person is acceptable. so you ask me has it changed? i don't believe it's changed. i think fbi needs an enema. i'll go back to had. i walked by shelly and were in washington last week. i walked by the hoover building and thought what a disgrace that the name is up there. what with know about the guy he was one of the most corrupt government officials in the history of the republican. and his name is still on the building. his etho is still in the building. that's why all we talk about whitey gull we are bsh bulger. >> on that cheery note. [laughter] i would like to thank you for coming out. i would like to thank shelley murphy, kevin. the book is whitey

as the medical and anthropologist coefficient the, policy adviser in. >> and never seen her nervous before. >> it's interesting. i don't think in as he introduced you to a large column before. he is dedicated his life to helping others and not in the world's most relentless in, starting with one clayton -- clinic to now a partners in health organization that spans more than 11 countries and. your work has truly him moved untouched make people. i met paula and i was a young medical student.

following my meeting with. when i was a resident, that's what i considered my social life . >> is still kind of like that on a mistaken. >> still is. he must understand how exciting it is some of these have probably listen to, and many were in the students who are about to explore the world. i listened to speeches many times. i would like to start by beginning, how did it all starts? eighty common roll ag him, was this part of a big master plan?

>> she just violated. these are with the really easy question. thanks to everyone who made tonight possible. as painful as it is to contemplate not having a disco here, you've done well. it staggeringly beautiful to be year and reflect the. it's a wonder and everyone here must be grateful this . that was my wedding of the master plan question. among think anyone has a master plan. but i would just say been an lot of what happens in by -- and life is serendipity one of the challenges that everyone trying beth -- breath on the planet has its ugly people level of good fortune

from armenia will to go to college is to understand when serendipity is attempting. i get involved in haiti a wasser by accident i was interested inborn. i actually planned to go after college. i wanted to go to settle. i'm sure you have heard this, but not that many people have. i have been saying and more recently in speaking with young people because scholarship committee would not even offer me an interview much less a scholarship. in fact abner and and and i wrote a letter to this group

, what i thought was really give french explaining to them why they would be so lucky to have me. about six months -- about a month later got a letter saying, you know, dear mr. farmer, thank you for the letter. unfortunately the doctor you addresses been dead for several years. in my defense, that was before the internet which are later invented. but i just want to say that haiti was a later -- a little bit plan b for me. so grateful when one that came to pass the. like a lot of 23 rolls of thought was knowledgeable and be. 1i learned a lot. still working with the same people i met that year.

the last 31 years. in fact about the same place, the same town. i hope some of your following what has been going on. [applause] moi. we have a celebration opening up when a modern medical center in central haiti in warm looking at want a trustee. and it was one of the most uplifting things weren't. so master plan in 1983 for 30 years later, but the same tired as not an accidental we're still working with the same team. the same places. it's an accident it takes 30 years to get some things done.

that is so started. >> thanks. i'm going to go back probably at the end, but you mentioned partnerships a bit but. through my career of a gun to their own doctor during clinical . to confine myself working across a lot of disciplines. >> you can fix my cellphone. >> i know. [laughter] >> go ahead. >> i'm going to add that to my list. and so what i've found is that but you would often talk to young people who are going into business school or who are considering theology and encouraging them to consider global health. can you explain how these provisions work? >> well, i can try. the college students as opposed to all the medical students were physicians and by intervening to

do internal medicine income of the reason is the same line, of course. i like to talk about how everyone can have a role in global health equity. global health equity is not the same as international health and . the same example from washington be about it on of the city very well. representation without taxation, the part remember. but head takes the subway across washington and new. what you see on one end of the subway in terms of life expectancy at birth mom. you go straight through the numbers. we study the medical school and public health because the other end of the subway, you have a 20-year difference in life expectancy. maybe that is airing a little bit, but is a major problem. global health equity is that international. it's about equity in washington.

the reason to talk to everybody in the field the you just mentioned and many more f -- equity in general is everybody's business. it will be easier to just talk to physicians and nurses. it would be easier to just address oneself to those of medical -- delivery of medical care, but if we don't talk to people in policy in business talk to one. i mean young people. dr. i school not too long ago. if we undo that it allows the myth that sometimes my expertise is required to have an opinion about equity, human rights, social justice, you know, what will happen to the world. that is got to be wrong to believe that expertise is going to save us.

♪ i like that. >> i explained that bad, what did for fun. i skipped, as we mentioned, for my school's right to medical school. i did not watch many movies. i am not sure i've seen the matrix. >> that seems to be repeated to me at least. we should get a dvd and watch it before you go back to boston. >> we will put that on the list. so these colorful metaphors. >> how many of you folks tessin the matrix? i rest my case. if you're going to emigrate to this country at the age of 14 you have plenty of time to watch the matrix. >> oh, my goodness. i have to watch it now. and so in the book you have these metaphors or you talk about the red pill, and is deasy for the soul. can you talk to us a bit about that?

>> it was summoned to be serious that particular speech was given at my alma maters, medical school to my own students. and a metaphor that comes from this movie, kind of silly and pretentious which i did not make fun of a little bit, even though i have to admit i've seen several times. the central conceit of the movie is that we are all living in this social friction. they're all living in the social friction. and that's the matrix. the system is there. the program to believe is the real world, but the real world, of course, is not like that at

pain, suffering, violence , what is called a lot in that book structural violence, not the violence that you saw in boston during the marathon, which is advanced violence, the violence of war, but violence that happens in everyday life. people who have to fight. one woman in state -- one woman in haiti says to me 25-30 years ago, every day is a fight for food and wood and water. i just sat there and thought, that is exactly what her life is like. five kids. she had to fight for food and something to cook it with and water. and you know, it's just -- when you go from that three hours

later back to a boston teaching hospitable, a boston teaching hospital very well during the marathon, after the marathon bombings because it was -- it was equipped to do so. very proud of our hospital, but to go between these extremes in three hours is violent as well. and it is not the kind of thing you want to talk about in a commencement speech. i am sure it will get a real big -- going to have a lot of the whooping and laughing. this weekend i'm giving you american university. they're going to talk about the bombing and what happened after the earthquake in haiti. i don't like talking about bad things. i just think if we are going to address them. >> agreed. >> when we think about your work. >> our work.

>> our work. when we think about it over time one of the things that you have thought of is that whether or not we are clinicians, we have to see ourselves partnering with others, including the public sector. >> yes. >> and, you know, i think a lot of challenges when i think about partner with the public sector. but everyone understands why. some people feel like it takes a long time in this low. why would we choose the public sector in these countries? >> well, thank you for letting me talk about it. clare, by the way, not only is an internist, but he says just before the of quick mean me have been lucky enough to work together to try and raise these roles that we sell. haitian and american. public-sector. private sector. ngos. private-sector, like the universities, the small community-based college when both worked for in cambridge. as private sector. ..

>> i don't think many people, well, in berkeley people think that that might not be good -- [laughter] but most p people understand -- most people understand, i'm probably going to get in trouble for that. [laughter] i'm headed out there shortly. you know, i'm an infectious disease doctor and like to talk about some of the things that have been rolled out in that arena. but if you ever want that to reach a lot of people, like say the citizenry of a country, the entire district of columbia, the state of maryland, you know, go down the list, whatever your unit of analysis is, it's hard to imagine achieving any kind of scale without working with the public sector. i learned that lesson, i learned that lesson, you know, intellectually you can get it out of a book. or you can stop and think, wait a second, i went to public

school, i went to high school. and, hey, junior high and actually elementary, all that was public school. you know, you show up to public school, did you get your shots? and i thought, wow, i got my shots. my vaccination -- we called them shots. you'd think they were, you know, a liver biopsy needle they were coming over to us kids with. it was all public sector. and i didn't think about that when i was 18 or 19. i started reading about it and thought, wow, it's really good when people have some basic rights in the public sector. and then working in rwanda the last better part of a decade has been a great experience, becaus you've seen -- i've seen, and in other cases other people have seen what can happen. you're at the lowest point, you know, ground -- whatever you want to call it, rock bottom. 1994, a million people lay dead, murdered. the entire infrastructure was in

ruins. lowest life expectancy in the world, probably the poorest country on the face of the earth. and now because they have fought to pull everybody together into a vision and a plan, including ngos like the ones that i work with, including human rights groups, including mission schools, including donors of all sorts, they said let's all pull into one plan to move forward to this vision where we wouldn't need foreign assistance in 2020. they said that after the genocide. and, you know, and they're getting there. it's amazing. their life expect be tan si has probably doubled in the last decade, infant mortality's plunged, deaths from childbirth, vaccine/preventable illness, you know, it's because of fighting for a system. and the public sector's not delivering all the services. they're working with other groups like ours, but they're

getting us to pull together. i think that's a good thing to see. >> paul, when we started, you said you'd never seen me nervous, and i actually reflected back on this comment about this building. when she spoke about preserving this building, it brought me back to what we are trying to preserve in haiti and the shovels we -- struggles we face after the earthquake. we flew together within two days of where they are, and the devastation was horrible. and so we started -- [inaudible] and i'd like us to end. when things get tough, i look at it as a source of hope. what does that mean from the 30 years to where we are now and this new hospital? >> by the way, i can imagine the reason i asked claire if she would do this because i can't imagine anyone a better companion in those dark times than claire was when her own

house was destroyed and when she lost many of her friends and family. and when the city wreaked of death, and it was just wonderful to have a fellow physician who was there day in, day out always with a smile. so i, it's my chance to say thank you for that. [applause] now, i wrote a book about this whole thing, and claire kind of stars in it. for some months people would say, claire, did you ever read the book? no, no. [laughter] she still has not yet read the book. now she had to read this book. the first few years i spent in haiti which were a blessing to me, certainly. i have a friend of mine from

first-year medical school, my friends from med school 30 years ago would tell you, paul, haiti really moved him in the direction that he was going to go or needs to go. so my debt's enormous. i've got to say those first few years when i was 23, it was very difficult. for ten years you spent, you know, time recounting victory narratives, you know? here you are 23 years old in the town in central haiti, and you write home or you go back -- in my case to mood -- and you tell stories to yourself about how great the work is and how much progress we're 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 there was a small team of us all in our 20s.

i was the only american the first be year. first year. and of this little group of young, enthusiastic people only half of them saw their 30th birthday. all through three good friends of mine. one died shortly after childbirth of an infection which i've never seen in the united states or at the brigham. another died of cerebral malaria in a psychiatrist's waiting office having been misdiagnoseed with mental i'llness, and the third -- illness and the third died in great pain and fear because he had typhoid and had a perfect ration of his small -- perforation of his small intestine. and he knew -- you know, he was afraid and rightfully so. and those tend not to be part of the narratives that you tell because they're so painful.

and so i think a lot more about it. it's like talking about the fact that things don't expect them to go the -- don't go the way you expect them to in college or in life. but those losses the first few years all remind me of that. all three of those people lived there. in fact, last week, two weeks ago, the baby who was born shortly before my friend died -- again, of a 19th century infection -- he's grown up, and he was there. so when you think about hope or think about doing things in northern rwanda, building a hospital there, starting the first cancer center in central -- in rural africa, i think that it is about hope. it's about trying not to be socialized for scarcity to assume that if you're working with people living in poverty, well, the second best or third best will have to do. and that happens a lot, i think, in haiti is everywhere -- and

everywhere. we lower our expectations for poor people in the united states, we lower our expectations for poor people everywhere. so the relationship between the failures of imagination that come when you're dealing with scarce resources and that town to me is that after the earthquake we'd already decided we were going to build a hospital. -- we were going to build a hospital you were in on that discussion, a community hospital. after the earthquake so many people said we want to help out in haiti. you were there that day, i know, we should build a teaching hospital outside of port-au-prince because the teaching infrastructure had been destroyed, you know? i think most people here know that almost all of haiti's federal buildings were damaged or destroyed in the earthquake.

imagine that happening in washington. in any case, so the reimagining was just like the reimagining of health equity. a lot of people said, well, you can't really build a teaching hospital in central haiti, and why would you have a university hospital? there's no university? that's exactly the point. you don't think the people in this town, this city want a university? and then there came all this partnership which moved me deeply, you too. people from all over the world saying we'd like to help. now, yes, it was chaotic and, yes, there were problems, but i'm just talking about the citizenry -- particularly of this country, corporations who i'd barely heard of said, oh, we'll build your i.t. backbone. that was hewlett-packard. i had heard of that, actually. [laughter] and on and on it went, you know? some of the most wonderful things of all were working with,

you know, building. there wasn't the capacity to have design and build, but there were a lot of people who wanted to learn how to build in haiti. they wanted to learn from master carpenters, master electricians, master plumbers, people who could build -- the largest sew or lahr-powered hospital in the developing world today. and not only were a lot of the, not only was money donated, but so, too, a lot of the equipment and then the labor. we had unions -- i love the name international brotherhood of the electrical workers. somehow it gives me chill bumps. [laughter] ibw, local 103. you know? yeah. i felt the same way. so they come down from boston and all over the united states to help us, help transfer skills. so, yes, it's true that there's no university in that town, but there will be, and there was no teaching hospital before this happened. but each when the hospital was being -- even when the hospital was being built, it was a teaching hospital because people

were learning how to build. so it's better than california earthquake standards, it has modern diagnostic technologies. it's connected to a framework of clinics and community health workers as always with partners in health projects. and it's -- not that it was a source of hope, it's that it is a source of hope and will be, for me in any case and for a lot of my haitian colleagues. >> thank you, paul. it is for me, i know that. we have a full room, and so i know there are many questions from the audience. we're going to 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. >> and if you won't mind introducing yourself. >> okay. my name's rebecca. i'm actually an elementary schoolteacher. which makes me reflect on something you said at the very beginning. you were talking about the discrepancies in d.c. which is

something i know very well -- >> sorry -- [inaudible] >> life expectancies and things like that. so it makes me think about being proactive and preventive. i was just wondering, we hear a lot about the clinics being built and kind of the back end of what partners in health and your work is doing for health care, and i was just wondering if you have proactive programs -- >> yeah. >> -- and educational programs to teach people all over where partners in health works about proper nutrition and prevention prior to outbreaks such as cholera as we saw in haiti a couple years ago. >> right. well, it's a great question, and it's one i'm sure a lot of people here think think about. first of all, the answer's, yes. we're very involved in education not just in schools or training, but also with patients in their homes.

and we formalize a lot of that. we can talk about that later. but in this arena what we have seen very often when the failure of imagination has struck international health or health budgets in a place where, say, you're talking about not $8,000 per person, per year in health expenditures, but $3. there what's happened is people pitted against prevention against care. >> uh-huh. >> so you'd hear people say -- you guys have heard this, i'm sure. you can't really treat aids in africa, you can only prevent it. now, it would be one thing to say that before a hypothetical epidemic, quite another to say when there are already 30 million people, you know, sick or living with hiv. same story for lots of other problems; diabetes, mental health. what we try to do at partners and health -- and it's not easy,

but we try -- is integrate prevention and care and move that prevention back upstream. just one little example, and then i'll stop. if you were to say, okay, you want to prevent hiv among women living in poverty, if someone said to me, well, you could probably do more by creating jobs than by having prevention workshops or lectures or, you know, talking to people about risk -- by the way, a person who said that to me was a woman living with hiv in haiti. she said you want to stop aids among women, hey, give us jobs. i would be hard pressed to say that was wrong, that those structural interventions are less important than anything we could do in health promotion through teaching whether we're doctors, nurses, schoolteachers or community health workers. so i hope that not only can we integrate prevention and care, but that we consider some structural investments that would protect people's dignity

and help. it's going to be hard, but it's going to be worth trying to do. thank you. >> thank you. >> thank you for being a teacher. [laughter] [applause] >> hi, my name is emily. i've basically been in the nonprofit sector since, i don't know, i was a girl scout and about 5 years old. so this is kind of like meeting a superstar for me. but my question really is more general in that, um, nonprofit work is always challenging, and you constantly feel like you're fighting, um, and that, you know, everything has to align to really be able to make a difference, um, toward any cause, whatever it is you're trying to -- whatever the mission of the organization. and you kind of said it perfect when you were talking about, you know, you've been doing this for 30 be years, and you didn't have a master plan. and i guess my question is more along the lines of how do you keep doing it for 30 years?

[laughter] >> yeah. >> because it feels, you know, you wake up every morning, you really want to make a difference, and sometimes it's just really hard to -- >> yeah. >> -- leave your apartment and not just sit and watch tv. >> yeah. [laughter] well, sometimes you should sit and watch tv. [laughter] and watch the matrix. [laughter] you know, i mean, first of all, if what you're doing isn't really ever a struggle, you know, sometimes you have to wonder, right? if it's not a struggle, you're not struggling to promote something or to achieve something, then you're going the see later. in my experience people eventually have these crises of meaning later on. so, you know, bravo for you for sticking with something that isn't easy to do. and i'll give you my little tips right now. but i think that's the nature of this work. is that it's not easy. certainly, you know, there have been many times -- and claire

mentioned one of them -- i've just wanted to run howling out of the room, out of the place x where i was. and, you know, i don't think that's pathological. i mean, it's bad when you start screaming and sounding really crazy, but, you know, these are, there are lots of really difficult circumstances that you can face in work that is turned towards social justice. and there's acrimony. and there's complaint. and there's struggle. and you're facing an undercurrent, a constant undertow of sensor yous opinion from somebody, right? somebody's not happy with it. so how do you do that for decades and decades? well, one is to believe in what you're doing. for example, i don't have any doubt that we can move forward. again, i'm lifting my hand up in this beautiful building towards some goal, health equity, for example. think about people who struggled

and were martyrs so that we could have civil rights in this country or full enfranchisement. and you go down the list. but there's something that you're moving toward. you've got to believe in that. and another one is you always work with other people. you work on a team. you know? and so i wasn't joking when i said that claire's buoyancy and positivity after the earthquake were, you know, i'm not -- i wouldn't want to try and face some of the circumstances i've faced without being around some people who really were positive in very difficult situations. in fact, i one day when the city -- and there are people who were here that will remember what the city was like, the city of portion awe prince -- port-au-prince, what it smelled like every day, one time i said to claire, you know, you're just

pathologically positive. i called her that for some months. you're working with a team, you know? when i went to -- [inaudible] after the earthquake which is the place that i met two of the three people who died when they were young in this squatter's settlement, claire was with me that day too. we'd been working at the general hospital downtown in the earthquake zone, and many of these people were also somewhere in the earthquake zone. several people here, i'm sure there are haitians here. when i went to the town right after the earthquake, that's what i really felt most of all there were patients everywhere. n., inside the -- in fact, inside the church, the church had been transformed into a casualty clinic. there were patients on the ground. not only on the ground, but the patients that the church, the equivalent of the synagogue, was cleared out. all the pews were gone, and there were just mattresses on the floor, and the whole hospital, the whole campus was just packed with injured people.

but, you know, it was clean, and it was -- people were being taken good care of, and it was such a feeling of fellowship. and i saw some of my former students, trainees from harvard, my haitian colleagues who were rocks. i saw them there, you know, providing this care. and, you know, just thought i'm part of that team, and you need to be op a team. you need to understand that your own quest for personal efficacy is not going to get you through these difficult times. now if you're doing the kind of work that i suspect you're doing. and give yourself some space. there are those days where you just think, you know, i can't do this. sometimes you can't. and remember also there's a cyclical part of it. if you work on a team, going to rwanda for me from haiti was a good thing. to go to a place that's organized and orderly, that's

hard for some people to believe. they think about death and destruction and despair, but that's what it was like. and there's also a way to say i'm going to take a break from this part of the work and do some other work too. and that's why i write this stuff as well. stop, stand back a little bit and say, you know, where are woe going and -- where are we going and how are we doing? >> thank you. >> thank you. thank you for sticking with it. [applause] >> hey, paul, i'm chuck woolery. concerning about the low aim development goals and the former calls for political will, you know, president carter world commission on hunger back in the late 1970s talked about achieving goals of ending hunger and addressing justice issues. and it said, basically, if we don't, there's going to be severe consequences. later, heavy aids came and a lot of other global problems, and

there was some clause at the end of that that mentioned we probably wouldn't achieve these goals without linking it to our own self-interests or particularly even maybe national security. and i've been frustrated through the years that more of us liberals haven't done that, and i just want to get your sense of why or should we or should we avoid that? >> well, you know, thank you very much. and i don't pretend to have an answer to that. instead i have seven. [laughter] no, all joking aside, there are people who are very comfortable with those frameworks, the framework of self-interests that justify engagement for the other, and some people do it really well. and i acknowledge that. they will lay out all the reasons that some intervention for good should be pursued in the interest of either security or human security. now, i'm much more comfortable with the human security paradigm, right?

human security means freedom from want, all the things fdr used to talk about in addition to the, you know, the four freedoms. but there are other complimentary paradigms, i think, that can help us pursue our goal. i mentioned one already which is the social justice agenda can, the human rights agenda. doesn't work for everybody, you know? it's not -- some people don't find it very compelling. i do. i think it's a good safety network, you know? if you go to boston and say, you know, should everyone have the right to orthopedic care, you may get people quarreling with you. but after the marathon bombing, you didn't have people say, well, should we have the right to this kind of surgical -- no one talks like that. everyone was happy to do their job and to help people throughout. so the rights paradigm isn't always used, but it can be useful as a reminder that, you know, every human regardless of where they're from or whether they're a citizen from a rich

country, poor country, has some basic rights. another one that is very, that does seem to move a lot of political 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're never going to break the cycle of poverty and disease that would lead out of underdevelopment without investments in health and education. and we have data for that. and a 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 some public goods for public health. you have an airborne epidemic, for example, in a room like this, if you had tuberculosis or influenza or stars, you know, you'd -- sars, you'd want there to be a public health strategy. you would consider it a public good to protect everyone here. so -- and there are other paradigms. the first three, the rights paradigm, you know, break the

cycle of policy and disease conclude paradigm and these public goods paradigms are all very powerful. and one of the things that has struck me in looking back over the last ten years and how far we've gone in global health in part because of aids, it really was, yes, all those justifications were made. but the most powerful one, if you ask me, was the one around justice, equality, compassion, mercy which were very hard to put into the kind of language that you see in a security or human security document. thank you. [applause] >> hi, dr. farmer. >> hi. >> i'm sarah hiller. thank you so much. it's billion a pleasure hear -- it's been a pleasure hearing you speak. i'd like to ask you about the role of mobile technology and global health. as many of us in this room probably know, there are more people who have cell phones these days, even more have

access to a cell phone that have access to a clean toy left -- toilet. >> yeah. >> and i think there are a couple of areas where m-health or mobile health could be helpful. one of them is what i call or think of as the back end where, say, a pharmacist in a health facility can send a text message to report their stock on hand. so on the back end of logistics management and making sure that health commodities are in the right place to serve people. and then there's the front end where we can send text messages to patients as reminders to don't, you know, don't forget to go to the clinic this day, or you can give them information on, say, family planning practices. what do you think is the area that's most ripe for m-health these days? >> by the way, i have to confess it took me about three years to figure out what front end and back end moment.

[laughter] >> i just made that up. >> no, i've heard it a lot. we've already mentioned it tonight. so i'm not sure i have it entirely mastered, the terminology which probably like the word i.t. backbone comes probably from new communication technologies and platforms. let me make a specific point and a general point, and i'd be glad to go into the specifics in greater detail, you know, afterwards. that, of course, is an idle threat, because you'd have to stand in line a while to talk -- [laughter] >> on e-health or electronic health, that's, this is the wave of the future for a lot of reasons. one, we can't manage clinical data, medical data without it. there's just no way. paper records, they don't work. you can have even in the matrix they don't work, claire. [laughter] so, you know, what we need to do is move faster to the use these

technologies to leapfrog problems that have been registered here in the third world -- rwanda, for example, has embraced e-health and m-health fully on the front end and the back end. [laughter] again, if you're a gastroespecialliologist, it's a very different -- [laughter] so let me just make a general point, almost philosophical but not. because i could go on in telling how we use electronic medical records in settings where there's no electricity, and we've had the failure of imagination. no electricity. but the general point is that technological innovation that comes from, very often from basic science in my field from the laboratory has to be transformed from discovery into delivery, right? and that gap is huge. and, again, we need to bring in

new tools to help us jump over that gap as well, how to move delivery -- how to deliver discoveries to people who need them. but it's not going spare us from the other work that was mentioned a minute ago, the work of believing in justice and equity. so what's our equity plan for cell phones? now, we didn't even have time to develop an equity plan for cell phones because people took them up in technology for reasons that i'm sure have been well studied. we need an equity plan for technology in general. and that's true of medical innovation. go right ahead and clap. i couldn't agree more. [applause] and that, by the way, the quickest that has ever happened in modern public health and medicine, the fastest it ever happened has been the global aids movement. why does that happen? well, a lot had to do with aids activists who pulled together and built these coalitions that span their own communities and

self-interests to places far away, to people never knew or met. that's what we need with a lot of technological innovation. to link that innovation that only a luddite would not want that, right? to link that to an equity plan that's going to involve the broad-based movement to share the fruits of science and technology. we've got to have that. that's one of the biggest human rights struggles of our time. >> thank you. >> thank you. [applause] there are. >> bon soir. >> bon soir. >> thank you both so much for coming. i really -- >> what's your name? >> the things you said. i have kind of a two-part question. you both mentioned how the town in haiti is a great symbol of community and for all of haiti. i was wondering if it has begun to see patients. if not, when that will grin. and then -- when that will begin. and what is the long-term vision for how this will be integrated

into the haitian health care system? obviously, there are long roads to go, but how will this be transferred or given over to the haitian people at some point? >> that is a great question. y, -- yes, the short answer. yes and yes. next question? [laughter] yes -- no, i'm kidding. yes, it is already -- there were 500 people in line monday when i was there. and the staff -- actually, to go back to the staff is already mostly haitian. so in a sense it has haitian patients and haitian staff with other people chipping in. so that transfer has already happened. i think your question, which is a great one, is really how is it going to be integrated into the haitian public system. well, first of all, some of this is worth underlining here, is that we built it for the haitian public sector.

it's actually owned by the ministry of health. we decided, as we have for the last decade, we would not build health infrastructure to be owned by partners in health or other private owners, only public sector. and that's what we did in rwanda, and that's kind of our mo now. trying to build capacity by at least putting in the infrastructure from the beginning. the hospital i mentioned in northern rwanda which has the cancer center, that's only two and a half, three years old. it's a beautiful hospital. and in that short amount of time, it's now 52% of the salaries, i think the number is, are already paid by the government of rwanda. so you see how rapidly it can happen when you have good organization, enough resources, commitment to the rollout of a plan at that level. in haiti i'm not expecting it will happen that quickly. however, since it is already opened by the haitian government, the trick is to take -- you know how you wall

off a project to get it done? duds that make sense? -- does that make sense? you say, okay, here's my project. i'm going to send a man to the moon or something, right? or i'm going to -- there are some bad projects, too, by the way, of destruct i things. seriously. that are, you know, built to destroy something. but when you're building something new and something as am beshes as that, it's okay to kind of have it walled off, right? but as soon as it opens its doors, it has to try and start functioning or we -- because institutions don't think -- we humans involved in it have to start trying to integrate it into a system. and that means referrals, right? so how do you refer -- [inaudible] the other towns on either side of it, how are we going to do referrals for port-au-prince, how are we going to tap into public sector insurance? we don't even know how to do that. in fact, a lot of public hospitals don't know how to tap into public sector insurance, which is pretty startling,

right? same government. they don't, hospitals don't have the, you know, docking capacity or connection. so we have a lot to do to learn how to do that, and we're very committed to it. and the way we set it up early on was to sign a ten-year memorandum of understanding. i hate that kind of jargony talk. my lawyer tim is here. he'll tell me i could say mou. [laughter] so that's how we laid it out, was just to go in that direction. it's going to be hard, i mean, it's hard to -- as claire said, i understand why ngos and missionary groups, a lot of them just do their own thing. it's sometimes easier. but is it the right thing to do long term? i think, no. i think the right way is to integrate, you know, through the mechanisms we've already used, building it for the public sector and trying to integrate it 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 know how to do it. i didn't say i know how to integrate, let's say a public hospital with a public system or how a tertiary referral or hospital should fit into a place, a whole country where there really isn't enough of that. i didn't say i knew how to do it. we don't say collectively we know how to do it. we have to learn how to do it. >> thank you. >> thank you. [applause] >> hi there. thanks so much. my name's brian, and i apologize because i think i'm going to have you repeat yourself just a bit -- >> it's never bothered me in the past. [laughter] repeating myself. >> the past few questions. but i think in policy just as other things there are flavors of the month, and the presence of a sort of champion for a specific goal is invaluable. and that's why your work has been so, um, incredible, because you've established frameworks

that are going to continue even past your time on this earth. and i wondered if you could speak a little more specifically about the challenge of institutionalizing good practices -- >> yeah. >> -- versus, and overcoming the challenges of personalities leading the charge. >> yeah. >> and i think that happens a lot in health in particular. >> yeah. 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. [laughter] and that's good. because -- you know, i think the benefits of beaurocratization and institutionalization outweigh the risks. bureaucracies are difficult to work with. they're slow, they're cumbersome, they have rules-based ways of moving something toward. and, you know, talling into --

falling into, you know, iron cage rationality, that's what he's talking about. so we want our institutions to be compassionate, responsive, even nimble. and when they're very well resourced and, in fact, you know, again, back to the marathon bombings and the hospital i'm lucky enough to work in, i was hardly surprised that, you know, the patients who made it there or some of the other hospitals, mass general, for example, did well because there are great, there's a lot of resources in almost redundant systems where you could have that many casualties and expect good clinical outcomes and rapidly delivered. and so, you know, the value of having an institution that is sound and not based on any one what vaber called charismatic leadership is a great thing to do. and we're all praying for it. anyone who has been involved in

partners in health noticed that we're all -- notice that we're all still involved in one way or another. i mean, one of the founders, five pound founders -- i won't mention him by name, is now president of a small affair called the world bank not too far away. [laughter] but everybody's still doing health and social justice work and fighting poverty in his or her own way. so the idea we heard a lot when we were young, this is not sustainable, it's built around small group of people is not really true because we're, we've sustained it. i mean, we've sustained our engagement and brought in more people. that's the best insurance you can have is bring in more people. and, frankly, bring in young people. because when you bring in young people, you bring in the next generation. and that's why i wrote the book, and it says that right on the cover. [laughter] in fact, a student of mine chose these speeches and edited it. he writes an essay at the beginning of it. you know, someone who's worked with partners in health if a

long time. so bring in young people, the next generation, opening up the endeavor to others, making sure that you don't lose the value of personal engagement. like i said, some big machine people have a hard time staying committed to it. infusing, you know, mixing it up in the sense of, as i said earlier, sometimes you're going to be wanting to work in the field -- you know, we call the field a place like a clinical setting -- 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 worth asking everyone to think about is that if you're a service delivery organization -- and that would be a lot of public sector delivery invest organizations. one could argue the ministry of health, in some places that's

what it does. but if you're a service delivery organization, what would it look like if every service project were fully leveraged by training and learning? what would that look like? we could use different language. what if every pih project, partners in health project, had formal training components not just for doctors and nurses, but doctors, nurses, psychologists, managers, hospital administrators, lab administrators, people who help us avoid stockouts, logistics, transport, partnership with the public sector back to claire's point, what would that look like if every project were leveraged? and then if every effort was leveraged was some kind of learning cycle? and in my field they call that research. but there are lots of -- >> canada. >> is canada like that? i just thought it was cold.

[laughter] so that's a hard thing for a group to do, to say, you know what? we didn't get it right the first time. second time, third time. how about, how are we going to keep improving that and bringing in young people? thank you. >> thank you. >> are we have time for three more questions. be. >> i came all the way here from haiti. i can have plenty of time. don't rush me out of this synagogue. [applause] >> my name's -- [inaudible] i wanted to thank you. i know that, um, me and many other, of my medical school classmates went to medical school because we read mountains beyond mountains when we were 18 and 19 years old. now i'm at the end of medical school and thinking -- and i was wondering, you know, how do you balance doing good for individual people, taking care of one patient and thinking more broadly about making changes on a system level for populations

of people? >> yeah. >> given that you have skills to help one, to help individual patients, how do you justify thinking broadly? >> yeah. >> well, i mean, let me just say that whether you as a practitioner focus on the delivery of health care to one patient, say you're an obstetrician/gynecologist and you see five patients in an afternoon or a morning. whether you do that or infectious disease doctor and see a half dozen patients, whether you do that or work on health policy, you still have to look at a big picture. so people do the small picture and people who do the big picture still have an effect on the system. and that's what i was saying rather long windedly to the young man who was just asking and was fond of canada -- [laughter] was that, you know, you really, you really -- all of us have to look at the big picture, right? because we're socialized as humans to look at it whatever it

is we're doing. i'll give you an example. policy, people make policy. they also lose sight of the big picture just as much, in fact, as people who actually don't work on the big picture. that should startle you. finish because you'd think that if you were working on policy, you'd automatically have safeguards against understanding, look, what i'm calling the big picture, but you don't. because policy is desocialized also. it is narrowly focused just like clinical practice is. so people say, well, i'm a policy expert. you can bet there's a lot more coming in the next 2 or 300 lines. [laughter] because their going to tell you exactly what policies they work on. so that's one thing i've learned a lot over the last 15, 20 years is that policy experts are just as vulnerable as clinicians to not seeing the big picture. the big picture is about not three worlds, first, second and third, it's not one world. what happens is in policy it's

linked to a pollty like a government, a nation-state, a city, you know, in our country it's states or districts. but that's not how -- i mean, if you're a bug, hiv, they don't look at the world that way. oh, gosh. montgomery county, i can't go in there. [laughter] so these are arbitrary constructions as well. and policymakers are at risk for losing the big picture. so that leads me back to my little bit of counsel to you who have now gone from 18-year-old to md-to-be. find something you really like to do. because if you like doing big picture work, to me, that could also include scholarly analysis of a complex social problem, right? that's big picture work. it's what historians are supposed to do. sociologists -- [inaudible] if you like to do direct clinical service, if you like

pediatrics, do pediatrics. >> i'm going to be a pediatrician. >> how could i guess in it's the hat. [laughter] so choose something that you really like to do that you can sustain for a long time and also be interested in the big picture no matter what you do. if you're a surgeon, think big picture. if you're a public health practitioner, think bigger picture. everybody hats to try and struggle with -- has to try and struggle with that. good luck. >> thank you. >> enjoy medicine. [applause] >> thank you. >> hi. my name is -- [inaudible] and first off, thank you both so much for coming. it's a pleasure and an honor to hear both of you speak and to hear your thoughts. so i do international economic development work, the infrastructure to which you alluded before, the best i can. and i focus mainly on a africa. and my question is about how you navigate the path of adding value and finding meaning while

also being an outsider in a lot of the societies in which you work. so being far away from home and wanting to respect the places that you're working in and find a way to contribute that's not, you know, condescending or coming in and trying to tell people how to live their lives. and be i think it's really easy -- and i think it's really easy when you're working on issues of equity if that's not your home to be a jerk -- >> i know plenty of people who find it easy to be a jerk in their own home country too. [laughter] >> that's certainly true. so i've tried to balance things having a family far away. so i've gone from working with farm beers in west africa to being closer to where my elderly family members are. but that means looking at a computer screen with 0s and 1s that represent someone else speaking to these farmers and finding -- trying to find a way that i can do something that's really useful that's also,

hopefully, has some personal meaning and all of that within the context of being an outsider. so i'm wondering how you have navigated that space. >> well, i'm going to ask, claire, to comment on this. >> please. >> as i just said, claire was pushed out of haiti as a 14-year-old, i think i mentioned that, and came here to this country. and was an outsider who became an insider and then back to haiti where she's no longer necessarily an insider in the way that you mean it. >> uh-huh. >> because there's that d word, diaspora, that gets applied. so just say one thing, i don't -- i'm not trying to be a guru and have an answer to all these questions, you know? i think that if you go back to first principles, how do you acknowledge your own privilege? i mean, if you're working with, you know, poor farmers, you

know, the ones with the hose not, you know, like my last name -- laugh a laugh then you're probably -- [laughter] then you're probably in a very egalitarian diet. you know, you're -- i got that all the time in haiti. you're rich, they're poor. you're white, they're black. i mean, sometimes you're well, they're sick. being honest about those power differentials is really hard to do. and it's pain. it's painful. because you don't want to be, a lot of people do want to be an unequal diaspora, but a lot of people don't. and, of course, you could come right back to this country close to your elderly parents and see pretty striking disparities here, too, as you all know, as we all agree. so i think that being honest about that, and it doesn't have to be a loud exercise. it can be a private or even spiritual exercise to think about that, reflect on it. it's always better when you're thinking about these things with

others. and just remember that humility and sometimes being quiet -- now, i haven't done a lot of that tonight -- [laughter] but humility and being quiet in some setting other than the place where you're an outsider, it's a good thing to do. as a physician, as physicians we've often had a very warm welcome that other outsiders don't enjoy. i've had that in prisons in russia, you know, where i can't, i can't tell you how pleasant it has been to work in prisons in russia, in siberia where because of the collegiality extended to me as an outsider. rwanda's a tough place, you know? after what happened there, you don't expect it not to be difficult. haiti is a very freighted relationship with one country above all others, and that is mine. guatemala, you know, the highlands of guatemala, working

with indigenous people, the ones i work with, their ire was actually turned to local elites much more than us, the doctors who were on their side. so i do believe, too, that we may get off a little of the sense of it is assumed if you're a doctor or nurse or direct service provider that you're, you could offer something of value back to your important word value. just like, claire, maybe you would have thoughts on -- >> sure. you know, as to what paul says about humility and, you know, being quiet and listening, when we talk about participatory research, i used to teach a course around that. we would ask our students to practice listening. and it turns out it's a very, very difficult task. um, we would say, you know, they have these games where you ask a question, how was your day? the question answers, i had a really long day. and from this point forward, you can no longer ask questions, you can only get yes or no answers.

you start realizing something like i have a really long day can mean there were many hours, or because it was emotionally exhausting, etc., etc. but you have your own understanding of what that means. the short sentence that's used commonly, that others use that you think you understand, but you don't. language is the same, culture's the same, context is pretty similar. when you go across countries, you have that added to how you perceived, how others before you are perceived. and whether or not you truly believe the person across from you is a person who's thinking and experience matters to you. are you here to get your program done, or are you here to learn and collaborate? that truly changes how you approach things. the second piece is about recognizing your privilege, you know? in haiti i learned that both in haiti and with haitians outside of haiti my patients are, have

experience, unfortunately, the class, you know, differences in haiti. and so when they see me as a haitian provider, they're happy that i speak the language, but they're a little nervous that i'm going to be a doctor who talks to them, speaks at them. and so i do literally things like position myself differently, bring things down, look at them in the eye, ask them how they're doing, ask them about their family members. the same thing i would do for anyone else, but it's also in how you position yourself. and the list goes on and on. i try to use that approach not just in how i interact with people, but also in how i read and write, you know, make policy recommendations, to make sure that it includes the voice of those who are experience and make your work really valuable and last longer. but it's really about this listening and humility is where i start. >> wonderful. thank you very much. >> thank you. [applause] thank you. >> hi there.

my name is liz, i work in food security, and i don't know how i lucked into the last question, but be i hope this is an adequate sum-up. [laughter] we talked a bit about the challenges of working with the public sector, and i hoped that you could tell us about one major success you've had with a public sector partner and one major success you've had with a private sector company and what you've learned about working with both groups and effective partnerships. >> you want to, you want to give this a try? i will, too, i'm not -- and then while she's talking, i'll be thinking about just the best answer ever. [laughter] >> so, um, after the earthquake in haiti, one of the things that was really, really challenging and truly tough was that the ministry of health building collapsed. what that meant was that the minister and his team had to work, first, out of someone's home. later out of a small building across from a school and now in a tent/i would call it, it looks

like, it really looks like a container, but they call it, you know, temporary housing. and so i found myself asking a lot of the ministers what they wanted, what they needed. but then there were multiple partners who were asking the same thing. and one of the things that i thought was a great experience of public sector partnerships for us was that we stopped. 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 found that the major thing for them was that these partners were all meeting with them and going back with internet and so on, and they were able to quickly tell the minister we're here. but the minister hadn't located their own staff and they didn't yet have. and so they hadñ to trust us wh something that made them look weaker in front of us as a partner. and so i think the biggest public sector learning for me was trust. and i think it came from years of work with the public sector,

from seeing us being in haiti for a long time, but also the positioning we took under stress. which is when you want to get things done quickly, and you don't stop and step back. that would be my public sector partnership that's worked. >> what about your private sector partnership? >> my private sector partnership that's worked, um, i would want to say it was when we had the consulting team come in to help us set up the ihrc. so after the earthquake in haiti, you know, again, things -- the infrastructure was very small, and the remaining infrastructure was very small for the public sector, and we quickly had to, the government of haiti had to say these are my priorities, and donors had to pledge and say we're going to meet your priorities against this. and there were all these concerns about how to make sure the money pledge was really aligned with the priorities and how we would know what the major projects were. and so they looked at what was in indonesia and wanted to quickly set up an office in

haiti that could manage this. also appointed a u.s. private sector partner, mckenzie, to help us do that work. and i had never been exposed to a consulting team, so i had no idea what they were structured like. but i learned a lot about the importance of analysis and data and so on and so forth. what i learned most was their ability to stop, look at their model and ask, treat the government of haiti as their client the same way they would if it were coca-cola asking them to change their marketing strategy and so on and so forth. so i watched a private sector team bring their best tools and sets to a public sector struggling with organizing and managing a large set of information. ..

a lot of groups, many. i just mentioned the one i work with most came together and got a lot done. a short amount of time. i'm going to say a decade is a long time. and some of the element, it's a public-sector example, although the example i gave from siberia is pretty shocking to people. go into a prison and a 26% case fatality rate for the disease we're looking at. that means a quarter of all the people on treatment died within about a year of going in there and working together with the ministry of justi