for. . . . . >> good evening and thank you,

thank you so much. thank you to esther and terry for hosting us tonight. i want to thank our team with a big thank you to whitney killing, just block, emory and cole schapiro. this event would not have been possible without you. my name is claire pr. i may mentee and colleague of dr. paul farmer. as a medical anthropologist and policy advisor, teacher. >> i've never seen claire before. >> paul farmer it's interesting i don't think i've introduce you to a large form before. paul farmer has dedicated his life to improving the lives of others with health care access others in the world's most forgotten places.

starting with one clinic, to now partners in health organization that stands 11 sites in haiti and all 11 countries around the world. your work has truly moved and touched many many people. i met paul when i was a fourth-year medical student, visiting harvard medical school in boston and following my meeting with him i basically followed him. i looked at calendars and events calendars all across schools and universities and hospitals and when i was a resident that is what i considered my social life, going to lectures of paul's. >> is still kind of like that if i'm not mistaken. >> it still is. you must understand for those of you that haven't read the read about how exciting it is for me to be here to talk about this book, but that has his speeches, some of them you have probably listened to and many of them

were aimed at students many like you who were about to explore the world. so paul i've listened to your speeches many many times and i would like to start at the beginning. how did it all start for you? haiti, they'd are partners in health, was this part of a big master plan? >> she just violated the rule. she was supposed to start with a really easy question. first of all i would like to say thanks too for everyone who made tonight possible and as painful as it is to contemplate not having a disco here -- [laughter] esther you have done good. this is a staggeringly beautiful place to be and to reflect and to -- a wonder that is preserved and everyone here must be grateful that it is. that was my way at getting out of the master plan question.

i don't think anybody has a master plan and since there are a lot of students here, more than i thought, i would just say a lot of what happens in life is serendipity. one of the challenges that everyone drawing breath on the planet or certainly people who have a lot of good fortune meaning able to go to college, is to understand when serendipity is a good thing and when it's not such a good thing or when you have to fight harder to make things happen. i got involved in a.d.. i won't say by accident because when i was in college i was already very interested in migrant farmworkers from haiti but i actually planned to go after college and the year before medical school, what i hoped would be the year before medical school, wanted to go to

the sun at all. i'm sure you have heard this but not many people have. i've been saying it more recently in speaking with young people, it never occurred to me that the fulbright scholarship committee would not even offer me an interview much less a scholarship. in fact i wrote a letter to this group and stomach all and what i thought was really good french explaining to them why they would be so lucky to have me join them. about a month later i got a letter saying dear mr. farmer thank you for your letter. unfortunately the doctor to whom you have addressed this has been dead for several years. [laughter] in my defense, that was before the internet which i later invented. [laughter] i want to say haiti was a planned b for me and i am certainly grateful that it came

to pass. i ended up in haiti at 23 years old. like a lot of 23-year-olds i thought i was knowledgeable in world english and as in the case with most 23-year-olds it was false. i'm still working for the same people i met that year and you know a lot of them. those who have survived the last 31 years. in fact i just got back from the same place, the same town. i hope some of you are following what has been going on there. [applause] thank you. i have such a wonderful time because we had a celebration of partnership there. it was one of the most uplifting things that i've ever seen. a master plan that would go in 1983 in 201,330 years later no

but at the same time it's not an accident that we are still working with the same team, that we are still working in the same places and trying to improve the quality of health care services we are giving. it's not an accident that it takes 30 years. so there. that is how it all started. >> thanks, paul. i will go back to it at the end that you mention partnerships a bit and through my career has gone from telemedicine to doing clinical informatics and i found myself working across a lot of disciplines and i have learned a lot. >> you could never fix my cell phone. >> i know. >> go ahead. >> i'm going to add that to my list. what i found is that you would often talk to young people who are going into business school or studying theology or all the disciplines and encouraging

them. can you explain how these partnerships worked? >> i can try. i think the idea of teaching college students as opposed to medical students or physicians training to do internal medicine, the same reason that i like to talk about how everyone can have a role and global health equity. global health equity is not the same as internatiinternati onal health. there is a famous example from washington about, i don't know the city very well. i know representation without taxation and that part i remember on the license plate that you take the subway across washington and what you see on one end of that subway in terms of life expectancy at birth or you go right to the numbers that we study and medical school and

public health and the other subway you have a 20 year difference in life expectancy. maybe that is tearing at little bit but it's a bigger problem. public health is about equity. so the reason everybody may feel that you just mentioned and many more it seems to me that equity in general is everybody's business and it would be easier to just talk to physicians and nurses. it would be easier to just address oneself to those who use serve with on a team of medical care, delivery of medical care but if we don't talk to people in policy, and business and again fields very different from our own, talk to young people and i mean young people. you went with me to talk to high school not long ago.

if we don't do that allows this myth is some kind of expertise is required to have an opinion about equity. you invite social justice on what's going to happen to the world. that's got to be wrong to believe expertise is going to save us. >> i'm going going to and explore an area that i'm not very familiar with. i explained that in lectures what i did for fun. i skipped years from high school to medical school so i can watch many movies. >> that needs to be remediated immediately. you should get a dvd and watch it before you go back to boston. >> i will put that on the list too. a colorful metaphor that you have. >> show of hands, how many people see the matrix? i rest my case. if you're going to emigrate to this country if the age of 14

you have plenty of time to watch the matrix. [laughter] >> oh my goodness, have to watch the matrix. in the book you have these metaphors we talk about anesthesia for the soul. can you talk about that? >> it wasn't meant to be serious too much. actually it was a speech given up my alma mater by my own students and the metaphor comes from this movie. it's as silly and pretentious movie which i did make fun of a little bit even though i had seen it several times. the central conceit of the movie is that we are all living in the social fiction. they are all living in social fiction and that is the major ex. the matrix is their is they're programmed to believe is the real world but the real world of course is not like that at all. there were a world has a lot of

grief and pain and division and destruction and slavery in it. that is where the metaphor comes from. i don't want to go into that too much. i was just trying to watch -- colin students who are watching at that time and show that i was a hip, young professor which sometimes works and sometimes doesn't. the idea though is that it's important to acknowledged pain, suffering, violence. that is not the violence that you saw in boston during the marathon which was violence of war but violence that happens in every day life. one women from haiti said this to me 25 or 30 years ago. she said every day is a fight for food and wood and water.

i thought that's exactly what her life is like. she had five kids and she had to fight for food and something to cook with and water. you know, when you go from that three hours later back to a boston teaching hospital, my boston teaching hospital did very well after the marathon bombings because it was equipped to do so and i'm very proud of our hospital at her gum but to go between these extremes in three hours, that is violent too. it's not the kind of thing you want to talk about in a commencement speech. i'm sure it would get a real big, a lot of whooping and laughing. this week i'm going to talk about the bombing and what happened in haiti. i don't like talking about bad things. i think if we are going to

address them we have to bring in the next generation and others on board. >> when we think about your work and we think about -- >> it's our work. >> our. if we think about it over time one of the things you have taught us is whether or not we are clinicians we have to be in partnership with others including the public sector. >> l. >> you know i think of a lot of challenges when i think about partnering with the public sector. not everyone understands why. takes a long time and it's slow and why would we choose the public sector? >> thank you for letting me talk about it. claire by the way is not only an intern but since just before the earthquake, we have been lucky enough to work together in trying to bridge these worlds, haitian-american public sector

and much more the private sector and ngos in the private sector's like the universities and the small community-based colleges in cambridge. that is the private sector. and then young and old patients, people who are providers. knitting all that together is possible and necessary if you believe that there is some grand social objective that we are pursuing. for example equality. if you look at the big rights struggles of the last 200 years, the struggle for slavery and the struggle for enfranchisement ignited states, the civil rights movement or you look at india's movement for basic rights, the ones embedded in democracies that were keeping their promises to the citizenry. you look at them and you say well why do people struggle for

rights, the right to vote or their rights for habeas corpus? is because these are important for everyone. doesn't ngo converter right's? does government confer rights? idea so even if you were not in the public sector or ministry of health or ministry of education of the public health department or the anna age, that's the public sector but you don't have to be working in those public sectors to think that they need to succeed to do their job. you do -- should there be a post office? should you be able to drink water and not get cholera? i think all of us believe that we should have those rights and so working with the public sector, it's obvious some days

i'm sure but in haiti did something that as you have pushed for the idea that it can all add up to more than the sum of our parts. so that is the main reason. another one is that if you are delivering something good like say a basic vaccination for kids. i don't think many people, as some people think that may not be good but most people understand and i'm probably going to get in trouble for that. i am headed out there shortly. or literacy, choose whatever you would like to roll out and i'm an infectious disease doctor and i like to talk about these things that have rolled out in that arena. but if you ever want to reach a lot of people, the entire district of columbia, the state of maryland, go down the list

whatever your analysis is it's hard to imagine keeping a scale without working with the public sector. i learned that lesson intellectually. you can get it out of the book or you can stop and think well, i went to public schools. i went to high school and junior high and elementary ,-com,-com ma all that in a public school. you show up and you get your shots and then i thought wow i got my shot. we called them shots. you would think they were a liver biopsy needle they were coming at us with. it was all the public sector and i didn't think about that when i was 18 or 19 and i started reading about it sinking wow this is really good when people have the rights in the public sector. and then working in rwanda the last better part of a decade has been at great experience because i have seen and i think others

have seen what can happen. they are at their lowest point, whatever you want to call it, rock bottom, 1994, a million people lay dead, murdered. the entire and the structure was in ruins. the lowest life expectancy in the world and probably the poorest country in the face of the earth and now because they have fought and pulled every together with a vision and a plan including ngos and the ones that i work with, including human rights groups and including mission pools, including donors of all sorts, it's all pulled into one plan to move forward with this vision where we would need -- 2020. they are getting their. their life expectancy is probably doubled in the last

decade and in that mortality has plunged. death from childbirth, vaccinations, q. no it's because of fighting were system. the public sector was not delivering all of their services. they are working in getting people together. >> paul when we started the set you have never seen me nervous and actually talking about this building. when she talked about preserving this building it brought me back to what we are trying to preserve and haiti. we flew together and for several days there were there and the devastation was horrible. so we started with -- and i would like to end with ballet. when things get tough i look at it as hope. talk to me a little bit about what that means.

>> by the way i just have to say i can imagine the reason i asked claire if she would do this is i can't imagine anyone a better companion in those dark times than claire was on her own house was destroyed and when she lost many of her friends and family and when the city reached its death. it was just wonderful to have a fellow clinician who was their day in was there day in and day out always with a smile. this is my chance to say thank you for that. [applause] i wrote a book about this whole thing in claire kind of stars in it. and i say claire have you read the book? she would say no. she still is hadn't read the book now she has to read it.

i would say the first two years that i spent in haiti as i said i have a friend of mine from first year medical school. i was a big shot medical professor. my friends for medical school would tell you paul, haiti really moved him in the direction he was going to go or needs to go. so my dad is enormous. i would say the first two years when i was 23 work very difficult. for 10 years he spent time recounting victory narrative. here you are 23 years old in a town in central haiti and you write home or you go back to medical school and you tell stories about how great the work is and how much progress we are

making but it's really not often like that. it wasn't like that. we started working on a health surveillance project which you know and some of you have visited and a small team of the soul of us all in our 20s, i was the only american in the first year. this little group of young enthusiastic people, only half of them saw their 30th birthday. all of them good friends of mine. one died shortly after childbirth of an infection called peripheral sepsis which i had never seen in the united states at brigham and another died of cerebral malaria. having been misdiagnosed with mental illness and the third a really vibrant young man died in great pain and fear because he had typhoid and had a perforation under the small

intestine. he was afraid and rightfully so. those tends not to be part of the narrative that you tell, because they are so painful. and so i think a lot more about it. in fact talking about the fact that you do with you expect them to do in college or in life. but those losses in those first years always remind me, all three of those people. in fact last week, a few weeks ago the baby who was born shortly before my friend died again of the 19th century infection he grew up -- so we think about hope and building a hospital there and starting the first cancer center

in rural africa. i think it is about hope. it's about trying not to be socialized to assume if you're working with people living in poverty, the second best or the third-best will have to to do and that happens a lot i think in haiti and everywhere. we lower our expectations for poor people in the united states. we lower our expectations for people everywhere. so, the relationship between the failures of imagination when you are dealing with scarce resources and to me after the earthquake we had our date cited we were going to build the hospital and you were in on that discussion. after the earthquake there were so many people there've reached out to partners in health and said we want to help in haiti. the haitian government and the ministry of health came to us and said, you were there that

day, you know we should build a teaching hospital outside of port-au-port-au- prince because the teaching infrastructure had been destroyed. i think most people here know that almost all haiti's federal buildings were damaged or destroyed in the earthquake. and imagine that happening in washington. in any case, reimagining it was reimagining health equity. why would you have a university as there is no university text that is exactly the point. you don't think the people in the city want the university? and then there came all the partnerships which moved me deeply. the stories that move to you deeply too, the stories from all of the world the routes and we would like to help. yes it was chaotic and there were problems but i'm just talking about the citizenry particularly of this country,

corporations who i've barely heard of him and said we will build your i.t. that bond, that was hewlett-packard. and on and on it went and some of the most wonderful things of all, working with building. there wasn't that capacity to design and build but there were a lot of people who wanted to learn how to build. they wanted to learn from master carpenter's and master electricians master plumbers. it was the largest hospital in the developing world today and not only were -- not only was money donated for so to a lot of the equipment in the labor. i love the name international brotherhood of the electrical workers. so now it gives me chill bumps. ibew local 103. yeah, i felt the same way. so they come down from boston

and all over the united states to help transfer skills. so yes it's true there is no university that there will be and there was no teaching hospital but even when the hospital is being built it was a teaching hospital because the people were learning how to build. it was built to better than california earthquake standards. it had modern diagnostics. it was connected to a framework of clinics and community health workers and partner of health projects. not that it was a source of hope but that it is a source of hope and it will be and a lot of my haitian colleagues. >> we have a full room so i know there are questions from the audience. we are going wrap up now and ask people to come up if they have questions. there are microphones at the end of each row. so please come forward.

>> if you wouldn't mind introducing yourself. >> my name is rebecca. i am actually at an elementary schoolteacher which makes me reflect on something you said at the very beginning. he talked about the discrepancies in -- something i know very well. the discrepancies in life expectancy and things like that. it makes me think about being proactive so i was wondering, we care a lot about the clinics being built and treatment are kind of the backend of your work with health care and i was just wondering if you have proactive programs and educational programs to teach people all over who are partners in health work about proper nutrition prior to outbreak such as cholera? >> it's a great pleasure and a lot of people here think about

here. everybody trained a public health in just a layout for stivale answer is yes. we are very involved in education. not just in schools or in training but also with patients in their homes. we formalize a lot of that. we can talk about that later but in this arena will we see very often and we see very often with the failure of the imagination has struck, international health or health budgets in a place where say you are talking about not $8000 per person per year in expenditures for $3. people pitted prevention against care so you have people saying -- you can't treat aids in africa. you can only prevent it. it would be one thing to say

that before the hypothetical epidemic and is quite another to say it when there are ready 30 million people sick or living with hiv. the same story for lots of other problems like diabetes and mental health. what we try to do a partners of health and is not easy to do but we tried is to integrate retention of care and move that prevention back upstream. one example and then i will stop. if you were to say okay you want to prevent hiv among women living in poverty if someone said to me you could probably do more by creating jobs than by having prevention workshops or lectures or talking to people about risk, and by the way the person said that to me was a person living with hiv in haiti. she said do you want to stop aids among women? give us jobs. i would be hard-pressed to say that is wrong and the structural

intervention are less important then anything we could do and health promotion through teaching whether doctors, nurses, schoolteachers or community health workers. i hope not only can we integrate prevention care but structural structural -- that would protect people's dignity. thank you for being a teacher. >> thank you. [applause] >> hi. my name is emily. i have been in the nonprofit sector since i was a girl scout, about five years old so it's kind of like meeting a superstar for me. my question really is more general and that nonprofit workers are challenged and you constantly feel like you're fighting and everything has to align to be able to make a difference for any cause

whatever it is, whatever the mission is of the organization. you kind of set of perfect when you're talking about continuincontinuin g for 30 years and you didn't have a master plan. i guess my question is more along the lines of how do you keep doing it for 30 years? do you wake up every morning and you really want to make a difference and sometimes it's just really hard? how do you not just sit in your apartment and just watch tv? >> sometimes you just should sit in your apartment and watch tv. first of all, if what you are doing is ever really a struggle and if it's not a struggle you are not struggling to promote something or achieve something that you are going to see later in my experience people eventually have these crises later on.

so, bravo for you for sticking with something and i will give you my little tip right now. i think that is the nature of this work, that it's not easy. certainly there have been many times and claire mentioned one of them and i wanted to run howling out of the room, out of place x where i was. i don't think that is pathological. it's bad when he starts screaming and going crazy but there are lots of difficult circumstances that can turn you toward social justice. there's acrimony and there are complaints and there are struggles and you are facing an undercurrent, a constant undertow of an opinion from somebody. somebody is not happy so how do you do that for decades and

decades? one is believing what you're doing. for example i don't have any doubt that we can move forward and lifting my hand up in this beautiful building towards some goal, health equity for example. think about people who have struggle denver martyrs so we could have civil rights in this country for full enfranchisement you go down the list but there is something, you have to believe in that. another one is you always look at other people and you work on a team. i wasn't joking when i said that claire's buoyancy and positivity after beer quake -- earthquake -- i wouldn't want to face some of the things i have faced without being surrounded by people who were really positive. in fact i won day went to the

city's and there are people who were here but remember what the cities were like and what they smelled like every day. at that time i said to claire you have to be pathologically positive. i called her pathologically positive for months. when i went to -- after the earthquake which is the place that i met two of the three people who died, claire was in that state too. many of the people in this room are also somewhere during the earthquake and several people here for generations there. when i went to,, that is what i really felt. there were patients everywhere and inside the church. the church had been transformed into a casualty clinic.

they were basically on the ground. the patients in the church, all the pews were gone and there were matches on the floor and the whole campus which was packed with injured people. but you know it was clean and people were being taken good care of and there were such a good feeling of fellowship. i saw some of my former students, trainees from harvard and my haitian colleagues who were rocks. i saw them there providing this care and i just thought i am part of that team and i need to be on the team. you need to understand your own quest for efficacy is not what is going to get you through these difficult times. not doing the kind of work that you are doing. so give yourself some space. there are those days where you think i can do this.

sometimes you can. remember also it's cyclical. if you work on a team, going to rwanda for me from haiti was a good thing. organized and orderly and it's hard to believe when they think about rwanda. they think about death and destruction and despair but that is what it was like. it's also a way to say i'm going to take a break from this part of the work and do some other work. that is why i write as well. stop, go back a little bit and say where we going and how are we doing? thank you for sticking with it. [applause] >> i am chuck woolery. i have been in global health efficacy of the year and i'm concerned about the development goals and the former calls for political will.

president carter and the world mission of hunger back in the late 1970s talked about achieving goals of ending hunger and addressing injustice issues and said basically we don't. there will be secured consequences. later hiv/aids come in a lot of those problems and there was some -- you mentioned that we probably wouldn't achieve these goals without linking it to our own self-interest but particularly many of the national security. i've been frustrated through the years that more of us liberals haven't done that and i want to get your sense of why or should we or should we avoid that? >> thank you very much and i don't pretend to have an answer to that. instead i have seven. all joking aside, there are people who are very comfortable with that framework, the framework of self-interest to justify engagement from the other and some people do it really well. i acknowledged that.

they will lay out all the reasons that intervention for good should be pursued in the interest of either security or human security. i am much more comfortable with the human security paradigm. human security means freedom from want and all the things that fdr used to talk about in addition to the four freedoms. but there are other complementary paradigms that i think and think an hapless purser our goals. i mentioned one already which is social justice agenda, the human rights agenda. it doesn't work for everybody. some people don't find it very compelling. i do. i think it's a good safety network. if you go to boston and say he should everyone the rights to orthopedic care you make it people quarreling with you but after the marathon bombing you didn't have people saying well do we have the right to surgery?

everyone is happy to do their job and to help people. the right paradigm isn't always used but it is a reminder that every human regardless of where they are from has basic rights. another one that does seem to move a lot of pedicle figures in the world is the economic logic that underpins sound investments in health care and education. i'm comfortable with that too because i believe you are never going to break faith pot cycle of poverty and disease without investments in health and education. we have a lot of data for that. the third one that i hear a lot, the kind of logic that you would use or i is that it is very smart to have public good for public health. if you have an airborne epidemic for example in a room like this,

you have aerosolized tuberculosis or influenza or sars you would want there to be a public health strategy. he was considered a public good to protect everyone here. and there are other things but those three, the right to paradigm -- equal rights paradigm and the public goods paradigm are a very powerful. one of the things that struck me looking back over the last several years and how far we have gone in global health is partly because of aids. yes all those justifications were made but the most powerful if you ask me was the one around justice, equality, passion and mercy which are very hard to put in the kind of language you see with a security document. thank you. [applause]

>> hi dr. farmer. i am sarah heller. thank you so much and it's been a pleasure to meet you. i'd like to ask about the role of global technology and global health. as many of us in this room probably know there are more people who have cell phones these days and even more have access to cell phones that have access to a clean toilet. >> yes. >> i think there are a couple of areas where mobile health could be helpful. one of them is what i think of as the backend where a pharmacist in a health system can send a text message to report their stock on hand so on the backhand of logistics management and making sure that health commodities are in the right place to serve people and then there is the front end where we can send text messages to patients, miners, don't forget to go to the clinic or

give them information on safe family planning practices. what do you think is the area that is most ripe for and health? >> by the way it took me three years to figure out what front-end and backend meant. >> i just made that up. >> i have heard it a lot. it was already mentioned tonight. i'm not sure i've entirely mastered the terminology. it's probably, the word i.t. backbone comes from new communication technology. i would be glad to go into the specifics in detail afterwards. that of course is an idle threat as you would have to stand in line for a while. [laughter] on e-health or electronic, this is the wave of the future for a lot of reasons. one, you can't manage clinical

data and medical data without it. there is no way. paper records, they don't work. even in the matrix they don't work, claire. [laughter] what we need to do is move faster to use these technologies to leapfrog problems that have been registered here. rwanda for example has embraced the health and mhealth fully on the front end and the backend. again if you are a gastroenterologist it's a very different kind of thing. [laughter] let me just take a general point. i could go on and talking about how we use electronic medical records and you know in settings where there is no electricity. the general point is that technological innovation comes

very often from basic science in my view, from the laboratory. it has to be transformed from discovery into delivery. and that gap is huge. again we need to bring in new tools to help us jump over that gap as well and try to move discoveries to people who need them. it's not going to spare us from the other work that was mentioned a minute ago, the work of believing in justice and equity. what is our judgment for cell phones? people took them up in technology for reasons i'm sure have been well studied. we need equity plans for technology in general and that is true of medical innovation. go right ahead and clap. i couldn't agree more and that is the way the quest -- quickest

it's ever happened in modern public health and medicine the fastest it's ever happened has been in the global aids movement. why did that happen? a lot of it had to do with aids activists who pulled together and built these coalitions that stand in their own self-interest to places far away. that is what we need that a lot of technical innovation to link that innovation and only a luddite would not want that. to link that to an equity plan that is going to involve a broad-based movement to share science and technology. that is one of the biggest human rights struggles of our time. [applause] thank you both so much for coming. >> what is your name?

>> i have a two-part question about mere belay. you both mentioned about how to great symbol of hope for the community and for all of haiti. i was wondering if you have begun to see patients and if not win that will begin and what is the long-term vision for how this will be integrated into the haitian health care system? obviously there's a long road to go but how will it transfer to be given over to the haitian people at some point? >> that's a great question. yes, the short answer. yes and yes. yes there were 500 people in line monday and the staff is there. actually to go back, the staff is mostly haitians on a sense you had haitian patience and haitian staff with other people chipping in. so that transfer authority

happened and i think your question which is a great one is really how will it be integrated to the haitian public system? first of all some of this is worth underlining here, that we built it for her vacation public sector is owned by the ministry of health. we decided as we have for the last decade we would not build health infrastructure to be on bipartisan health or other private owners. only the public sector. that is kind of our ammo now, trying to build local capacity in public health capacity by at least putting the infrastructure in the beginning. the hospital i mention in northern were one of which happen to the cancer center that is only two and a half or three years old. and in that short amount of time it's now 52% of the salary is already paid by the government ever wanted. you see how rapidly it can happen when you have good

organizations and enough resources to roll out a plan at that level. in haiti i'm not expecting it will happen that quick way however it's owned by the haitian government. in a high you wall off a project to get it done? does that make sense? you say okay here is my project. i'm going to send a man to the moon or something. or there are bad projects too by the way, construction projects, seriously that are built to destroy something. when you are building something new and ambitious is okay to have that kind of walled off. as soon as it opens it has to try to start functioning. we humans involved in it have to integrated into the system and that means referrals. how do you refer from the other

towns on either side? how are we going to do referrals in port-au-prince and tap into public sector insurance? we don't even know how to do that and in fact a lot of public hospitals don't know how to tap into public sector insurance. the same government, the hospitals don't have the capacity or the connections. we have a lot to do to learn how to do that but we are very committed to it. the way we have set it up early on was to sign a 10 year memorandum of understanding. i hate that kind of jargon. my lawyer tim is here. he will tell me if i can say mou. that is how we laid it out, just to go in that correction. it's going to be hard. as claire said i understand why ngo and missionary groups, a lot of them just do their own thing.

it's much easier but is it the right thing to do long-term? i think it's the right way to integrate through mechanisms we have 40 used to try to integrated in all those ways. it's a great question. i also hope there are people in this room, young people especially who will be committed to this because i don't not do it. i didn't say i knew how to integrate a public hospital with public insurance or how a tertiary referral hospital should fit into a place that a whole country is -- and we don't say it collectively. we have to learn how to do it. thank you. [applause] >> hi there, thanks so much. my name is brian and i apologize because i think i'm going to have you repeat yourself just a bit. >> never bothered me in the past. repeating myself.

>> i think in politics as of the things there are flavors of the month and the presence of the champion versus the goal is invaluable and that is why your work has been so incredible because you have established frameworks that are going to continue it even passed your time earth. i wondered if you could speak a little more specifically about the challenge of institutionalizing good practices and overcoming the challenge of personalities leading the charge. >> very astute. first of all i have to say thank you for saying that it will be institutionalized beyond my time on this earth. that of course would suggest that you are my retirement plan and that is good. [laughter] you think there are the benefits

of bureaucratization and it suits his -- institutionalization. we know the risks. bureaucracies are difficult to work with, they are slow and cumbersome and they have rules-based ways of moving something forward. the sociologist talked about the iron cage and that is what he was talking about. we want institutions to be compassionate and responses and even amble. when they are very well-resourced and in fact getting back to the marathon bombing and the hospital i'm lucky enough to work in, i was hardly surprised that the patience who made it there or the other hospitals mass general for example, there are a lot of resources and almost redundant systems where you could have that many casualties and expect very good clinical outcomes and rapidly deliver.

the value of having an institution that is sound and not based on any one what is called charismatic leadership is a great thing to do. we are all praying for it. everyone who is been involved in health notice that we are all still involved one way or another. one of the founders, five founders and i won't mention them by name because there is a small affair called the world bank not too far away but everyone is still doing social justice work and fighting poverty in his or her own her own way. the idea that we had when we were young that this is not sustainable is not really true because we sustained it. we sustained our engagement and brought in more people. that is the best insurance you can have is to bring in more people and frankly bring in young people. when you bring in the next

generation, and that is why i wrote the book and it says that right on the cover. in fact a student of mine chose as an editor. he bringing in young people, next-generation opening up the endeavor to others, making sure that you don't lose the value of personal engagement. some big machine, mixing it up in the up innocents as i said earlier sometimes you are going to want to be working in the field, calling the field the place like a medical setting and sometimes maybe not. all of these strategies can build enduring institutions if they have a good goal. and another thing that is worth saying here and we are asking

everyone to think about is that if you are a delivery organization and there are a lot of public sector service organizations. one could argue the ministry of health. in some ways that is what they do. if you are a service organization what would it look like if every service project were fully leveraged by training and learning? what would that look like? i could use a different language, if every health project had formal training components, not just for doctors and nurses that doctors, nurses, psychologists, managers, hospital administrators, web administrators, people to avoid logistics, transport, partnership of the public sector ' claire's point. what would that look like?

and then if every effort was leveraged with some kind of learning cycle. in my field they call that research. >> is canada like that? i just thought it was cold. that is a hard thing for group to do to say you know what? we didn't get it right the first time, second time, third time. how are we going to keep improving that? >> we have time for three more questions. >> i came all the way here from haiti. i have plenty of time. don't rush me out of the synagogue. >> i wanted to thank you. i know that me and many of my medical school classmates went to medical school because we read mountains beyond mountains when we are 18 or 19 years old.

now i'm at the end of medical school and i was wondering, how do you balance doing good for individual people taking care of one patient and speaking more broadly about making changes on the system level and for populations of people given that you have the skills to help individual patient's? how do you justify thinking broadly? >> well let me just say whether usa practitioner focus on the delivery of health care to one patient, say you are a gynecologist and you see five patience and an afternoon or a morning, whether you do that or or -- where do you do that or work on health policy you still have to look at the big lecture. so people do the small picture and people do the big picture still have to look at the

system. that is why i was saying rather long-winded lead to the young man who was fond of canada, that you really all of us have to look at the big picture, right? we are socialized as humans to look at whatever it is we are doing. i'll give you an example. people who make policy they also look at the big picture just as much in fact is people who don't work on the big picture. that will startle you because you think if you're working on policy you automatically have safeguards against understanding what i'm calling the big picture but you don't because policy is socialized also. it is narrowly focused justified by clinical practices. ..

>> policy makers are at risk for the big picture. that leads me back to the council 18 year-old set by and something you really like to do because if you

like doing the big picture worked that also include a scholar of the analysis of a complex social problem. that is what historians and sociologists and anthropologists if you like to do direct clinical service or pediatrics do that how could i guess? is that. [laughter] so choose something you like to do and also be interested in the big picture no matter what you do if you are a surgeon think of the big picture a public health practitioner think of the big bear picture. good luck. enjoyed medicine. figure.

from both the view i do international economic development work to which you alluded before and a focus and my question is how you navigate the past of adding value and being far away from home to inspect the places you working and a way to contribute and it was easy working on an issues of equity is easy to be edger. >> people can be a juror can their own home countries also. [laughter] >> also to have of family faraway site go from working

with farmers in west africa to being closer to where family members are but that means looking at the computer screen with zeros and ones to find a way i can do something that is useful but hopefully has personal meaning and all within the context of being an outsider. how do you navigate that? >> go also ask clear to comment because does she was pushed out of haiti as a 14 year-old and i came here to this country and was an outsider who became insider then back to haiti where she is no longer the insider because of the diaspora.

i'm not trying to be a group to have an answer to all these questions but i think to go back to the first principles how do acknowledge your own privilege? but you are working with for farmers but you are in a very egalitarian die of. you are richer than they are pork. you are well, they are sick. be honest about the power differentials. and it is painful because a lot of people do want to be on an equal diets and of course, you come back to

this country and elderly parents to see the striking disparities. i think being honest even a spiritual exercise it is always better when you think of these things and just remember humility and sometimes been quiet. sometimes in a place for you are an outsider. and to have a very warm welcome that other outsiders don't enjoy. and i cannot tell you how pleasant it has been to work in prisons and russia in siberia because of the

collegiality but rwanda is a tough place you don't expected not to be difficult. haiti is one country above all over -- others of their relationship and guatemala with the indigenous people the ones i work with i would turn to the local elites more than the doctors. i do believe we may get off and it is assumed if you are ahead doctor or nurse or direct service provider you could offer something of value. but maybe clear you have thoughts? >> also what he says about humility and being quiet and listening when we talk about purchase of a tory research, we would ask

students to practice listening and it turns out it is a very difficult task. we would say they have these games or they would ask questions. how was your day? i had a long day and from this point* forward it can no longer ask questions you only get yes or no answers. i had a long day mean because it had many hours or socially influencing but you have your own understanding for what they think that you understand but they don't. the context is similar when you go cross-country you have added to how you perceive others before you are perceived in weather and i you to the belief the person across from you is thinking of the serious matters.

you here to get the program 10 or to learn and collaborate? that changes how you approach in the second piece is to recognize your privilege. in haiti i learned with those patients have experienced the vast differences so when they see me as the haitian provider they're happy but they are nervous i will be a doctor who talks to them or at them so i do literally position myself differently. looks them in the eye and ask them how they are doing with their family members the same as anybody else but how you position yourself and this goes on and on. also what i read and the recommendations to make sure it includes the voice of those who have experience

but could be valuable but it is about listening and humility. [applause] >> hello. we talk about the challenges of working with the public sector and could you tell us about one major success that you have had and what you have learned in the partnership? >> when she talks i will think of the best answer ever. [laughter] >> with the earthquake in haiti one of the things that

was really, really challenging was the ministry of health building collapse that the minister and his team had to work first out of someone's home, later across the school and now in a tent over it really looks like a container but they call it temporary housing. and found myself asking what they've wanted nor needed but multiple partners asks the same thing and one of the things i got was the public sector partnership that we stopped and looked at what the public sector needed instead of imposing what we thought they needed and within the first few days we thought the major thing was the these partners were going back and they're able to quickly tell the

minister but he had located the own staff so they have to do trust us with something that makes us look weaker. and that is the biggest public sector of learning and from seeing as being in haiti for a long time but the positioning under stress so that is the partnership. >> what i would want to say is when we had the consulting team come in to help set up so after the earthquake the infrastructure was very small for the public sector and we quickly had to say these are my priorities and

the donor had to pledge. there were all these concerns about to make sure the money pledged was in line with priorities and the major projects so they look negative indonesia and was to quickly set up an office in haiti and a pullout of partner to help us do the work. i had never been exposed and i had no idea but i've learned a lot about the importance of analysis and data. what i've learned is the ability to stop, look at the model and asked or treat the government of haiti as their client. just like coca-cola asking to change the marketing strategy so the team brings their tools to struggle with

organizing and managing a large set of information. >> both of the samples of our public and private because that is what the word is the best experience i have had seven knee where i have been is administrative health. there is a dynamism there, a plan and private players, a lot of groups and i have sent many of those a team together to get a lot done in a short amount of time. i decade is so long time. but it but i gave from siberia is shocking.

go into a prison, 26 percent fatality rate that means one quarter of the people on treatment died but then one year of going in there to work together with the administrative justice officials, mortality was at zero. fact is number two. in the present. but they were a captive audience. [laughter] but the private sector example i have already said. jim and sarah build a construction company up in boston, sold it and what will he do? he is 50 years old and he will go work than the earthquake happens. he meets former student dr. david walton from harvard medical and we get

together and we say we will build this hospital and the companies that came in to help, the skills that they have and i know how to build the backbone or set up to the manufacturing plan for this of the you need for malnutrition. anybody else calls and ready to be therapeutic food. i know how to manufacture that but a lot of companies came in to help to watch how they do the work and they could move at and i was in tears practically with joy by the way seeing how this had come together to build this terrific project.

[applause] >> big data will change how we live and work and think and the journey begins with the story of the flu. every year the flu kills tens of thousands of people around the world but in 2009 and new virus was discovered and experts feared it could kill tens of millions. there was no vaccine

available the best that authorities could hope to do was slow the spread but to do that they needed to know where was. in the west the center for disease control had doctors report new flu cases but collecting and analyzing takes time so the cdc picture of the crisis was always one or two weeks behind which is an eternity when a pandemic is under way. around the same time engineers said gold developed to the alternative language to predict the spread of the flu not just national be but down to the regions in the united states. they used to go search. it handles more than $3 billion searches per day and saves them all and it took 50 million of the most common search terms and compared when and where they were searched for with new data going back five years.

the idea was to predict the spread of the flu through web searches alone. they struck gold. what you are looking not right now is a graph that shows after crunching through almost half a billion mathematical models come a google identified 45 search terms that predicted the spread of the floor with a high degree of accuracy and here is the official data of the cdc and here is google's protected data but where the cdc had a two week reporting live google to stop the spread almost in realtime. a strikingly, the google's method does not involve contacting the offices. instead it is built on big david the ability to harness

to have a novel insights and goods and services. let's look at another example. a company coming in 2003, and that passengers knew he was taking an airplane which is he bought his ticket well and it bans and that made sense but he could not help but asking the person how much he paid and he asked another passenger and he paid less even though they had both bought the ticket much later than he had. he was obsessed. who wouldn't be? but he is computer science professor so what he realizes is whether they

want to buy a new fans are this saturday night stay might affect the price but instead realized it was hidden in plain sight to say all you needed to know was the price that every other passenger paid on every single other airline, for every single rate and every single route to a fall of civilization for an entire year or longer. this is the big data problem but possible. he gets a little bit and found out if he could predict this high degree of accuracy if the price presented online is a good price and if you will wait because the present is likely to go down. he called the project hamlet. to buy or not to buy.

that is the question. [laughter] but a little bit got a good prediction. a few years later he was cringing $75 billion price records and it almost every single flight for an entire year and to microsoft word -- knocked on his door and he sold it at $100 million with the data was generated for one purpose and reused for another so it was just for all the input.

>> think of how the typical american ease 30 percent buys processed food food, 90 percent come 84 percent of americans see the children in a fast-food restaurant at least once a week and when the consumer enters to restore, they are met by hundreds of not thousands of brands. as they shop for beverages they could buy pepsi pepsi, gatorade, lipton tea, zero missed, a root beer, energy drink, bottled water if there health-conscious they could buy naked juice or perhaps quicker cereal, cereal, also puffs' tweet for meals or stacks they could buy a

potato chips, seven ships ships, crackerjack, for teredos but what the consumer doesn't realize is all of those brands are owned by pepsi. pepsi is the largest food company in the united states if you want to call those items food and the second-largest in the world. or they could buy van ness the product and i will not go through all of those brands but it has about 6,000. 94 billion in sales and 10 point* four in profit. it has about six point* 4 billion of profits because it is the biggest food company in the world and not just in the u.s.. so basically with the every subset factor of the food

industry we have just a few companies that are controlling all of the brands. 20 companies control the highest percentage in the grocery store and of those, 14 control organic food so it is basically controlling what people each. then we have a grocery conglomerate. wal-mart the setback and one ad of every three girls shriek dollars goes to wal-mart. it does have but to wonder if they have clout or political power, the multinationals use this political and economic power to dictate food and foreign

policy? so they pesticide regulation, and nutritional labeling and to but it has become so powerful it could buy public policy. >> host: there are some lobbying full time but they have hired 13 former members of congress and 300 former staffers of the white house and congress. so the technology industry has a lot of clout. and wal-mart is really part bearing up in some ways.

with the genetically engineered this week korn and they plan to have 40 percent of the sweet corn engineered and of course, it will not be labeled. your but the model is basically pushing cost on suppliers using every share of kirkuk but we don't have

enough time to really get in with it this evening but she says it is cheaper with those environmental laws where they could have an easier time dictating policy and so increasingly our food is being produced in these countries and if you talk about organic it is difficult to even verify in the west that they are

meeting the standards. you can imagine how this is happening in places like china. >> [applause] i know it has been very hot and i appreciate it. i would like to talk over 30 minutes about the book "the savior generals" then have questions from you if that is okay. there is a whole sean rush of general's, leadership and the terms of what succeeds and one fails so the great captains by a man named dick