Harvard School of | Debrework Zewdie, Former Director of the World Bank Global AIDS Program, and Deputy Executive Director and COO of The Global Fund

BEVERLY HO: Good afternoon. My name is Beverly Ho. I'm a physician from the Philippines and a candidate for the master of public health in health policy and management here at the Harvard TH Chan School of Public Health. It is my privilege to welcome all of you today and to introduce Dr. Debrework Zewdie.

Her 30 year career in strategy, policy implementation, management, and teaching encompasses national, regional, and global levels. Among the many highlights of her career are her innovative and groundbreaking HIV/AIDS program for the World Bank, her co-leadership and management of the organizational restructuring of the Global Fund to fight AIDS, , and in her capacity as its deputy executive director and chief operating officer, and her instrumental role in making the unique structure of UNAIDS a working reality. By pioneering the call for a large scale multi-sectoral response and subsequently providing direct financing to civil society and the private sector, she changed the landscape of HIV/AIDS financing.

Dr. Zewdie's passion for women's health also led her to be a co-founder of the Society of Women and AIDS in Africa. She's a sought after lecturer and public speaker in leading academic institutions and mass media outlets, as well as a thought leader, having published in over 100 journals and book chapters on a variety of subjects. Dr. Zewdie obtained her PhD in clinical from the University of London and was Senior MacArthur Fellow at the Harvard Center for Population and Development Studies.

She's currently a Menschel Senior Leadership Fellow at the Harvard TH CHAN School of Public Health. Before I turn the session over to our moderator for the day, Dr. , Harvard University Distinguished Service Professor, and Joan and Julius Jacobson Professor of Public Health, please join me in welcoming Dr. Debrework Zewdie to the Voices of Leadership Series at the Harvard TH Chan School of Public Health.

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BARRY BLOOM: Debrework, welcome. It's an enormous pleasure and joy for me to be able to have a conversation with you and have such bright students to be able to listen in to our conversation, and hopefully, people around the world. This is a program that brings to this place people who've exerted real leadership in a variety of areas of health around the world. And perhaps, there's no more fitting conclusion to this first year of Voices in Leadership than to hear from you, to answer for all of us a question that, since I've known you for 25 years, has always been on my mind.

How is it that a little girl who was born in a provincial city in managed to create, organize, motivate, run the largest program in health that the World Bank had ever done before that time? And we want to hear about how that happened. But let me just start by asking you to tell us about the experience at the Bank and how one moves this giant male dominated organization.

DEBREWORK Thank you, Barry. Both the pleasure and the honor is mine. It's a wonderful institution and teaching brilliant ZEWDIE: students is such a joy. I joined the World Bank in 1994. When I joined the Bank, there were bits and pieces of HIV/AIDS programs, mainly, in health projects. There wasn't anything to scale or something which would-- in my opinion-- would have made a difference. And around 1999, a study, a demographic study, from Botswana came out, which showed that life expectancy due to HIV/AIDS in many of these countries is declining. We used that has an opportunity. Because up to that time, there was a big push, unfortunately, from most of the economists of the Bank who didn't want the bank to get engaged in something long-term, indefinite, and may not be economically cost effective.

So when we got that study on the demographic of Botswana, we said, well, is the Bank's business development? Yes. Does development affect life expectancy? Yes. Then we said, so, if that is the case, whatever affects life expectancy should be the Bank's priority.

So that's what we used to be get-- we have to develop a strategy. We called it Intensifying Action Against HIV/AIDS-- Responding to a Development Crisis. We had to use that language. Nobody was going to pay attention if we just pitched it as yet another health problem. We had a wonderfully leader-- leaders at the World Bank. Jim Wolfensohn was the president, Callisto Madavo was the vice president of the Africa region, who, when we showed you this life expectancy graphs, said are you telling me that life expectancy in Zimbabwe is what it was when I was an elementary student. We said yes. That made all the difference and open the door for us to put the first billion dollar project for sub-Saharan Africa.

BARRY BLOOM: So what follows, naturally, is how did you get there? In the sense that you were put in charge of AIDS, what was

your background that enabled you to have the intellectual and scientific qualifications to persuade the economists, a very unusual circumstance?

DEBREWORK I started working on HIV/AIDS in Ethiopia. First program, the first cases, it was a very difficult time where aid was ZEWDIE: not coming to Ethiopia from the north. We were socialists, so we had to make do with the little we have to put a surveillance system to protect the blood supply system, primarily, because we didn't know what it was.

And from there, I moved to what was known as the AIDS control and prevention program, which was funded by USAID based in FHI and I was based in . That gave me an insight to 16 African countries where we had programs. And it's from there, I came to the Bank. When I came to the Bank, it's a formidable institution, brilliant people. They're heart in the right place. They may not always be doing the right things, but an institution which could change the way AIDS was ravaging sub-Saharan Africa.

So I was waiting for that opening. Incidentally, nobody does anything by one's self. It's a group effort. It's all circumstances, leadership, people below you who work on this. So I'm not going to claim the whole team as if I did it by myself. So I had seen the epidemic, I had seen what it is doing to sub-Saharan Africa, I had also seen the reluctance on the part of the governments of Africa to either use their own resources or seek help.

This was something that they didn't want to touch. At the same time, we would go on a mission to a country, it could be any education mission or health mission, you go back after three months, your counterparts have died. So this was a reality which was happening in Africa then. And I had a belief that if anybody could do anything substantive, it's would be the World Bank, because there wasn't a Global Fund, there wasn't PEPFAR then.

And the way to do it was to sensitize the decision makers in the Bank, so that they give us this. I organized a two day seminar. In fact, Harvey Fineberg came from here. The first day, we looked at the evidence, the science, the . The second day was a policy meeting, where we had the leaders of the bank listen to this. Then we were given a go ahead to come up with a concept, which we did. And we wrote it in a very different way, the normal Bank instrument was not going to do it for us because it takes anywhere from 18 to 36 months from concept to board approval. There was a small instrument which was created to deal with an emergency for hurricane in the Caribbean Islands.

We took that instrument and it was fast, it was on an emergency basis, it didn't ask a whole lot of things from the countries, which they take months to prepare. What we added to it was, again, something which was not usual at the bank, we said here we are, the drugs are very expensive, but there is a lot of care and a lot of prevention which is being taken care of by civil society organizations, religious organizations. So we needed an instrument which allowed us to channel resources to these unusual group for the World Bank.

They agreed to the timeline. They agreed to money being channeled directly to civil society organizations. And they gave us $1 billion.

BARRY BLOOM: How could anyone imagine turning Debrework down with making such a case?

DEBREWORK Yeah, I have a lot of charm. ZEWDIE:

BARRY BLOOM: Tell us a little bit about your training. You're not trained in economics, and yet you've had a powerful role in the most important economic institution in the world. How did you come to get into the AIDS business?

DEBREWORK Clinical immunology, a good segue to get into HIV/AIDS, but when I was in Ethiopia, I was working in a research ZEWDIE: institution, but participating in the national HIV/AIDS control program. At one point, I was instructed by the government to take over the national AIDS control program. My initial reaction was I won't because I'm a researcher.

I had a wonderful boss who was also my professor at the university, who sat me down and he said, what difference are you going to make as a bench scientist in Sub-Saharan Africa? Because we were struggling to get this reagent from this country, in the wrong one from another. He said if you go into policy strategy development, you will make a difference.

BARRY BLOOM: And you did.

DEBREWORK That was the best advice I got. ZEWDIE:

BARRY BLOOM: You were great believer in the Bank and its potential for good. Not all of your colleagues, who once worked in the Bank and left and have written books about how the bank has created dependencies, and that foreign aid has done more harm than good-- give us your perspective on how you see the overseas development assistance and foreign aid and its impact, both on HIV and AIDS, which I think is substantial, but also, your views on the impact of development assistance more broadly.

DEBREWORK The Bank is a wonderful organization. Since I'm talking to students, it is one place where you get a lot of very ZEWDIE: bright, intelligent people who can solve problems. All you have to do is walk out to the corridor or to the coffee shop, and you will get these brilliant people who are committed to development. It's a wonderful organization to

work for, provided it has a good leader. And I was very fortunate to be at the Bank when the leader was this extraordinary individual who believed in development, who called the Bank out on the way we have been doing business, the way we have been treating countries. I remember his first town hall meeting with us, he said you are servants of the countries. If I hear anybody going to a country and dictating terms, I'll fire you. He was that kind of leader.

So it is a big force to contend with. It has huge power. There have been several mistakes, like structural adjustment, but the Bank learned and turned around. If you know what you're doing, if you have a supportive environment, meaning the person who is above you, you will succeed at the Bank. So that's is a wonderful place to work. Does it mean that all-- I believe the Bank staff is now over 15,000-- are brilliant people and-- no.

Country ownership is being misunderstood and not paid enough attention to, both by the Bank and many development institutions. In my opinion, in 2015, there shouldn't be any prescriptive development. Development should be a dialogue. Go to a country and say what is it that we can help with. Have you tried this? It worked in country X.

Secondly, this is not the 1920s, where there were very few educated people from developing countries. There are a lot of people who graduated from these institutions, who look like you, who are working in developing countries, who you should treat as an equal. That's the second. Thirdly, whether it's agriculture, education, infrastructure, projects succeed if they are owned by the population that you are trying to help. So whether it's the World Bank or any other development agency, if they do not have these three critical elements to make development work, I think we are wasting a lot of resources.

BARRY BLOOM: I couldn't agree more. In my field of tuberculosis, when WHO put out a prescription of directly observed treatment, a great epidemiologist from Tanzania said every country has to invent it's own directly observed treatment program. It can't come from a book from Geneva. Which leads me to the question of the relationship that you've had with other international organizations, the progression from the Bank, to the Global Fund, back to the Bank, and then to the Global Fund. Global Fund is a major player in financing in country activities in AIDS, TB, and malaria. Tell us about that experience.

DEBREWORK When we did the multi-country, the $1 billion program for the Bank, the UN agencies that makeup UNAIDS played ZEWDIE: a critical role. We came up with the money, but the agencies came up with their know how. So they owned this $1 billion multi-country program as much as we did, which was a good thing and which also paved the way to the Global Fund.

The Global Fund is another fantastic institution which is saving so many lives, which should be supported and protected. I believe that what the infrastructure we laid out with the $1 billion from the Bank prepared the countries for the Global Fund, especially civil society organizations where we had taught them how to define their programs, how to manage resources, and how to measure impact, not forgetting getting a plus or a minus, but for managing by results, where the ones who successfully could write a proposal to the Global Fund and get resources and scale up their programs. These are the organizations that have made, not only a big difference in TB, malaria, and tuberculosis, many people, especially now that we're discussing universal health coverage, associate these vertical programs to doing only one thing. The health infrastructure in many of the countries, where the Global Fund is, where PEPFAR is, and where the World Bank is, have been built with the resources that came for AIDS, tuberculosis, and malaria. A third of the Global Fund resources goes into building the health infrastructure, an equal amount of the map went into building the infrastructure.

So 2015 is a decisive year as we move into universal health coverage. The gains of these, for lack of another word, vertical diseases needs to be protected because the gains are very fragile. And if the intensity with which we are doing it now decreases, we may regress to a more difficult problem which will take more resources and more lives.

BARRY BLOOM: One of the targets for development was the Millennium Development Goals, where there were three major of the eight goals that had to do with health. And they expire this year. And the world is groping for another vision. The unique thing about the MDGs was for the first time, they set of numbers. They set targeted goals of how many lives to save, how many people to protect against various diseases, targets for education and other things. We're moving into uncharted territory now of the tentative goals, only one has to do with health. From your perspective, how should the sustainable development goals incorporate health in the future for the next 25 years?

DEBREWORK I'm worried. I have been to some of the discussions and there is logic for having put all the health goals under ZEWDIE: one umbrella. The worry that I have is do we bring everything to the lowest common denominator because we are going to this big thing which nobody would-- who would quarrel with universal health coverage? Or do we have a plan to maintain a transition so that we get all the good things from these programs that work to eventually lead us into a universal health coverage.

If that's the kind of discussion that's happening, then we should be OK. Sustainable development without giving due attention and significance to health cannot happen. It just cannot happen. It's this convolution about looking at the economic issue only, divorce of a healthy individual who can contribute to development is something which the economists need to find the language to teach us how that make sense.

So that is how I look at it. If it is done properly, and if we are not going to bring down everything to the lowest common denominator, if pledges are fulfilled, the pledges for MDGs have not been fulfilled yet, so where are the resources and the commitment going to come from just because we changed a name and we went from eight goals to 17 goals? So these are things which may not be discussed in a political environment, but they need to grapple with this and say it is going to work because we are going to change all of this.

The MDGs, especially MDG 5, maternal mortality, has not been reached in many of the countries who need to reach MDG 5. What is going to happen to MDG 5 when you move into sustainable development or universal health coverage? The same thing with HIV/AIDS.

A lot has been done, it's a success story, but we haven't even managed to reach half of the people who are in need of antiretroviral treatment. The other half do not even know whether they are infected or not. So with all of these unfinished agenda, goals are good, commitment is good, what we should worry and question is how is this going to be different. What's different? BARRY BLOOM: Do the economists, do the people who are the top policymakers, actually appreciate what was done through the multi-country AIDS effort? I found it strange that, until last year, or two years ago, a graduate student here and a junior professor showed that antiretroviral treatment in KwaZulu-Natal and South Africa increased life expectancy of the population by 11.3 years. Does that count for policy makers? And why did it take the Harvard School of Public Health to do that?

DEBREWORK It does. There were economists who were helping us, who were working with us, and giving us this instrument to ZEWDIE: show-- we had to show cost effectiveness. There was no way around it. And thanks to Brazil, Brazil was the first country that showed by treating their patients, and they used their own money, they could not only relieve the hospital beds for other treatable diseases, but also save resources. So those kinds of things were useful and we had economists amongst us, those who where helping us with this.

There were the skeptics. In fact, one of the funny things that happened was, nine months into the project, a huge evaluation was done. Some of the countries had started only three months ago, some six months ago. And they came up and said the map is a failure. We said they haven't even started. Of course, the evaluation, which was done properly later proved otherwise.

We also call it learning by doing. As we went into the programs and when we find out something was not working, the instrument was such that we were allowed to change gear very quickly. In places where we were pouring money in the general population, for example, it proved that the money should be going to risk behavior groups and mitigate the epidemic. We immediately changed the way we were doing business in these countries.

So as we were going, we were learning and we were doing it. And we had a lot of economists with us. But it's just the way the Bank-- and it is, by the way, the same as finance ministers in countries think, when they think of development, health is not the first thing that comes to their mind.

BARRY BLOOM: Within one week of the declaration by WHO that Ebola was a global epidemic threat, we had the privilege of having 10 ambassadors from Washington come to Harvard where we were able to ask them what their needs were. And yes, they needed-- this was in August-- their needs where equipment, supplies, but most importantly, their needs they felt were training. Couple questions-- one, what is the precedent that you would like to see from the work on HIV and AIDS, TB, and malaria applied to the West African countries that have suffered so greatly with another outbreak of Ebola?

DEBREWORK So during the Ebola epidemic, I looked at the countries who were getting resources from the Global Fund, ZEWDIE: PEPFAR, and the World Bank for HIV, and other funders. These Western African countries, fortunately, didn't have a whole lot of AIDS and they were not getting these huge resources these countries got to build their health systems.

To me, what we saw on Ebola in 2015 is testament to how badly we did development in health all of these years. Because if we had a viable health system, if we had a viable surveillance system, many of these countries would have been on top of it during the Ebola epidemic. Nigeria used the set up which was put in there to eradicate polio to trace that one patient and arrest the epidemic. So anything, whether it's a vertical program, which does not contribute to building health systems, so that countries would deal with epidemics such as Ebola, I think we should pause and say are we doing the right thing. If we are not, let's change gear and think the broader issue over while we are solving this problem, we need to prepare this countries. Because pouring money on an emergency basis and pitching tents and doing this fabulous, which should be appreciated, is not going to do it when the next epidemic comes.

BARRY BLOOM: I share your concern that there's a desperate need in many countries to support, develop, expand what we would call health systems. But you and I both know that it's much easier to get money for the name of the disease, whether it's AIDS, or heart disease, or cancer, than it is for health systems. What are your thoughts of how we as a health community can change that picture or at least add to it?

DEBREWORK It needs to change at all levels. The first ones would be the development instead-- they should look at ZEWDIE: themselves and say what did we get out of these resources that we have been pouring into this-- whatever they were doing. So that's the first one. The second one are the recipient countries themselves. They should put their own resources, no matter how little it is, because that's the only way to sustainable development and response.

If aid for HIV/AIDS stopped tomorrow, many of these countries will not be able to sustain their programs and that should be unacceptable. There are countries that are really very, very poor. That's a different kind of system. But for countries who should be doing things themselves, they should be encouraged and the development institutions and the developed countries should not be putting their money if they don't see a response, both in terms of policy and strategy, and also, sustainably maintaining this-- every development project on paper has an exit strategy, they call it. It's only on paper.

That needs to be translated into action, otherwise we will be talking about the exact same thing. The most frustrating thing for me when I was listening to these STG discussions in the UN in 2015 was the same things we discussed 30 years ago when we had been the HIV/AIDS epidemic. This cannot go on.

BARRY BLOOM: Let me raise a question that I, looking at this audience, I would like to hear some questions from, but let me start that discussion. You were a woman in leadership at multiple levels, at the National Research Institute in Ethiopia, in the World Bank, in the Global Fund, in the Committee for Women in AIDS. What did you have to face? What did you have to overcome? How did you do it? What's the trick? We all want to know that because you have done so spectacularly well.

DEBREWORK I'll give you one example. In 1986, when I was much younger and I was working at the National Research ZEWDIE: Institute in Ethiopia, we were a management team off eight people. And he was calling going on a sabbatical, the eight people, two women, six men, and he appointed to me as acting executive director of the research institution for a year.

The day before he flew out, the minister called us to his office and said I have a petition from six of these eight people saying that she shouldn't be acting. We should be given acting, we are more senior than her, we are more knowledgeable than her. And the minister and my boss had discussed this. It was something agreed. And he said to him, we are going to put her in a very difficult position. Is there anything you want to do before you leave? Both of them looked at me and they said how do you feel. I said I'm fine. My boss left. The minister said you have my full support. The following day, I go-- I don't know if you have been to the National Research Institute. It's a very old building and it has a doorway to go into the executive director's office. There are two guards on either side of the door. And I have been working in that institution for a long time. What they do when they the executive director comes is they get up, they salute and say good morning to him, and he says good morning, passes.

I come in, they both remain sitting. They didn't say good morning. I went into the office. So the first thing I heard yesterday was this mutiny, the second one is this. I said I'm going to put a stop to this now. So I asked my assistant call me these two guards and their boss. They came.

I said is there anything wrong? They had no clue. They said nothing, nothing. I said, well, how do you greet so and so when he comes? It just dawned on them. I said it has nothing to do with me, it is this chair you respect and this institution. Of course, they were in panic. I said don't worry, don't do it again. In half an hour, that had gone through the entire institution.

I had to do that to show them I can lead. I wish there was a better way of doing it, but that was the best instrument I used. So I spent a year-- what I didn't tell my boss and the minister was I was three months pregnant on top of all of that.

BARRY BLOOM: Oh, my goodness.

DEBREWORK So I spent the next 12 months working with these hostile people, changing them one by one. In a very short time, ZEWDIE: I could turn around all of them, but two. And that taught me how to work with people who may disagree with you, if you have a clear communication strategy, if you don't push them away because they are not your friends, we needed all of us to run the institution and we did. That prepared me for anything else I faced after that.

BARRY BLOOM: Terrific. Let me turn it to the audience in the studio and ask if there are questions. And if so, could you raise your hand and then get a microphone? And tell us who you are and ask the question.

AUDIENCE: Hi, my name is Noor and I'm an MPH and student here at the school. Thank you for sharing your insight. My question relates to how do you get cancer on the World Bank agenda? In a similar way that AIDS was not on their agenda, but cancer is the next big killer in low and middle income countries, what kind of leadership skills do you recommend us who would like to tackle this project to do? Thank you.

DEBREWORK The first thing is you have to know what you're talking about and you have to know a little bit more than the next ZEWDIE: person. I have to say this, you have to know it even more if you are a woman, if you are from any marginalized group. So that's your first instrument. Because the moment you open your mouth and make sense, even people who do not like you will listen.

The second one should be you should be totally committed. This is difficult. This is-- people will do all kinds of nasty things to discourage you, but you need to be committed and stay your ground. The third one, which you have to be lucky, you have to have a good leader who you can go to, who could support you, or who could lead you, and stand by you. So these, when these things, and I'm sure there are many more, come together, then you can. You can change. AIDS was worse than cancer at the World Bank. At least cancer, you know, everybody-- AIDS was a sexually transmitted and the people who get them are people that society shouldn't even care for-- injecting drug users, commercial sex workers, poor people. So it was a hard sell than cancer, which cancer, many people may be able to identify with. But knowing what you want to do and having excellent evidence will turn even a deaf ear the other way around.

BARRY BLOOM: Other questions?

AUDIENCE: Hi, my name is Jing. I'm currently ASM2 student from the Department of Health Policy and Management. I understand there are so many international efforts going on right now in terms of either TB or HIV/AIDS. I would like to know what's your attitude or recommendation about the better coordination and mapping also existing international initiatives to coordinate those efforts and probably complement each other in setting, not only the agenda, but also setting up the alternatives or solutions to solve these problems? Thank you.

DEBREWORK It's difficult. When we did the multi-country AIDS program, I told you it was owned by the entire UN family. We ZEWDIE: came up with something which was called the three ones. One national strategic plan, one national coordinating body, and one monitoring and evaluation system, because what was happening-- and I have a very nice graph which I show my students-- you used it as well, Barry-- is if you take one country, they entertain about 500 missions a year from the donor who gives you $100 million to the donor who gave you 5,000.

They all come and visit, they all require an annual report, they all require a financial report with their system, they all have their own monitoring and evaluation indicators that you have to respond to. You can't do anything with this. We all agreed-- donor, governments, donor agencies, the UN agencies-- to go through these three ones and things improved a little bit. But have it being the worst thing we have, you see this donor who was bolted to three ones coming and saying to the country but, you know, my parliament, specifically, wants this. Can you do this for me? And my congress wants that.

So it is difficult. It has come a long way. There is a huge improvement because it makes sense. There are development institutions who are happy to use another financial report or another annual report, but there others by the nature off the institutions themselves, they require. Only one thing will change this-- the countries. If the countries have-- say, to five agencies, this is what I want for my people, this is the reason why I want it, this is the evidence. You go and sort out what you want to go among yourselves, I need this much money, and this is how I'm going to report it. There are very good examples, Rwanda being one of the best ones.

So when countries start saying this is not how I want to do it in my country, and when donor agencies, governments, respect country ownership, that's the only way it can work. Otherwise, this would continue. And it's a huge waste of resources.

BARRY BLOOM: Other questions? Please.

AUDIENCE: It's a follow up question on that and this question was actually sent in from our online audience. So in the climate of international AIDS today, there are many emerging donors, like the bilateral organizations or private donors. So what do you see the role of World Bank moving forward? DEBREWORK The World Bank should always be there to do the kinds of things which other development institutions will not be ZEWDIE: able to do-- building infrastructure, training. These are things which are the purview of the Bank, and being there for the poorest of the poor. There is an instrument, a Bank instrument, which gives grants. Not many people know that the resources that are going to the poorest countries in the world from the World Bank are 100% grant.

So because of these unique things that the Bank does, and more importantly, the convening and convincing power-- a minister of finance in a country will listen to a World Bank staff than a WHO staff. We don't respect the WHO. So these are things which are unique to the World Bank. And it has decades of development based practice. The Bank is known as a knowledge bank, and it is indeed a knowledge bank. So these are irreplaceable which the Bank, I hope, would continue to do.

AUDIENCE: Hello, thank you for speaking today. My name is Jing Liu. I am a physician, a general internist, but also, a research fellow nearby at one of the teaching hospitals.

My question kind of relates more to maybe some advice you can give to people at my stage of life who are in training. I'm about to enter the job market in a few years, maybe considering academia and to continue my life in research, policy oriented research, or maybe to do something else. Maybe do government, or NGO, or industry, or whatever type of work. And also, at the same time, we have a small family and things like that. So can you comment a little bit about any advice you would give to someone at this point in life?

DEBREWORK Passion, a lot of passion. You're young, you're brilliant, you are in one of the best institutions which should ZEWDIE: hopefully prepare you. Passion to do something, whether it's poverty, whether it's disease, and you strengthen that passion with the best learning you can get, the best evidence you can get. And nothing replaces technical excellence.

So whether you are teaching students who would go into development or into academia, or you are going to development yourself, you need these things. You need to arm-- this is your time, when you are in this institution, to get the most out of what's available there, to prepare you for that passion that you want to do. Whether you are going into academia or development, one thing you need to remember, as young people in 2015, is development is doing what you want other people to do to you.

You don't need a degree to treat somebody in country on the way you want to be treated. Why would you go and dictate? Why would you go and say I know it better than you. So if you flip that and say these people live this, they know, I'm going to listen to them. I am the technical person, I have a global view, and I will share what I know with them, then jointly, we will come up with a solution which they would embrace.

So if you do these fundamental things and with the passion and the know how, and it's a certificate, by the way. The moment you say I graduated from Harvard, half the door is already. Then you carry the other half with you.

BARRY BLOOM: Let me jump in and ask. You have-- we are privileged to have you here teaching a course for students. You are interacting with our students. We know we're Harvard, we know we're sometimes up in the clouds, and we worry a bit about whether our students who are not flying in the clouds, but in the real world are well-prepared. Tell us something about how you share that experience with the real world and what you would like to see them take out from your course and from their training here. DEBREWORK I was given this tremendous privilege to come and teach and to choose what I wanted to teach. So I used the ZEWDIE: history of the HIV/AIDS epidemic, the name of my course is leadership and public health-- from HIV/AIDS to universe health coverage. What I am teaching the students is the value of leadership. It was the leadership turn out in the HIV/AIDS epidemic in all, whether it's government, civil society, activists community, it's exemplary. That's why these things happen.

Taking them through that, showing them what happened in countries at the beginning of the epidemic, what succeeded, what didn't, and trying to share with them, you will know the epidemiology, you will know the science, you will know all these things, what you don't know, what I wasn't told and what maybe what you were not told is this negotiation, this dialogue of becoming a development practitioner. So that's what I'm trying to-- and last week, we had an assignment. They did an assignment.

I wanted them to write one page letter to the minister of health or to the head of a funding agency. And I took the words verbatim and I projected it back to them. The minister of health should meet with the minister of finance and do this. The government should embrace civil society. Then I said who are you.

You cannot be a development practitioner if you go and dictate. the person on the other side could be your colleague. Maybe you went to Harvard together. My message to the person on the other side is just because somebody's coming with a briefcase full of money doesn't make them your superior. You are your country's representative to be able to sit there and say this is great.

But this is how-- so that is what I'm trying to share with them because I have seen it as a recipient, when I was in my country, where really very young men and women would come and tell me what to do. I have seen it up at the World Bank, I have seen it at the Global Fund. It doesn't work. It doesn't.

AUDIENCE: So I have a question. My name is Nishant Shah, I'm a MPH degree candidate here at the school. We touched a little bit about some of the mentors that you've had and then, of course, the challenges of being a woman in leadership positions. I'm wondering are there women leaders that you look to for inspiration and for guidance in your decisions and in you in your leadership roles?

DEBREWORK Barry, I would answer that. There is something which I left out, unintentionally. What I would like to see, yes, you ZEWDIE: are a fantastic institution. I think it's a privilege both to learn and to teach in this institution. That's the same things I said about the way we should change how to do development needs to happen here as well. It cannot be certain types of people prescribing development to other types of people.

They should be here, they should be on the table. They should participate in teaching, they should participate at students. So diversity is good. It's good for development, it's not a charity. Women leadership, they are fantastic. It's good. Let's try it. So these are things which would lead me to answer.

Yes, I have been blessed with phenomenal women who, and men, who guided me, who I learned from, who I have a lot of respect for. And we need more of them.

BARRY BLOOM: I have to interject here to say that I was privileged to be dean for 10 years in this school. And every second semester, I met on a regular basis with students and always asked the same questions. And one of those questions, particularly of the graduating group, was what was your most rewarding experience at the Harvard

School of Public Health. And the answer in 10 years was the other students. Faculty are good, but it was the

other students. And that student body has increased from about 20% percent from international students now to about 35 or 36%. So we have worked hard to get a diverse student body to go out in the world. We could do a little better with the faculty, it would seem to me, which is why it's fun to have you here. Debrework, we have only a few minutes left. Give us some take home messages that you think it would be good for us to ponder after this wonderful discussion and conversation.

DEBREWORK For the students, and you have an international body of students, nothing replaces being excellent in what you're ZEWDIE: doing. Whatever degree you're doing, you have to be excellent. The second one is passion. You need to have enough juice in you to go out and change the world, and it is possible. You can do it.

I'm very happy to see many of the audience and the students are young women. So the singular message I'll have for them is you need to know what you're doing. But more importantly, you need to speak out. If you do not speak out, you're forgotten. How many times do you say to yourself, I wish I said that in a meeting. Say it. I would rather you say it than being quiet and not being counted.

BARRY BLOOM: I guess I get the last word. I cannot tell you what a joy it is to have you back here. You were here 20 some years ago and I wasn't here. There are a lot of messages that came out today-- excellence, passion, commitment to a set of values. And I think that is really shared by certainly all the students that I know or they would probably be in business school or somewhere else.

What I think that I take home from this and as an immunologist like you and as a lab person like you, I've been privileged to go see a big part of the world that is not present in Cambridge, Massachusetts, of lives, diseases, problems, systems that you can't write about, you have to experience. And one of my take home messages, you have brought a vast lifetime of experience to a great institution like the Bank. We all need to collect those experiences if we want to do development well, to be able to relate to people who are just like us, but in a very different circumstance. And there's no book or course that I can give that will replace that experience.

So I wish you the very, very best. I wish our students the very best. And thank you so much for this wonderful conversation.

DEBREWORK Thank you. ZEWDIE:

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