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Posts Tagged ‘CSIS’

The Kaiser Family Foundation (KFF) and the Center for Strategic International Studies (CSIS) held a panel discussion Wednesday to assess the global health outcomes of the G8 and G20 summits held in Canada last month, where world leaders pledged to reduce maternal and child mortality through the Muskoka Initiative for Maternal and Child Health.

Participants discussed the financial commitments made by G8 nations to reach Millennium Development Goals (MDG) 4 and 5, which deal with reducing child mortality and improving maternal health, respectively. HIV/AIDS was not addressed. Panelists included Jennifer Kates of the Kaiser Family Foundation and J. Stephen Morrison of CSIS. They were joined by Leonard Edwards, the Canadian Prime Minister’s Personal Representative to the G8 and G20 summits, and by Mark Abdoo, Director for Global Health and Food Security on the White House National Security staff.

G8 members committed to contributing an additional $5 billion for the next five years, which will be used to strengthen country-led national health systems in developing countries. Funding will enable delivery on key interventions along the continuum of care, from pre-pregnancy to early childhood.

G8 leaders anticipate that the Muskoka Initiative will mobilize more than $10 billion over the next five years. Already the governments of the Netherlands, New Zealand, Norway, the Republic of Korea, Spain, and Switzerland have collectively pledged $800,000, while the Bill and Melinda Gates Foundation has pledged $1.5 billion over the next five years.

In the past, the global health focus of the G8 has been on reducing the prevalence of HIV/AIDS. However, G8 members have fallen way short of their commitments. In 2005, G8 nations pledged to achieve full universal access to HIV/AIDS treatment by 2010, and pledged to expand HIV/AIDS budgets by $50 million by this year. Jeffrey Sachs, special advisor to the UN Secretary General on the MDG, reports that G8 nations have fallen $30 million short on their pledge.

In 2007 in Norway, G8 leaders pledged $1.8 billion to achieve universal access for children to HIV/AIDS treatment by 2010. UNICEF estimates that an additional $649 million is needed to meet their pledge.

HIV/AIDS is the leading killer of women of reproductive age worldwide. The G8 pledged to reduce the number of maternal deaths by 64,000 in the next five years. However, that goal cannot be achieved without integrating HIV/AIDS care into maternal health frameworks. HIV/AIDS prevention and treatment must be included in all discussions of improving maternal and child health, or else the goals set out will not be achieved and the G8 will continue to fail to meet their commitments.

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Last week, the Center for Strategic and International Studies (CSIS) brought together a number of panelists from various administration agencies and NGOs at an event called “Linkages between Gender, AIDS, and Development – Implications for U.S. Policy.”  Panelists discussed the importance of placing women’s and girl’s health at the forefront of the Obama Administration’s global health efforts, and how policymakers and implementers can integrate programming that has already been proven to be effective, into the new Global Health Initiative. 

Ambassador Eric Goosby, the U.S. Global AIDS Coordinator, opened up the event by stating that women and girls are disproportionately impacted by the HIV/AIDS epidemic, and focusing on women and girls when implementing programs to fight HIV/AIDS will yield positive results for not only women and girls but entire communities. 

According to Goosby, 62 percent of individuals on PEPFAR-supported treatment are women.  PEPFAR will start new women-focused programs next year, such as a new gender-based violence initiative, and the PEPFAR Gender Challenge Fund, which makes an additional $8 million available for strengthening gender-based programs.

Ambassador Goosby explained that the Obama Administration’s new Global Health Initiative will build off existing programs to ensure that the necessary linkages are made to integrate family planning, reproductive health, and HIV/AIDS services.  He explained that women and girls should have access to a ‘one-stop-shop’ for services.  In addition to making more services available, Goosby underlined the importance of engaging in diplomatic dialogue with leaders to encourage them to address discriminatory laws and practices against women.

The resounding message of the day was the importance of integrating reproductive health services, family planning services, maternal and child health services, and HIV/AIDS services all in one synergistic package to ensure that women and girls in developing countries have all the tools they need to protect their wellbeing. 

Dr. Marsden Solomon of Family Health International (FHI) in Kenya explained the necessity of integrating such services by citing that 60 percent of their HIV/AIDS patients have unmet family planning needs.  He went on to explain that integrating HIV/AIDS and family planning services reduces unintended pregnancies, prevents vertical transmission, and improves maternal and child health overall.  FHI began integrating their HIV/AIDS and family planning services in 2001.  Their services include ARV and PMTCT treatment, STI treatment, pre and post-natal care, cervical cancer screening, and post-rape care, among others.

Amie Batson, Deputy Assistant Administrator for Global Health of the USAID, argued that women’s health should be promoted not just in health-related programs, but in economic growth programs, education initiatives, and in governance as well.  Health service accessibility should be expanded as well: commodities should be available at more locations, such as at kiosks or beauty salons.

A number of panelists emphasized the importance of integrating HIV/AIDS services and prevention techniques into economic development programs as a way to address both economic and health disparities.  Lufono Muvhango and Julia Kim described their successes in battling both HIV/AIDS and economic underdevelopment with the Image Program in South Africa.  The program not only provides microfinance loans to women in villages, but also implements gender training programs which aim to empower women to have the confidence needed to fight against sexual violence. 

In South Africa, it is estimated  that a quarter of women are living in abusive relationships.  Women involved in abusive relationships are 50 percent more likely to be infected with HIV/AIDS, compared to women who do not fall victim to intimate partner violence.  After reaching out to 12,000 women in 160 villages in South Africa, the Image Program has not only seen a significant increase in HIV/AIDS awareness, but has seen a 55 percent reduction in the risk of physical and sexual violence.

Pearl-Alice Marsh, the majority professional staff member for the House Committee on Foreign Affairs, stated that there are two major issues blocking progress in women’s health and HIV/AIDS concerns.  The first is funding: Marsh stressed that advocates must continue to pressure Congress to maintain their financial commitments, as well as help African nations get a handle on their budgeting so they can contribute more to the fight against HIV/AIDS and increase their ownership.  The second issue deals with global women’s health being a proxy for anti-abortion advocacy.  Marsh explained that letting ideology and politics get in the way of women’s health amounts to femicide, and more should be done to ensure that such rhetoric does not hinder progress in global women’s health.

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This post is by the Global Center’s Rabita Aziz.
 
Dr. Luis Sambo, the World Health Organization’s Regional Director for Africa, spoke to global health professionals and African diplomats today at an event sponsored by the Center for Strategic and International Studies (CSIS), about progress made toward achieving goals in the Abuja Declarations made roughly a decade ago.
 
The first Declaration, signed in 2000 by many African heads of state,  made commitments to reduce prevalence and consequently mortality from malaria by 50 percent by 2010.  In a second Abuja Declaration, signed in April 2001, heads of states declared HIV/AIDS to be a matter of emergency.
 
African leaders resolved to place the fight against HIV/AIDS at the forefront of their respective national development plans, as well as consolidate the foundations for the prevention and control of the disease through a comprehensive, multisectoral strategy involving all development sectors of government.  The leaders pledged to take more responsibility for the HIV/AIDS response, while also calling for an increase of external resources. 
 
In addition, the Abuja Declaration removed all taxes, tariffs, and other economic barriers to access funding for HIV/AIDS related activities.  Leaders also pledged to allocate 15 percent of their annual budgets to the improvement of health sectors.  The Declaration called for improving the availability of medical products and technologies, as well as supporting the development of vaccines.
 
Sambo said not all of these goals have been achieved.  For example, African nations on average allocate 6 percent of their budget to health sectors, instead of the pledged 15 percent, due in part to budget deficits.
 
But he also noted many successes in the fight against HIV.  Since the Declaration, there has been an improvement in diagnostics, care and support, and prevention, and dramatically higher coverage of antiretroviral therapy. In 2002, only 2 percent of patients in need of treatment were receiving it; in 2008, that number jumped to 44 percent.  HIV prevalence has dropped from 5.8 percent to 5.2 percent, and the rate of new infections has declined by 25 percent in that timeframe.  And since 2004, the annual number of HIV-related deaths has fallen by 18 percent.
 
Sambo said much of these successes were achieved thanks to external funding mechanisms, such as PEPFAR and the Global Fund.  He stressed that Global Fund and PEPFAR funds made significant contributions to change lives and provide hope.  Sambo also expressed high hopes for President Obama’s new Global Health Initiative, and expects it to be a powerful initiative that will bring many positive results.
 
Despite these achievements, Sambo warned that not enough is being done and gaps in funding are allowing prevalence and mortality numbers to remain high.  For every HIV patient being treated, three more are newly infected, he noted.  Fifty- five percent of HIV infected pregnant women are not receiving ART prophylaxis, while 58 percent of all infected people have no access to ARV treatment.  Life expectancy in the continent has dramatically shortened, with an average life expectancy of at least 60 years in the 1990s, to less than 50 years in 2010. 
 
Sambo also stressed that HIV-TB co-infection continues to be an emerging problem, as the number of TB cases continues to increase and remains the leading cause of death among HIV patients.  The emergence of MDR- and XDR-TB is making the HIV response even more difficult.  Sambo expressed that the failure of integrating HIV and TB services has caused many of the difficulties, and that it’s difficult to achieve integration when two-thirds of funding needs for HIV-TB co-infection are unmet.
 
Health programs, he said, are receiving half of the funding needed for the HIV response.  In total, Africa requires $12 billion to deal with the HIV/AIDS crisis, but is receiving $6 billion.  He said $2 billion is required for the TB response, but $1 billion is available.  In addition, he said $10 billion is needed for health systems strengthening, but African nations have $5 billion at their disposal.
 
But Sambo said funding wasn’t the only issue.  He said African nations need to take on more responsibilities and ownership of programs, and broaden their health policies to go beyond disease control.  In particular, he said, broader health determinants need to be addressed, such as poverty, lack of food security, lack of education, and environmental degradation.

He cited a need for increased support for maternal and child health, as well as a larger focus on women’s and girl’s development.  Nations also need to develop capacity for health research and information systems.  Most importantly, leaders need to make a renewed commitment to fighting the HIV epidemic, as well as use funds more efficiently.

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This post is by the Global Center’s Rabita Aziz.

Dr. Thomas Frieden discussed the Centers for Disease Control’s global health agenda today at an event sponsored by the Washington-based Center for Strategic and International Studies. Frieden, who became director of the CDC in June 2009, spoke about the CDC’s work in reducing the prevalence of global HIV/AIDS and about his commitment to tuberculosis control. Frieden led New York City’s efforts to control and reduce multidrug-resistant tuberculosis cases in the 1990s. He then went on to work with the Indian government to assist with national tuberculosis control efforts, which resulted in more than 10 million patients being treated and 2 million lives saved.

Frieden outlined the themes and goals of the CDC’s new Center for Global Health, led by Dr. Kevin DeCock. The new Center aims to strengthen the use of data to manage health programs and bolster governmental public health systems. Other goals include developing country capacity, ensuring global health security, and ultimately helping people live longer and healthier lives. Working to achieve these goals will generate trustworthy data that can be relied on to make good decisions, and it will also help create good public health sectors.

Frieden went on to say that it is essential to develop disease-specific programs as a means to achieving their goal of helping people live longer and healthier lives. He said it’s imperative to establish effective HIV/AIDS and TB programs, and implement methods that we know work, while also learning more about things we don’t yet understand. It is also imperative to garner political leadership and commitment, as many decisions made in the field of global health are political decisions.

He cited PEPFAR as an excellent example of what can be achieved with proper political commitment and leadership. Frieden explained that before PEPFAR, there were countries in Africa in which two-thirds of all adult deaths were attributed to HIV/AIDS. The scale-up of ARV treatment has drastically reduced these numbers and has extended the lives of millions. He went on to say that PEPFAR-funded ARV treatment has helped in reducing the spread of HIV as well. He also cited big successes in reducing the number of vertical transmissions, with over 300,000 children of HIV-positive mothers being born free of HIV in recent years. In addition, programs like PEPFAR help support ministries of health and strengthen health systems, which has a positive impact on other areas.

Frieden also spoke of the success of TB programs, which have cured 36 million patients and have saved 5 million lives in the past 15 years. Despite these achievements, Frieden emphasized that TB programs need to be strengthened further, as there are too many countries facing drug stock-outs and dealing with poor laboratory capacities.

One audience member asked Frieden to comment on the recent reports of of HIV-infected persons being turned away from clinics in PEPFAR countries such as Uganda, in part because of flatlining of funding for global AIDS programs. Frieden responded to this concern by saying, “We’re not at a situation in any country where we’re limiting expansion.” He went on to say that an effort is being made to encourage other nations to step up their own treatment programs.

Watch a portion of Dr. Frieden’s discussion here:

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The Center for Strategic and International Studies yesterday unveiled  a new “must-read” report for global health advocates, “Smart Global Health Policy.” While a panel at the Congressionally-chartered Institute of Medicine, made up primarily of scientists, issued recommendations on US global health policy last year, the CSIS panel is the first to involve high-level business leaders and sitting members of Congress.

The report drew on observations made during a study trip to Kenya, but it is unclear if consultation in developing countries went beyond that, for instance to include global representatives of affected communities and of developing country civil society, such as those on the boards of UNITAID and the Global Fund.

The report and the webcast of the launch event are available online.  Here are a few highlights:

The report makes a strong case that it is in the interest of the United States to continue and increase  our investment in global health and that the issue should matter to all Americans. It calls for keeping funding for AIDS, TB and malaria on a “consistent trajectory,” doubling spending on maternal and child health to $2 billion a year, forging a collaborative response to emerging heath threats, establishing strong coordination of global health policy across US agencies, and increasing support for multilateral efforts.

In 2009 there was a massive drop off in the expansion of treatment by US programs, and the report notes that AIDS advocates are “particularly anxious” at the slowing growth rate, a stalling that could also impact health systems.  The report suggests that funding is a concern for treatment advocates, yet, in fact, HIV prevention advocates have also been quite alarmed at the essentially flatline funding picture.

Despite World TB Day (March 24) being just a few days away, no mention is made in the report of immediate tuberculosis funding concerns, lowered TB targets in the 6-year Global Health Initiative or USAID’s role in responding to TB.  Instead, the report includes TB within a much longer timeframe, stating that “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.”

In terms of overall funding, the report calls for less spending in the near term than either the IOM panel or the Global Health Initiative coalition did; instead, the CSIS document endorses the President’s proposed funding of $63 billion by 2014.  While the IOM called for specific increased funding levels on AIDS, TB and malaria consistent with Lantos-Hyde, the CSIS report does not delve into specific funding levels, with the exception of maternal and child health.  Instead, taking the long view, it calls for $25 billion in annual spending by 2025.

One exciting aspect of the CSIS report is that it endorses innovative financing as a means of raising funds for global health.  The report does not touch on the concept of innovative taxation for health, recently championed by maternal health advocates at Family Care International and many other groups. However, it identifies some specific mechanisms, such as borrowing the money needed through an international finance facility, and it urges the US National Security Council to review the most promising ideas on innovative financing and develop a US position.

Admiral William J. Fallon kicked off the launch event, stating that global health is a “bipartisan enterprise… which can unite US citizens in collective action.”  He stated the importance of maintaining forward momentum, noting that “we do not want to coast or slide backward.”  Helene Gayle said that global health efforts are showcasing the American spirit of generosity and said “we need forward momentum even in a period of constrained resources.”

Jack Lew, the top State Department official developing the US Global Health Initiative, spoke about the Administration’s goals in developing the new strategy. He said that the Administration’s aim was to “challenge a way of doing business by moving beyond a primary focus on disease treatment.”  He said the goal was “not to do harm to existing programs.”

Advocates for effective HIV prevention have felt stymied in recent weeks by the lack of specific HIV/AIDS guidances from the Administration to the field and have noted that Kenya’s Partnership Framework with the US even appears to rule out family planning integration.  Family planning came up at the event when Dr. Michael Merson, of Duke University, criticized the Canadian government’s rejection of the inclusion of family planning as a part of its maternal health initiative.

But Lew’s presentation did not delve into details — and there was no opportunity at the event for questions from the floor.  He stated that program integration was crucial to meet the needs of women, and he commented on the importance of having family planning and HIV/AIDS services in one location.

The report is particularly noteworthy for the very strong focus on measurement for accountability in delivering services. Business leaders at the event decried the reporting burden on health programs and, along with Dr. Merson, called for a common set of impact indicators.

Rajeev Venkayya, Director of Global Health Delivery at the Bill and Gates Melinda Foundation, said that measurement matters because it allows us to maximize efficiency and stretch dollars while identifying what works and what doesn’t.  In addition, measurement allows us to hold accountable institutions, organizations, and even individuals, which in turn allows for greater project improvement.  Exxon Mobil Chairman and CEO Rex Tillerson agreed, and cited a Lancet article which said that evaluation must be a top priority for global health.

Robert Rubin, former US Treasury Secretary and former head of Citigroup and Goldman Sachs, told the audience that global health leaders “face wrenching choices” as a result of US fiscal problems.  He asked two members of Congress, Rep. Keith Ellison and Senator Jeanne Shaheen, whether global health is an issue that can “break through the mire” on Capitol Hill.

Senator Shaheen said that the issue can succeed, but it is crucial to explain to Americans that international affairs spending is only a tiny fraction of the US budget, much less than people realize.   She said it was cheaper to spend on global health than on war, noting Bill Clinton’s recent statement about the appreciation of PEPFAR expressed by Muslim residents of Tanzania.  She also said the current committee structure in Congress is an impediment and endorsed the recommendation included in the report for a consultative body that would work across committees.

Congressman Ellison also voiced strong support for greater US action on global health, stating that “infectious diseases know no borders.”  He said that while in Kenya, he made good progress in persuading Kenyan leaders of the necessity of stepping up their own contributions.  He suggested that by reducing US spending on outmoded weapons systems the US could improve its budget outlook and make global health spending easier.

Gayle Smith, the NSC official leading the development of the US Global health Initiative, was the concluding speaker at the event. She said global health was a bipartisan issue and that in fact President Obama specifically directed that the achievements of the previous Republican Administration be recognized.  She praised the CSIS report, and said that its ideas were remarkably congruent with those of the Administration.

She said the Administration’s commitment to fighting global HIV/AIDS was “absolute” and, she added, “this will grow over the life of the initiative.” She said the Administration’s plans for the Global Health Initiative “include an ambitions set of targets in terms of outcomes.”

She did not respond to concerns submitted to the Administration by the Global Center, TAG, the Global Health Council, and the GHI Working Group that the Administration’s targets regarding tuberculosis contradict a directive from Congress approved in 2008 as a part of Lantos-Hyde.  In fact, it was surprising that the event unfolded without  reference  to the consultative process which numerous NGOs have engaged in regarding the US Global Health Initiative or to the detailed analyses these groups have submitted to the Administration.

There were a range of reactions from health NGOs to the event.  Eric Friedman at Physicians for Human Rights noted the “surprisingly little attention in the report to human resources for health and health systems, and no mention of including civil society in the development of country compacts.” He praised the report for “proposing that the Administration develop a long-term, 15-year framework for making progress in and committing the United States to improving global health, a good idea so long as it does not set the stage for underambition, and is flexible to respond to changes in the years ahead. ” He also would have liked to see “a recommendation that the United States should deliberately integrate a right to health approach throughout U.S. global health programs, including the consistent focus on equality, accountability, and participation that this entails.”

Matt Kavanagh at Health GAP praised what he heard from the report, which included an emphasis on keeping up the fight against HIV/AIDS, especially important for the health of African women. But he noted with concern that “some of the Administration comments that seemed to favor prioritizing ‘cheap’ interventions that do not work in the long term, such as single dose nevirapine instead of treatment for HIV positive mothers, an approach abandoned long ago as ineffective in wealthy nations.”

The American Medical Students Association’s Farheen A. Qurashi said that the report “takes a bold, but necessary, approach to U.S. global health planning by insisting upon a 15-year comprehensive plan.”  She said, “Unfortunately, the Commission’s report does not appear to specify the need for scaling-up of PEPFAR investments versus the dangers of flat-funding, and instead uses language that suggests that a continuation of current levels of funding without annual growth is sufficient.”

On health systems, she said that “though integration and health systems strengthening is mentioned in general terms, and the need for training and retention of health care workers is noted, there is no detailed analysis of the measures, funding, and support necessary to establish and retain adequate numbers of health professionals and other health care workers.”

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Evaristo Marowa, UNAIDS Country Coordinator for Botswana, said today that major opportunities to prevent HIV, and save billions of dollars in the long run, will be missed if the US and the international community fail to increase AIDS funding for Botswana and other countries in southern and eastern Africa. 

He made his comments in a presentation at the Global Health Council, where he also provided a powerpoint:  Botswana HIV epi and responses.  Dr. Marowa’s presentation comes as global AIDS advocates anxiously await next week’s release of President Obama’s budget proposal.  His urgent warning about the danger of donors adopting a flat or near-flat funding approach provided an interesting counterpoint to last week’s CSIS publication on HIV prevention, which did not mention the need to increase funding in its recommendations to the US government.

Dr. Marowa is a physician with a specialty in dermatology and sexually transmitted infections (STIs). He trained at Universities in Harare, Kinshasa, Liverpool and London.  Since September 2006, he has been the UNAIDS country coordinator in Botswana, and previously he worked in Tanzania, Zimbabwe, and Bangladesh.

HIV prevalence in Botswana has fallen in recent years from 38% to 24%, with declines seen particularly in young people. The country has had strong leadership on the issue at the highest levels, which Marowa called “visionary and committed.” Prevention of mother-to-child transmission has been “an astounding success,” with a transmission rate of about 4%.  A large proportion of people have been tested for HIV, about 60 to 70%, and access to antiretroviral medications is also high at about 85%.  PEPFAR has been a major support to these programs, providing about $90 million a year.

However, he said that a high degree of internal mobility in the population, multiple concurrent partnerships, low rates of male circumcision, low condom use, and high rates of gender-based violence, which form the basis for an ongoing HIV/AIDS crisis.  Marowa also cited alcohol abuse as a contributing factor, an issue on which he said the current president was very active. (more…)

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Despite a nearly flat budget, US Global AIDS Coordinator Eric Goosby today promised a “steep increase” in PEPFAR’s prevention activity, as the program pivots from an emergency US response to a broader long-term, country-driven endeavor. Indeed, Dr. Goosby signaled that PEPFAR will be as aggressive in scaling up prevention services in the next five years as it was in scaling up HIV treatment in the first five years.

Dr. Goosby spoke at a forum on US priorities in HIV prevention, hosted by the Center for Strategic and International Studies. In his opening remarks, Dr. Goosby described the huge challenge facing HIV prevention experts, noting for example, that for every 2 patients put on antiretroviral drugs, there are five who become newly infected. He also cited a National Intelligence Council estimate that by 2025, there could be as many 50 million HIV positive people living with HIV—25 to 30 million of whom would require treatment.

Dr. Eric Goosby Talks about PEPFAR's New Plans for HIV Prevention

PEPFAR’s efforts going forward will center on “combination prevention” models that deploy biomedical, behavioral and structural elements. Dr. Goosby said PEPFAR’s new effort to more accurate map the HIV/AIDS epidemic in high-burden countries will help program officials develop more effectively targeted strategies that move “from the demographics backward.” And he said PEPFAR would also try to better evaluate programs so they know what works and what doesn’t.

“We want to be nimble enough in our understanding of what we’re doing to identify efficacy and move the machine … when we see something that indeed does impact,” he said.  (Click here for more on PEPFAR’s five-year strategy.)

During a panel discussion afterwards, Dr. Goosby was asked how PEPFAR could achieve such ambitious prevention efforts with only minimal funding increases. He said the modest funding increases allocated so far, along with cost savings, such as anticipated decreases in treatment costs and eliminating funding that’s now directed to multiple groups to serve the same populations, would be sufficient to beef up prevention at time of constrained budgets.

He also said the US is pushing other wealthy countries to step up their commitment to combating the epidemic, so multilateral organizations, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, would be better funded. 

“The Global Fund is kind of the future,” he said. “We need to work hard to make it everything it needs to be.” He said discussions with other G8 leaders have already begun, but the effort will require leadership from President Obama and Secretary of State Hillary Clinton. (more…)

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