Gayle Smith on the Federal Role in Global Response to Health and Climate Crises

[Gayle Smith]

I think the difference, quite frankly, between the COVID pandemic and the Ebola epidemic is that there was, for the first time in my lifetime, a real challenge to data and evidence and a questioning of the facts. We have entered into a period where facts seem to be debatable by some. And so it was more complicated, quite frankly, during COVID -- much more.

[Rick Stoddard]

I’m Rick Stoddard from Mathematica, filling in for J.B. Wogan, and welcome back to On the Evidence.

This episode is another in an occasional series on the show that we call Evidence in Government, where we talk about what’s happening in the halls of government and the role evidence can or should play in decisions that could improve people's lives.

My colleague Mike Burns leads these episodes, and he is Senior Director of Communications and Public Affairs here at Mathematica.

Our guest for this episode is Gayle Smith, former administrator of the United States Agency for International Development, or USAID, during the Obama Administration. She is currently the chief executive officer of the ONE Campaign, an international advocacy organization working to combat extreme poverty and preventable disease.

Mike talked with Gayle about how the federal government’s use of data and evidence in response to global health emergencies has evolved over two decades—from HIV and AIDS, to the Ebola epidemic, to the COVID-19 pandemic and climate change—and what policies and legislative actions are needed for continued progress and potential prevention of future crises.

We hope you enjoy the conversation.

[Mike Burns]

Gayle, thank you so much for joining us. I know you've got a lot going on, saving the world, so we appreciate you taking some time to talk with Mathematica today. Let's dive right in.

[Gayle Smith]

Sure.

[Mike Burns]

So, in 2016, while you were USAID administrator, you spoke at a Brookings event on the role of evaluation in assessing the impact of foreign assistance. You explained that USAID, over the past five years, had built evaluation into its DNA. And you stated that development is aspirational, but it's also a discipline. What spurred this shift from, as you put it, saying, "This is our success" when describing USAID projects and programs, to instead explaining, "This is what we know and how we have learned from trial and error"?

[Gayle Smith]

Thanks. That is a great question. I mean, originally, it came out of an exercise we did when I was at the White House to establish a global development policy. But one of the things we defined as critical to that is bridging that gap, as my quote suggested, between aspiration and fact. And USAID spends a great deal of money. It's taxpayer money. We've got to persuade the Congress to give us more. We also need to know whether we're being successful and effective. And evaluation in the field of development has become a much more prominent issue. And I think we felt that if we were a bit more rigorous in looking at what worked and what didn't, we could do several things.

One, learn from it -- learn to take more risks, right? If you have a better sense of what works and what doesn't, you might get a little bit more creative. And make the case to the American public and the Congress that we can invest these resources to positive, demonstrable ends.

[Mike Burns]

This learning really came at a key time, because, of course, we can't forget, while you were at USAID, you helped lead the U.S. response to Ebola. How did you apply evaluation to the response? What were some of the lessons learned?

[Gayle Smith]

Yeah. Well, one of the things that happened is that we ran this whole process to kind of overhaul how we did development, build evaluation in. I was actually still at the White House during Ebola, but playing a leading role there. And my friend Raj Shah was leading USAID at the time, and he was a real nut for data and evaluation. And I think the thing that really, really helped us -- and a lot of this was USAID, a lot of it was the Centers for Disease Control, with WHO and others -- was our ability to track the virus. Right?

Because what we needed to do was make sure that we could move faster than the virus. That's how you win and turn an epidemic around. And there was a lot of data available. There was increased capacity built, and it was the thing that informed where we put treatment centers, where we invested our resources, what we needed in lab and diagnostic capability. And I'd say, as challenging as that whole experience was, and as horrible as it was for the people in those three countries in West Africa, the fact that we had this tool in our hands that allowed us to track the virus, track the response, and therefore move in real time, was probably the most significant and impactful resource that we had.

[Mike Burns]

On the topic of epidemics, in 2017, after you stepped down from USAID at the conclusion of the Obama administration, you become CEO of ONE.

[Gayle Smith]

Right.

[Mike Burns]

Then, in 2021, at the request of the State Department, you took on a temporary role as coordinator for Global COVID Response and Health Security, where, again, you played a leading role in the U.S. effort to end a global pandemic of COVID-19. How did data and evidence inform that fight?

[Gayle Smith]

You know, it's interesting. In many ways, it was similar to Ebola, or similar to the fight against against HIV and AIDS. In a health crisis, and particularly when you've got a virus, a lot of data can be generated. There's a lot of monitoring. Testing will tell you a lot, diagnostics will tell you a lot. You can literally track and map the spread of a virus. And that information was critical, as was data on the incidence of COVID cases, the death rates, the availability of things like oxygen and things that were so critical.

So, again, these are the tools that allowed us and the rest of the world, again, to map out a response, to see where the spikes were, to see where the vulnerabilities were. I think the difference, quite frankly, between the COVID pandemic and the Ebola epidemic is that there was, for the first time in my lifetime, a real challenge to data and evidence and a questioning of the facts, so that, in many ways, it was harder than I think it otherwise would have been, because for whatever reason, we have entered into a period where facts seem to be debatable by some. And so it was more complicated, quite frankly, during COVID -- much more.

[Mike Burns]

And that's particularly troubling, given the scale of this global health crisis. And you really -- you had a front-row seat. What would you say have been some of COVID's biggest impacts on major global health issues, like HIV/AIDS, malaria, and maternal and reproductive health?

[Gayle Smith]

Look, on the negative side, the pandemic has had a huge impact on global health -- negative -- in a number of ways. At periods where people were under lockdown and/or health systems were under stress, which was at large intervals throughout the pandemic, the ability to treat patients -- say, TB patients who have to go back for treatment on a regular basis, people who need to go and get their ARVs.

If the clinics are closed, unavailable, stressed, full of COVID patients, it became much, much, much more difficult. So we did see some losses, in terms of the progress that's been made over the past years, because of the impact of the pandemic. The pandemic also had huge financial implications. And so we saw a decline in investments in the health sector, in the sort of day-to-day building primary healthcare, these capacities to fight other diseases, because it was divergent to COVID.

On the other side, I think one of the things we did learn is that decades now of investment in global public health, by donors by also by governments themselves in many cases, including low-income countries, has built a foundation that was helpful. There were systems to use as the basis for testing, treatment, and so on. There was a greater capability than there would have been, had this hit 15 or 20 years ago, to collect data and, again, track the virus. But it had a huge negative impact, I think, on the world's progress on global public health.

[Mike Burns]

So, in the past, you've warned that our bilateral and global agencies are not moving fast enough to combat things like HIV and Ebola. And I'm sure you've also seen how funders can get fatigued by these same issues despite the effect they have on human health and well-being. Has this view changed since the pandemic? Has ONE evolved as a result?

[Gayle Smith]

Well, look, I think what we've seen on something like HIV and AIDS, that's an area where I would say the world has really sustained its focus. And that doesn't happen everywhere. But it was 20 years ago almost that PEPFAR was launched by President Bush, but then supported by subsequent presidents, or most of them. The Global Fund for HIV/AIDS -- or AIDS, TB, and malaria -- other things started. And support for those has been sustained, I think, in part, because we can demonstrate the impacts: in terms of the number of people worldwide who are now on ARVs; in terms of cutting the global death rate from HIV in half; from the babies that are alive now because HIV wasn't transmitted to them by their mothers. I do think there is a "crisis of the moment" problem that we all face.

So, for example, after the Ebola epidemic, there was a great interest in what came to be known as global health security -- building the capacity to prevent, detect, and respond to global health threats. That was sustained for a year or two, and then, frankly, a lot of funders -- some government, some outside of government -- kind of lost interest, went to the next thing. Then, whoops, what do you know, we've got a COVID pandemic. In that, we saw a spike in increase in surveillance, in all sorts of things we need to do so that when another virus hits, we will be better prepared. That's already begun to wane, that interest.

So I think there is a challenge in terms of sustaining interest and financing long enough to do that thing which we know is very smart, but we don't do, which is invest in prevention and preparedness. We still kind of -- The world tends to wait until things get bad.

[Mike Burns]

You mentioned PEPFAR.

[Gayle Smith]

Mm-hmm.

[Mike Burns]

And actually, this year marks the 20th anniversary of the law -- the President's Emergency Plan for AIDS Relief. It's estimated to have saved 25 million lives around the world, improved health outcomes. And ONE has pointed out that we aren't in the finish line yet against HIV and AIDS. What's it going to take to get to the finish line and to cross it?

[Gayle Smith]

It's a really good question. And we're not at the finish line yet, but I just want to take a second to say something about how far we've come and where we would be if this hadn't happened. HIV is a much more lethal virus than COVID. And so if you think about, had that gone unchecked, what it would mean for the world, it's pretty dramatic. I think what it's going to take to get over the finish line is three things.

One is sustained funding. This is not the time to dial back. The second is sustained investments in political capital. Look, it takes political leaders in countries all over the world to make the decision that this is a priority, to empower health ministers, to allocate the funds from budgets to do this. That takes political capital, and that's probably harder today than it was years ago, because I think a lot of people think, "The AIDS epidemic -- isn't that kind of over?"

And then I think the third thing is really focusing on those people that the world hasn't yet reached. If you look at where incidence of HIV is highest now, it's girls and young women, many of whom don't have the agency to be able to prevent getting infected. It is people who may otherwise be discriminated against or isolated. And so we've really got to double down and focus on those groups of people that still haven't been reached and to whom ARVs are just a hope.

[Mike Burns]

On the piece about funding it, I know we're in appropriation season.

[Gayle Smith]

Yep.

[Mike Burns]

It's a little sticky, to say the least. You've defended budgets before. What would be kind of your recommendations to appropriators, to members of Congress as we, hopefully, come out of August recess and fund the government? What would you say to them at this, I think, really critical time?

[Gayle Smith]

Well, I'd say, "It'd be a really good idea if you'd fund the government." So that would be -- that would be number one. But I'd say a few things. I would say, "Take a minute to reflect on it and take the credit for what the world has achieved with the United States, I think, very much in the lead on HIV and AIDS to date." And one of the great things is that there's really been a bipartisan, nonpartisan consensus on this, and people should be proud of that and take credit for it. And also recognize what that means for the United States. People all over the world know and identify the United States as the country that took the lead on this. I think I would also make the point that it's really in our interest to do this.

We know that threats, like viruses, cross borders, so we've got some enlightened self-interest to put on the table. What I really would say, though -- because HIV and AIDS, this kind of funding is a part of what we include in a foreign-aid budget -- I would argue for a really robust, big foreign-aid budget. You started by asking a question on evaluation. I think USAID is much better today than it's ever been on showing the evidence of what works and what doesn't. If you look at the Millennium Challenge Corporation, they're state-of-the-art on that. So I think we've got the transparency, the ability to show what works. I think it's in our interest to have a robust foreign-aid budget. I'm also one of those who also believe that it's an expression of our values. So I'd make a very strong pitch that this is really an important moment to lean in.

[Mike Burns]

That's a great message. Let's hope they hear it...

[Gayle Smith]

Yeah. [ Chuckles ]

[Mike Burns]

...and they take it to heart. So, switching gears just a little bit...

[Gayle Smith]

Mm-hmm.

[Mike Burns]

...I'm very curious to hear your perspective on the intersection of development finance and climate change. In a statement welcoming the appointment of Ajay Banga as president of the World Bank, you said that, "The capital needed to support low- and low-middle-income countries hit by a pandemic, climate change, and rising food and fuel prices is in short supply." What actions are needed to deliver climate-resilient development amid constrained finances?

[Gayle Smith]

Well, we've got to unconstrain the finances. And this is something that's a big priority for the ONE Campaign and many of our partners and people around the world at this moment. It's very kind of policy-heavy and wonky, but the short story is that there's a real push to modernize the global financial architecture, and particularly things like the World Bank. These multilateral development banks are really important institutions, but they were built a long, long time ago. And there are steps that could be taken in modernizing those institutions that would generate a lot more capital than is presently on the table. So we are pushing for that because we've just got to have more money on the table. We can't do climate change, pandemics, the shocks of food insecurity, all of these things, on the cheap.

And again, going back to prevention, if we invest in it now, we reduce the risk of greater cost to human life and budgets all over the world in the future. So that's how these things come together. And we really see that development and climate change are linked. You can't really delink them, whether on the impact side, that climate change and poverty feed each other in negative ways, or in the way that there are all sorts of solutions in terms of climate change that could be game-changers for economic growth and development. So we see them as together, but we've got to get more resources on the table. And there's a good opportunity to do that.

[Mike Burns]

So, just one final question.

[Gayle Smith]

Sure.

[Mike Burns]

I know this is an important issue to you. I read a "Politico" interview you did with Ambassador Linda Thomas-Greenfield, where you mentioned the pandemic's extraordinary economic impact on women. What needs to happen now to address those gendered impacts on society?

[Gayle Smith]

Look, I think, over time, one of the things we really need -- and given that a lot of the focus of our discussion here today is about data and evidence -- we need gender-desegregated data. We need more data to prove something that I think we can demonstrate in fact. But I find that we've got to repeat too often. In almost every crisis, you can look to a greater negative impact on women and girls. And there are a lot of reasons for that, most of them having to do with access to the tools they need and status within a country and an economy.

So I think that's one thing that we need. It needs to be part of, if you will, the regular order of assessing how we are. I think the other thing is -- and it's certainly not the case men can champion the causes of gender very well -- and I've seen many of them do it -- I think we need more women also in positions of leadership in this field. I think that would make a difference.

And the last thing is, we just need to measure, measure, measure, because the evidence and the data is there of not just the negative impact on women and girls but of the opportunity costs that are incurred if we let that continue.

[Mike Burns]

Well, I think that is a great message to end on. Gayle, I want to thank you so much for your time. Where can folks learn more about you and about the ONE Campaign?

[Gayle Smith]

Go to one.org. And we would love to have you join us in our campaigns. You can learn more, and we'd love to see you.

[Mike Burns]

Thank you so much, Gayle.

[Gayle Smith]

Thank you.

[Rick Stoddard]

Thanks to our guest, Gayle Smith, and thank you for listening to another episode of On the Evidence, the Mathematica podcast. If you liked this episode, please consider subscribing to catch future episodes of the podcast. We’re on YouTube, Apple podcasts, Spotify, and other podcast platforms. You can also learn more about the show by visiting us at mathematica.org/ontheevidence.