that. Do everything you can to dance around the fact that you know and they don’t know, but don’t give up. If it doesn’t work the first time, try it again. He had various strategies for doing it. What the volunteers go there for and what PEPFAR is [there] for may be somewhat different. As we heard before, there are all kinds of motives for people to go over. If they have different motives, we don’t know what they will do when they get there.

Should there be limits on what they do? Should we say that we don’t really care what else they do, as long as they do their treating, and if they are there to do something else, go for it? Or should you say, look, we are there for AIDS; the rest of the stuff you can do on some other trip to Africa?

With public–private partnerships, you have the additional consideration that some of your private partners may have commercial motives. They may be pursuing those. They may be using your cover as a way of legitimizing them. So what do you do about that? It is a chronic problem, of course.

Finally, I was wondering whether it would be useful for the committee to say that there should be some ethical constraints, some ground rules that govern basically all aspects of the program. It is very hard to draw these things up without being vapid. The ideal is something that is general enough so that you don’t come up with immediate counter-examples, but specific enough so that it has some actual force. A few times, somebody actually achieves these.

Just thinking this through with some colleagues, here are a few candidates. I am not necessarily endorsing any of these, and certainly not this set of six. But they are examples of what these rules could look like:

  • Benefit to the host country is the fundamental criterion of adequacy.

  • Capacity-building over the medium and long term is the primary goal.

  • The work of a PEPFAR volunteer corps should be coordinated with other initiatives to allocate resources rationally.

  • Needs are defined by host countries.

  • Standard of care is defined by the needs of the host country.

  • Volunteers should respect hosts values but must be governed by their own values, including equity in selection of patients.

I think when one comes up with the magic formula, something that has the right degree of bite and generality, it is very, very useful, because it gives you a benchmark against which later infractions or deviations can be held to account.

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