
and their birthrates declining, developing countries
will continue to have the world’s highest birthrates and
most youthful populations.10 In Africa, South Asia,

and other low-income regions, women’s health status
and that of their families will benefit directly and
considerably from better access to contraceptives.
The poorest 2 billion people are also likely to
experience high rates of traffic deaths and injuries and
to have rising premature death rates from diabetes and
cardiovascular disease, connected to tobacco use, poor
diet, and obesity.
Fourth, there is no guarantee that the consensus
that enabled our current progress will last. At
home, we face a weak economy, stubbornly high
unemployment, division over reform of our own
health system, record deficits, and a swiftly rising
national debt. The dire fiscal situation is leading to an
intensifying discussion of possible tax increases and
spending cuts. Bipartisanship has frayed on multiple
fronts; bipartisan unity on global health could be the
next casualty. The ongoing debate over the future
of U.S. foreign aid may distract policymakers from
health priorities, even as American global health
advocates are fragmented, anxious, and engaged in a
polarizing competition for funding.
Americans firmly support U.S. investments in global
health, yet they are relatively unaware of the actual
impacts of the more than $30 billion the United
States has expended on HIV/AIDS and malaria
since 2003. Advocates struggle to find compelling
language to describe the global health challenges,
opportunities, and risks that lie ahead. And while
experts acknowledge the need for a new evaluation
paradigm that ties goals to measurable results, they are
hampered by a lack of agreed methods and standards,

quality data, and established analytic capacities.
Internationally, we face potentially daunting long-
term carrying costs for ART, influenced in part by
rising rates of drug resistance to current medications.
Improving maternal and child health, another global
imperative, is a complex, long-term project that
will require patience, perseverance, and new models
that succeed. Economically strapped countries may
not be able to fulfill their pledges to commit more
of their budgets to health. At the same time, many
face internal political barriers to better governance
and resist changing laws to guarantee gender equity,
to better protect women and girls, and to end
discrimination and stigma.
The Time to Act
These challenges are formidable. And
yet, if we act now, we know they can be
overcome.
First, we have more interventions today than ever
before. We have learned a vast amount about how
to deliver treatment, especially for those living with
HIV, tuberculosis, and malaria.We are learning more
“The president’s six-year, $63 billion Global Health Initiative
promises broad developmental
benefits that extend well beyond important health services. Its
success will be enhanced through
broad-based expert advice—of the kind this Commission has
gathered—and by adopting a
business mindset of accountability, systems planning and
careful measurement of true health
impacts. I am very hopeful.” — Rex Tillerson

“On U.S. college campuses we’re finding that our students have
an unconsummated desire for
sacrifice and service. They want to make a difference in the
world. It’s the role of universities
to develop global health education, research and service-
learning opportunities that meet this
desire while also adding value to communities in which students
serve. ” — Michael Merson
about how to effectively prevent disease through
changes in behavior and links with other development
challenges. New vaccines have become available, and
several others are expected to become available in
the next few years. Critical health messages are now
reaching remote communities through the use of new
low-cost technologies such as cell phones and simple
computers. Operational research is showing us how to
deliver interventions more effectively. And, especially
in a time of budgetary restraint, global public health is
a “best buy”—one that can bring preeminent benefits
to the larger U.S. development and poverty-alleviation
agenda, buoying education, agriculture, infrastructure,
and sanitation priorities.
Second, we know the long-term, strategic, integrated
use of U.S. smart power has a multiplier effect.
Investments in global health bring greater shared
global security. Consistent, high-level U.S. leadership
can inspire other donors and partner governments to
reach their targets, convince private industry to create

and deliver low-cost vaccines and medications, and
spur greater efficiency in programs funded by multiple
donors such as the GAVI Alliance and the Global
Fund. To give just one example, in October 2009,
when the United States committed 10 percent of its
H1N1 vaccine stockpiles to the developing world, 10
other countries joined with similar pledges.
Third, the international health community
increasingly recognizes the need to streamline cross-
cutting donor demands and to create new evaluation
tools that better track performance and build
accountability. There is also a new understanding
that national governments must shoulder higher
responsibilities, while donors must make greater
The Consortium of Universities for Global Health
(CUGH) comprises more than 50 schools with global
health programs, working collectively to define the field,
standardize curricula, expand research, influence policy,
and coordinate projects in less-developed countries.
A CUGH study shows that the number of students
enrolled in U.S. and Canadian global health programs
doubled from 1,286 to 2,687 between 2006 and
2009. Spurred by this surge in interest, 20 universities
from the United States and Canada came together in
September 2008 to form a coordinating entity.
The Consortium held its first annual meeting at the
National Institutes of Health in September 2009,
attracting 250 representatives from 58 universities.
The meeting featured panels on public engagement
and global health financing, a conversation among five
university presidents, a keynote address by the Office

Special report, six months onHaitiFrom sustaining lives .docx

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