 Thank you. Would you mind? All right. Welcome, everybody, to this health session at the World Economic Forum. I am David Agus. I am a professor of medicine and engineering at the University of Southern California. And today I'm privileged to lead a session, which I think is asking one of the most critical questions that, you know, the title is US-centric, but I think you'll see from the panel is that it really is a global question that we want to address. And that is, really, is health care a right? You know, in the United States, health and food represent about a third the U.S. economy. And yet if you look at the discourse, almost none of it is about health. So the discourse at times is about health care finance, but it's never about health. Today in Washington, there's X bandwidth for health, and almost all of it is on health care finance. And I think that discourse over time has to change. One of the things that really shocked me from reading both of their works, and these are two of the great writers of our time, is it's not just the ideas, but it's who the ideas are talked to and how people perceive the ideas. So I think what I learned and I think what we want to get out today really is different ways of approaching the same problem and how people and their backgrounds influence what they feel and what they think. And in the long run, how that can help all of us get to a solution that makes progress. With me today are literally two of my heroes, some remarkable writers who've made an impact on me and I think everybody else who've read their works. Atul Gawande is a physician, a surgeon, a writer, a public health researcher. He's a professor at the Brigham and Women's Hospital at Harvard Medical School, as well as the School of Public Health and Sam Their. Sam was my mentor. My father trained under Sam as an aphrologist. The Sam Their Professor of Surgery at Harvard Medical School. His books, many of which you know include The Checklist Manifesto and Being Mortal, have made enormous impact on medicine and thinking about medicine. And he's also a writer from New Yorker. In fact, his article in The New Yorker about healthcare as a right is what really brought out the World Economic Forum to think of this session and pulling the groups together. And we have Arlie Russell-Hawkchild, who is a professor at the University of California, Berkeley, and who wrote a book that came out this past year called Strangers in Their Own Land, Anger and Morning on the National Right. A finalist for the National Book of Award and really a staggering book about embedding herself in Louisiana and learning about the right. And from a constructive point of view, how they think and approach problems and how we are where we are in this country based on the thinking that's there. And so we're privileged to have both of them today. Why don't we start out with a tool? You wrote this piece that kind of spurred this. I'm not blaming you, but give us a little bit of background. Where did it come from? Why did you decide to do it? The biggest impetus was we've spent the last year in the United States in a battle over whether we wanted to repeal Obamacare and whether even the commitment of the idea that government should play a significant role in supporting people's ability to live long and healthy lives. Is that a bedrock goal? Is that not? It felt like we were in two completely different worlds within the United States. But then I also do public health projects. I'd come from visiting in Namibia and in India. And I began asking people there, do you think health cares are right? And they were in places where they weren't living like they had a right. They couldn't get access to the care that they needed. And so I'd ask there and they'd say, I absolutely believe health care's a right. It was a meaningful, important thing in their lives. It was a goal that was not being met, but you could live up to. And so when I was then going from Namibia, literally from Namibia back home to Ohio, I grew up in Athens County, Ohio. It's in Appalachia. It's the poorest county in Ohio, about 30% below the poverty line. My mother is a pediatrician there. My father died. He was a surgeon there. And when I'd sit and talk to my friends, we just avoided politics. So I wanted a way in to just figure out how to talk about it. And I figured we could talk about it at a moral level. And so I began asking people, do you think you have a right to health care? And to put some context on it, three of the people I sat and talked to, I first started talking to my friends and then I talked to their friends and their friends and meet other people, three of them had been bankrupted by health care costs. And maybe one or two out of the couple dozen I talked to said, they think health care is right. Even the swiping bankrupted, they did not think health care was right. And when I probed, I said, why, what they heard it to be was a demand to pay for other people's health care, pay even more for other people when I can't even afford my own. And then somebody realizes the US is a place where you can have working people who have no insurance or insurance that they can't really use with a $3,000 deductible and no money in the bank for it. And they can be bankrupted for their health care while paying taxes for poorer people to get safety net coverage, to get Medicaid coverage that's a better health plan than they could ever dream of. No copays, no deductibles, no premiums. And that is incredibly important. And I felt like I was seeing something I was missing in engender's incredible bitter feeling because it raises the question who deserves care and who does not deserve care. Or the other better way to put it is whose life is really valued in our system and whose life is not valued in our system. And whether it was, you know, we've got projects in Namibia, in Estonia, in India, and in Ohio, that question whose life is really valued and not, and the backlash against the safety net because you have people who are paying for that safety net who don't feel their own life is valued in the same way. That's interesting. So Arleigh, obviously you went to a different part of the country, a few thousand miles away in Louisiana and a very different group of people with a different background. How would they approach that same question? Well, you know, I came from one bubble to another bubble because I got interested in how we can deal with the difference between them. So Berkeley, you know, is geographically different. I felt myself in a media bubble, in an electronic bubble. And so the people, what I did in this project is try and bridge the two worlds in Berkeley, California. Everybody thinks healthcare is right and in Lake Charles, Louisiana, nobody does. And what I came to realize is that that was part of a larger, what we could call red state paradox, that it's the states in the country that are the poorest, that have the most disrupted families, that have the worst education, the worst medical care, the lowest life expectancy, who receive more funds across the nation from the federal government in aid than they give to it in tax dollars and they revile the federal government. So it came down to why do you hate the federal government? What goes on with it? Because if you have a right to medical care, it's the government that's going to vis-a-vis which you have that right. So what I found is that actually underneath all the political rhetoric, there is a deep story and it goes for those on the right and left. What is a deep story? A deep story is what feels true about a salient issue and you take facts out of the deep story. You take moral precepts out of the deep story. It's just what's left, what feels true. And you tell it, it's almost like in a dream that the right-wing deep story is you're waiting in line as in a pilgrimage facing up a hill at the top of which is the American dream. Your feet are tired. That line hasn't moved. I talked to people who hadn't had a raise in two decades. It's not doing well. So your feet are tired. You feel like you don't begrudge anybody. Really, it's just that you deserve to move forward. And then another moment of the right-wing deep story, there seems to be somebody cutting ahead. What's that? Well, it would be through federally mandated affirmative action programs. It looks like blacks are being given opportunities for jobs that have always been reserved for whites and were still women, again through federally mandated affirmative action, are being given opportunities that have always been reserved for men. And then you see refugees and you see, even in their mind, public sector workers. And even in their view, they think environmentalists are putting animals ahead of them so that the oil-soaked brown pelican endangered Louisiana national bird, state bird, seems to be waddling up ahead of them. And they feel, whoa, I'm going back further. So another moment of this deep story, there's Barack Obama waving to the line cutters. And they feel that the federal government has marginalized them and that actually what's happened to blacks could happen to them, I'm talking about blue-collar whites pretty much in Louisiana. So they, yeah, they don't think the government is their friend, largely for that reason. Book is amazing that way and describes the story of this line of people climbing. It reminds me of feeling like you're in the airport security line, in the airport boarding line. You know that there are nine zones now, you're in zone seven, and those people are cutting ahead of you and you want to, you know, you're like, how, that's not fair, I paid to be at this level. The thing that took me out of that though was to recognize there were moments in our world where people don't feel that way. And so liberal and conservative, back home where I grew up, almost nobody was against Medicare. Nobody was against the universal coverage plan we have for people over age 65. But they didn't see it as being something that's like a right. They saw it as social insurance. We all pay in. We all paid a tax in any time we've paid. We've paid our way in and we all benefit and we benefit as equals. The CEO or the janitor, they all get the same benefits. They're all treated the same way and your life is treated as one of equal worth. And in a situation where there's a safety net with certain benefits here, or you know, so the mistake we made in America rooted in the World War II route is that we tied your health care to your job. Where you get your health care is first and foremost tied to your job. So that means if you got the right job, you get great health care, you get the wrong job, you may have no health care. You can have neighbors who have extraordinarily different capacity for taking care of one of the most important things in your life survival. And then, you know, we create a patchwork system around it where different people get different deals. We're all kind of paying for it, but not all benefiting equally. And so Medicare and that kind of approach of saying we all pay in, we all get back. Most of the world has arrived in that place. It's the way we've arrived when it comes to schools, when it comes to roads. We all pay in and we all benefit. We don't say there's a separate lane for illegal immigrants. We've all paid in. Now, that central idea is playing out in the politics, the components of American health reform that are universal have been extremely popular. No preexisting condition exclusions covering your kids up to age 26 on your plan. Being able to assure a certain level of cost sharing coverage and subsidy no matter what level you get to. But as soon as you start saying, well, you're mandated to buy this plan or have other considerations like some people will get a much better plan than others, that's where you get this battle brewing. You know, obviously we in our country believe in rights. We have a right to smoke. We have a right to sit all day. We have a right to be as large as we want. Does society have the obligation of paying for the healthcare ramifications of our behavior? Is somebody who smokes cutting the line to get that overhead bin storage space that I wanted as simple as that? I mean, so what would the views be on a question like that? Do you want to jump in first, Arvind? All right, well, all about overhead bin storage space. Yeah, you know, it's interesting. People I came to know felt a right about owning guns, for example, very powerful. And a right to eat as they wanted to. They resented Michelle Obama's garden of organic vegetables and to improve the eating of schoolchildren. Well, you know, what if they want to eat, crap, excuse me, that's their right. You know, their children's right and their parents' right. So, real heels in for that. But what you don't see unless you're close up is they're actually very generous in other areas of their life. If their neighbor gets sick, you know, they will be over there. They will do everything they can through the church. They do a lot for ill members. And so it's a question, I think, of drawing a cultural bridge and in a way crossing over an empathy wall to get to tap into their good angels and their notion of what's collective. Often they would say, oh, the problem with big government is that it takes community away. And what's community? Well, if I'm walking on the road and a guy has a car, he has to stop and pick me up and vice versa. So they almost romanticize something collective. They aren't the ultra individualistic, iron-ran figures that I went in imagining they were. So if we just move back to somehow drawing a bridge between collective good in the private sphere and what the government can do, it's collective. I'm not sure I answered your question. They tripled the insurance rate for smokers in that county in Louisiana. Would they be upset? Should the non-smokers subsidize the smokers? I'm almost certain they would not be upset. Not upset. It's not hard to ratchet up the sense that once you're in the game of, I've got nine zones, who belongs and which zone, then you create 19 zones and you go even farther. I had many conversations and continued with my friends back home about why do men have to pay for women for reproductive coverage? Contraception, that's elective, that's not my responsibility. And yes, you can say, hey, I thought we were all born at some point or another and we're all in this together. But if you take the view of this year, I'm 52 years old, why do I pay for anybody to have any reproductive needs? I should have a plan for me and for my needs. And insurance is the idea of socializing risk and bringing it together. And then who belongs in that pool and who deserves to be there? The more we drive towards the idea that there are the deserving and the non-deserving, it creates, you know, are we going to pay for the smokers and non-smokers? We pay for the people who do not exercise and who are obese. There's another way of coming to understand, and I think this is the way we need to recognize what the whole role of health care is, the way the debate is driving us towards the idea that we really just need universal catastrophic coverage. That life is a series of events in which you're generally healthy, you have a catastrophic event in your life, you get sick, you're covered, and then you get back to normal and you go on your way. And then maybe a few years later, you might have another event that needs coverage. And it's more like, you know, your house catching fire. And instead, if you watch what the course of an 80-plus-year life is nowadays, it is the accumulation of health events, a health crisis from which you never completely recover. You now are a cardiac patient, you're now a hypertension patient, you're now someone who has diabetes, you're now someone who has XYZ. And there's a mix of genetics and life choices and your community and your options and availability in life that add up to that mix that you're going to have. And living a long life is about having a regular source of care and access to your needed medications along that way. And we did a study this past spring, Kate Baker, a Republican economist, and Ben Summers, a liberal economist, and I was the doc, although Ben's a doc too. And we analyzed the last 10 years of data around healthcare coverage. And the studies around what happens when people gain healthcare coverage is, the first thing that happens is within a year, they're financially better off. Their health hasn't improved very much. A year later, they report feeling better, about a quarter or no more feel there and good to excellent health. But again, you don't measure any mortality improvement. At five years, when people have had a regular source of care and have access to their medication, they have a 6% reduction mortality. It seems to be an improved mortality to every step along the way. And when you piece it apart, what you find is the people at the biggest gains were the people who had chronic disease, HIV, cardiac disease, cancer. If you have, you're in and out of coverage, your coverage falls apart, no surprise. You don't do well with cancer or HIV or cardiac disease. So when you think about, okay, now am I going to penalize people who have these conditions by saying, okay, you're not going to get your medications anymore. Well now, we're going to end up with fewer people who can work. You're going to end up with people who don't just die early, they're disabled earlier. And we're simply, thank goodness, not just in the United States, but around the world unwilling to leave people simply suffering in those circumstances. The event that we say, look, I want to charge you differently and make you pay for your consequence is really your entire life. And I think we are, as we think of these as less transactional, less about what are we paying for this year, but as we're supporting people across a lifespan with one item which includes healthcare, but also education infrastructure, those all add up to better lives. Yeah, I mean, you hit it, right? I mean, the data are very clear is that if you give people basic healthcare, in the long term it's economically beneficial to a society, right? They're going to work more, they're going to get less catastrophic diseases, it benefits. Yet those arguments are never what's put out there. I mean, the data from Affordable Care Act are real. In the short period that we had it, we actually saw more catching cancers early, more taking card medicines, diabetes medicines, et cetera, and there's a benefit there. But yet why don't we see the politicians, the media, the religious leaders pushing the economic arguments, which are the arguments about which section in line you're in? Why aren't we seeing them work? Right, I think it has to do with something I told, mentioned earlier, that the idea of a right disguises the contributors from the non-contributors, right? And the contributors, they're the workers. Among the people I came to know, there's an almost religious belief in work, not the effect of your work, not how good you're at work, but just the fact of working is a source of enormous honor and importance. One woman even told me, well, they ought to pick up all the cemeteries in France, American soldiers that fell in World War I and World War II and bring them back to the U.S. And we'd get American lawnmowers and get American workers attending those graves. I mean, that's how strong the idea of work is. But the argument that, look, if you give good healthcare, you get more people working, that's on the other side of this bridge that we need to cross. But they think the people that aren't working don't want to work and that it's moral, work is moral. And so people that aren't working, people who are cutting in line or way behind them in line, those people don't deserve it. So that line of thinking is one side of it, the other side of it is, they do have a sense of commons when it comes to disability ramps. I asked them, well, how about disability ramp? You're not disabled, you don't need it. Yeah, no, there should be disability ramps, that's good. So there is that, we need to just add more things to that vector. They're all for disability ramps, into churches especially. I've got a couple thoughts about this because I see it's not just in the United States, it's a global phenomenon, we underinvest in health. You've got surgeon handwriting, that is kind of scary. So two things to add with my scribbled notes and my surgeon's handwriting. One is, for example, we've been doing work in India. We're working in the state of Uttar Pradesh. In Uttar Pradesh, they have almost doubled the rate of newborn death as in elsewhere. As we've been doing our work there, you've gone through three elections that we've seen changes in government during that time. We're talking about a quarter million people who are lost because of death rates that we're measuring 5% newborn death at or within seven days of birth. So one in 20 when we could be at one in 200 or even better. It is not a political issue. It is the parties come and go and parties have tried to make it, that this is our economic future, this is your children and you should hold your government accountable when you're allowing and failing to address this level of quality disparity. And it's simply not on the agenda. So you don't have people in Uttar Pradesh saying, well, that was your kids death, not my kids death. That's right. It's not that there is a sense of government ultimately not being the force that can create that change. So some of it might be that you don't think the government can solve it. Some of it might be that really other issues are much more salient like jobs and so on and the investments you make here and having kids that are healthier and so on will pay off in jobs, but it's much further down the road. It's not on the political timeframe. The second thing though is that once a benefit is in place, removing it will get you in huge political trouble. So you go after the NHS in England. You go after Medicare in the United States. You go after the hospitals that are in existence in India. You have tremendous impact. So there is an experiment Jim Kim is doing at the World Bank that I think is a potential game changer, which is baking into the loan interest rates that countries get for their sovereign debt, the human capital. So you know if you have, for example, stunting, which is at 30% in India, that's at 38% in Rwanda, but that leads to poorer brain development and you're taking 30% of your population offline from the future GDP growth of the country. So Jim Kim is now creating a human capital index that with the World Bank now starting to calculate, I don't think they've implemented yet, but he's saying they will, starting to calculate that you will pay a higher interest rate on your sovereign debt unless you address this. In which case you could make a quarter billion dollars on your next loan and by investing in this space. So I think putting the connection together so that investing now and benefit now for the sake of this long-term connection, I think that may be some of the most powerful and important ways you can go about it. But at what level would you do in the US? Would you do the local level, the state level, the federal level? Yes. How would we do that? So yeah, I mean I think you would arguably start to bake in that if you have a community that has better investment in its infrastructure and its education and its health care, and you know the connectors, how much this pays off in the future productivity of that city economy, that state economy, that when they go for their loans or their ratings, that that may be an avenue for driving. Because the problem is that the long-term benefits of health pay off over a longer run and you don't have short-term pain for not investing. It's just like we also don't invest in bridge maintenance. We'd rather build a new bridge and let the bridge fail. You can keep a bridge going for 100 years. We let them die at 50 years and build a new one because you can put your name on it and you can have much more payoff now for that than the maintenance costs. Well, the tiny scale of a politician is four years. So why would he or she put out capital today that's going to benefit the next regime? Yeah, wouldn't benefit for a long time, right? It's exactly the same thing. Unless you put those, made them pay financially now for those losses. You know, in Louisiana, a very oil-dominated state, as you know, I wonder what would happen if you would say to Exxon and to us at Go and Phillips 66, actually we're not going to give you a loan, unless you clean up the pollution. Because in this area it's one of the most polluted areas in the entire world. And second highest death rate from cancer for men. And there's something called Cancer Alley that goes from Baton Rouge to New Orleans in the past, where people can't work. There's an instance of three generations, a grandmother, a mother, and her daughter, all on respirators. So you're really cutting into human capital. He's not going to be great workers. The same argument applies. But I wonder if you could connect that to the terms of a loan to the companies that aren't cleaning up the environment. There's certainly different scales to do this. The Grimim Bank does it at an individual level. In order to get a loan from us, you have to be vaccinated. You have to take seeds and grow them. You have to have a nutrient toilet, etc. And the impact is staggering on human health. So there are ways that we can actually prevent disease that are cost effective. There's a pill a day that if you take it every day, reduces not the incidence, but the death rate of cancer by 30%, heart disease by 22%, and stroke by 16%. And if everybody who should take it in the United States does take it over the next two decades, an extra 900,000 people are alive and we've saved tens of billions of dollars. It's called a baby aspirin. It mentions like that. They're very inexpensive. That actually can have a major impact on public health. How do we make it so people do that? How do we make it so that those things are enacted? And that we're not as Grimim Bank-ish and saying, listen, we're going to take away your house unless you do it. How do we get people to realize a behavior today that has a long lead time to impact has a benefit? You can appeal to people's sense of two senses. One is self-reliance. Okay, baby aspirin. I'm going to take care of myself. And that's a very important value for the people I came to know. The other would be that you want to... Yeah, you want to do for your family. You want to be alive for your family, so you appeal to them more. So to get that normative behavior changed, you need leadership. But who provides that leadership to the people of Louisiana to tell them to do that? Well, I think it would be good to go to church leaders and tell them, hey, you want a healthy congregation. You want to keep them alive. How about this? I think a lot about this. The research center that I have is called Ariadne Labs and it's a center for health systems innovation. We're really interested in understanding how you scale. And the first way we try to scale is by awareness and teaching. And in medicine, for example, the way you get doctors to do the right things, you just teach them longer. Now you can't graduate and go into practice until you're at least 40 years old in medicine. We just keep on teaching more. That's a lot of fun, by the way. It's a lot of fun. And what we find is no amount of teaching will lead to eliminating the problem of, you can teach doctors all you want to wash your hands. At the end of the day, we still have a lot of people that don't wash their hands. It's a huge variation. So then we move to, okay, we're pissed. We're going to sanction you. We're going to have mandates. So you're going to have malpractice litigation or you're going to have regulation or you're going to have a law passed where your seat belt, take your aspirin, those kinds of things. And there's two problems. It's totally crude and indiscriminate. There are people who shouldn't take the aspirin. It's not beneficial. But in the public health world, people argue, hey, just put the aspirin in the water. You're going to save more people than you're going to hurt. Sure, you're going to kill a few people, but you're going to save a whole lot more people. And there's an argument for that, right? Purely utilitarian, this is what you do. The A, people don't like that. They don't want to be the one who dies because you put it in the water. The mandates, people game them. They figure out how to work their way around them. So in general, mandates pay for performance. They do increase performance, but only marginally and at high cost. And they're not very flexible. You know, new study comes out, aspirin's not so great at this, you know, make an adjustment and you spend four years in the legislature debating it. The way people really drive it is by systematizing it. You bake it into being a norm of the system of making it work. We're actually at work doing this in Estonia. So Estonia is 1.3 million people. They're a single-payer system. They have everybody on a single electronic medical record. And they have committed to the fact that they have an unusually poor survival for men. They are one of those countries where, you know, long-term survival for men is not at all kept up with the rest of the population or women in particular. Heart disease is number one killer, so it's aspirin, statin, and hypertension control. And the main approach has been to systematize, first of all, that everybody has a primary care clinician assigned to them, that you have someone who's your fallback primary care clinician, which meant incentivizing the specialists to become primary care physicians. And 50% have now switched from specialty care to primary care. Second is having a nurse or a community health worker who then tracks these three things. How many people are on their aspirin? How many people are on their blood pressure meds? How many are on their... are getting their statin and have it offered to them? After just one year in 15 sites, we've got it up to about 60% from less than 10% receiving any one of these. And seeing readmissions already going down and likely see payback in improved longevity. And the role of that nurse is create a relationship with people and be able to say, what are your goals? And if your goal is live longer and be able to survive... have a better life, then here is what you can do. And we will get it up to over 90, 95%. We've seen it in local places in the United States. But the average person in the United States who should be on high blood pressure control only 40% have it recognized and under control. Statins is about the same. Aspirin is better, but still, as you say, no, we're near hitting over 80 or 90%. So before we turn over questions in the audience, I just want to ask you each one question. I mean, in one sense, you've both been hiding behind veils. I mean, you're talking about, you know, Ohio, Louisiana. What's your own opinion? I mean, do you think healthcare is a right in our country? Or should be a right in our country? My view is yes. But I also think it's not a helpful question. So I can say, do I have a right to my physical security? Absolutely. Do not kill me. Now, that does not answer how many policemen am I willing to pay for? How big of a court system am I willing to pay for? How many, you know, patrols do you have going around? We talk about it right as if it answers all the questions. And it's just, it's not even the beginning of a question. It's like, what's your feeling about how important it is? It's like, yeah, it's very, very important. And now, all the questions still remain open. That's a good point. I do believe, of course, that healthcare is right. But I also agree with that. I told that the rights discourse has deeper things behind it that we need to focus on. And for me, the real issue is getting people to think that it's good to have a common good that we share a lot. I think we've divided into two very different sides that don't feel that we share a lot. And the people who resent those who are cutting in line don't feel that they have anything in common with the people who are cutting in line. And that goes to a premise that we're all, it's dog eat dog world. We don't share a lot. So I care a lot about that. I want to also add one thing. I told was talking about men in Estonia who have a lower life expectancy than women. And that made me think about the genders. Actually, one solution to this, I think, is to appeal to women who, in my experience... They get rid of men. No, no, no, no. To keep them alive. But they have... You know, this doesn't show up in polling that there are enormous differences between men and women in attitudes toward healthcare. But I think, or welfare, but I saw it all the time because women are more likely to be caregivers. They're in the health system more than men are. And they're recipients of healthcare. They live longer, and so they're at the other end. And so I think the appeal might start with them and spread. I mean, listen, that's what the grooming bank did. And they were very successful with that focus. All right, questions from the audience about this enormously important broad topic? Yes? Not a question, but a comment. I was just really struck by a common theme between the discussion, which is how do we help people change? How do we get people to engage in health behaviors? And I feel like there's a real opportunity for behavioral scientists, psychological scientists to inform the conversation that what we know is that we have to tap into each individual's their values, and they have to own them. They have to own the goal because we can't say, Aspirin's good for you. Don't you want to take an aspirin? We have to really come at the conversation in a different way so that we provide the information, but the patients say, oh, I could live longer and I want to do that. And so we really have to come at it from a different direction where we're engaging them in owning the goal. So that was just my broad thought. That's a great point. I mean, today's world where technology can personalize messages. We have the ability, based on each of these many subcultures in our country, in every country, to personalize many messages and we're not taking advantage of it. Right, and I would completely agree with what you're saying. And I think what that means is we need more face-to-face, unmediated contact and that in that contact, we need to kind of say, I'm interested in your experience with, let's say, aspirin or anything else and I hear what's bothering you. You know, if you've got a grievance, if this is your deep story, okay, I hear it. And then say, okay, now let's talk. And often if you go back to what was good in the old days, that's, you know, well, you know, there were fewer processed foods in the old days. You know, there's carrots and turnips and apples from the tree and that's the old days, they'll hear that. Old days, good days, you know, so you find the avenues through that kind of contact. I think it's, I mean, listening is it, you know, we all, I'm sure, get a lot of aggressive negative emails. Every single one I try to answer, when you answer, people's shoulders go down. You paid attention and you listened and the next email almost uniformly isn't aggressive and isn't negative. It's pretty wild. I would love to also chime in to say, I think there's something really fundamental that you're getting at, which I've found to be really important in my last book, Being Mortal, which is about the role of healthcare. In the 1950s, 1960s, the role of people in healthcare was a paternalist role that we know what the best goal is for you. We may not even tell you your diagnosis if you have a terrible diagnosis. We're gonna give you, you know, if there's three options, we're gonna make the choice about what you have and just trust us and you're in good hands and you'll be fine. We rejected that in the 70s and 80s because we didn't always agree with the choices that doctors and nurses and hospitals made on our behalf. And we wanted autonomy and we graduated into a world where really healthcare is regarded as almost like a retail enterprise. You tell me what you want. Do you want an MRI? Do you want the red pill or the blue pill? And then, you know, we'll give you what you want. But when you're in cancer, I'm in cancer, when you talk to people about, here's your situation, here's the tough situation, here are your choices given the facts of where you are. Option A, option B, option C. Here are the risks, the benefits, the pros, the cons. Now what do you want? The most common answer I get, probably the things you get is, well, what would you do? And then the answer you are really taught in med school to give back is, look, there's no wrong answer here. It's really just whatever you want and we'll follow through on that. It's not for me to say. And people really feel abandoned in that moment and what you're getting at is this role of being the counselor and healthcare's critical role is understanding what are your long-term goals in your life given that you don't get to live forever. So besides just living longer, what do you want to be alive for? What are you willing to sacrifice? What are you not willing to sacrifice? What's the minimum quality of life you find acceptable? What are the trade-offs you're willing to make and not willing to make? And then I can make a recommendation based on experience and knowledge and so on to help meet that goal. Do you want to eat that half pound of steak? Do you want to take that aspirin? It varies a bit on what really matters in your life. If it's the joy of just eating a good meal and you're not thinking you want to put a refrigerator lock on your door, then there are other people who are like, I love that meal but I'm really striving for something. I want to be healthier. I have things that I really want to stay. I want to feel better. You have to tune, according to people's goals, and I think people want a system that does not make them feel that they are just being told what to do, but that's in line with what their goals are, and goals do vary from person to person. But it takes conversation to get to those goals and value systems. An ongoing conversation because people's goals change. Yes. Go ahead. My name is Anjara Jackson. I'm a physician from the United States and clearly everything that you've all said just now, especially about individuals sort of taking personal responsibility, it's so important that we get individuals and communities to buy in. One of the problems though is sort of this delayed gratification because we're talking about long-term goals. People want to see some sort of immediate result. I mean, even when people are sick, they don't always follow what they need to do to get well. So one of the questions that I have for you in terms of just healthcare overall in the United States, you were mentioning this program in Estonia. Smaller country, more homogenous. How do we translate that to this huge, multicultural, multiple diverse, how do we get people to really buy in and start to make changes that are truly going to make a difference? So I'll give my two cents on it and see where you guys jump in. I think this is a dramatic shift from 30 or 40 years ago. The 1940s, 1950s when we created insurance, healthcare was about rescue. I'm going to give you penicillin to rescue you from your pneumonia. We have these new operations. We can give you dialysis to rescue you from dying from end stage renal disease. We didn't have data though. And then you had the Framingham Heart Study in the 1960s and 70s that started telling us, hey, people who control their blood pressure have a better outcome. People who don't smoke have a better outcome. And then we started recognizing if you do certain things now, it pays off a couple of years from now. Now we know things based on genetics, based on your profile, based on your community, where you can take actions now that will matter 20, 25, 30 years in the future. That's really hard for us. We don't function in that kind of a way. And it's a negotiation and it's a part of making that more visible to people and trying to turn that into daily habits and goals now. I don't think we should pretend that any of us are good at that. But one thing we know is that people who are in a regular source of care around their primary health needs, regular source of care for the majority of their needs, including prevention and projecting in the future with data around what matters in your life and then getting your need in medications, do remarkably better. So despite our fragmented system, despite all the battles we've had, we are in a situation in the United States where we have the people who have regular sources of care, their longevity is improving. So even though we've had stagnating longevity in this sector of the high school-educated only male part of our community, those are the people who have become most disconnected from the rest of society. And so the ways in which we are tying people back into community, giving them some basic public supports like a regular source of healthcare, I think is a crucial way forward. And we see that in many other parts of the world as well, that economies improve in being engaged in economies, drive survival upward, but then are you engaged in and part of a primary health core as your care? I'd say that I'm not sure that an incapacity to delay gratification goes to the source of the problem as I saw it. They can delay gratification. In fact, the people I came to know really stoical, you know, and took pride in putting their job first or their family first. They were capable of, you know, not just drinking beer and smoking. They were capable of it. But at the same time, they also got their backup when it came to the right to smoke or the right to eat unhealthy stuff. And there is an apron that I saw a bunch of times. But if the cook ain't fat, I ain't eating it. In other words, you know, that's not your delayed gratification apron. But there's some truth in it. So it was a conflict they were in. I think you hit an enormously important point. And it's the lack of a feedback loop is when you do something, you get something back. And the problem is that in medicine, no matter how we try, we can do population health, it's hard to do individual preventive health. And so when I don't know, necessarily a marker for health, I can't measure it, how do you optimize on a parameter when you don't know what that parameter is? So I do think putting resources to actually develop health indices so we can have an individual feedback loop is something that we as a country, as a society, as a world need to do, and we're not. Yeah, you could just throw it. I think you were talking about delayed gratification. It's sort of a question of incentives. Is there a question of decent incentives here? So you know that you can drive 100 miles an hour on Ohio Turnpike, you will get a ticket, right? So is there a way, you know, it's a naive question, but can you say if you don't exercise, your taxes will be higher? I'm just trying random examples, but is there a way to attack this question from the disincentive side, not just from the incentive side? I think this partly goes to what I was saying before, that when we try to regulate and control through incentives, they're very crude and not terribly effective. What we know is that, you know, punishments are more effective than carrots, so sticks are more powerful than carrots. And so yeah, if you punish people for doing the wrong thing or punish them for the right thing, you shape behavior in certain ways, much more powerful to simply systematizing things, building in certain defaults. You know, for example, building in defaults that require you to walk in order to get to the Congress Center from your hotel, because the shuttles don't work very well. The, you know, getting... We're supposed to keep this positive. All right. And I think, you know, blue zones are these communities that have cropped up in the U.S. and now starting to be elsewhere, ones where you're building in the defaults, for example, that the kids walk to school as a regular part of, you know, a walking school bus for kids who live within a mile of the school, where, you know, groups of kids will be escorted by an adult to get to school, that people are building in half an hour of walking in the workplace and standing in other kinds of ways of doing it. So you can approach it through the punishment route, but we found that you just don't get that far, but systematizing it. So it is the default of the community that we're going to have... You know, we're doing it more and more in the schools. You don't have the fried food, you don't have the sugar drinks, and people are building in better eating habits, and we're seeing ways that's paying off. And then in the way we structure communities and structure work, and it's actually no more costly than trying to create the whole enforcement mechanism and the police are gonna, you know, go after those problems. I would second that. If we were to create that disincentive of the people that I came to know, this is a Trump base, would say, oh, the regulatory state, you know, is bearing down on us, and well, these days you can't send your kid out to the playground without putting a helmet on and knee pads so they can go down the kiddie slide and, you know, the nanny state. So one runs into that belief system. Yes, you have to, related to the goals that she was talking about earlier, the community has to agree on those goals. You know, we could, we did, you know, we now have 65 and 70 and 75 mile an hour speed limits in different parts of the world because we have all agreed that, you know, we'll take a few, we'll take a few hundred more deaths over having to have 45 mile an hour speed limits or 30, you know, we could have even fewer and I'll drove at 25. So those are legitimate societal goals to trade off in certain ways. As we get toward the end, let's take one more question and then I want to summarize where we are. It just occurred to me, maybe we should also frame this, not only as a right that you're entitled to but that there's responsibilities that go with that, which you've been talking about but haven't really articulated that as something that goes kind of hand in hand with a right, just like we have a right to vote and there might be certain responsibilities that go with that as far as education or something to understand the system. Just putting that out there and how do you articulate that responsibility without threatening people that you're being invoking a nanny state or creating any negative connotations but I think people like that pair up. Yeah, that's great. I mean, we've done it. We have mandatory childhood vaccines that we mandate. I mean, we could do other mandatory health things on the preventive side. I mean, we don't mandate getting an HPV vaccine. We can eliminate 40,000 deaths a year if we did it with almost no downside but there's a reticence to actually pushing things, unfortunately in this country. When I asked people about why they like Medicare it was because they saw it as much as a duty as a set of rights, right? That we all followed our duty of paying in while we were working. We all paid our Medicare tax and then we earned the right to have the coverage back and that sense of in many ways what does it mean to contribute and to serve your duty equally is the key question. So in Medicare, because everybody, if you've worked even a quarter in your entire life you have paid in some Medicare tax and if you've worked for a tiny fraction of your life that has made you eligible and everybody, the people I was talking to they understand perfectly well some people are paying in a lot more and other people are paying in less but there's a general sense that that was a fair, equitable way that everybody has contributed and served their duty of making a contribution. If there are certain payment schemes where people feel like it's way out of whack and some people aren't paying anything at all and then that's not fair and so that sense of duty comes in. I almost think that that's why I feel like the rights discussion gets us off in the wrong direction. It's really what are the duties that we're all going to contribute so that we're all enabling that this capacity is available to all. Treating everybody's lives as being of equal worth. Equal worth in our lives means that we are all equally responsible to make a certain contribution and that we're all treated as worthy of respect and dignity and having your life chances. Right. I like this very much as part of the solution. The people I came to know had a strong sense of duty and what I really think we need to do in this country is do what I would call symbol stretch. We have a duty to take care of yourself and to be healthy and that is a contribution to the whole but how do you start with, how do you get someone to accept that? I think you start with what their sense of duty is, duty to their family, duty to get to work on time. They already are there. You just have to stretch the symbol and say, actually, isn't there another duty here that's a contribution? People could hear that. I love this conversation. It gave us a different perspective, at least me did, on the arguments regarding health. If you each want to summarize in a sentence or two as we have a minute left to the audience what you've taken away from today, your vision for Middle East peace, your vision for ending World Hunger in one or two sentences would be great. I would go back to this contributor's comment that we really need to find ways to talk across these cultural worlds that we're now split into and I totally agree with, I told that rights doesn't get us there. We maybe have to symbol stretch the very idea of a right, a right to live in a healthy world. So that and that's the main thing. That's great. I'll say with the thing that ties it all together for me is that I think the debate over rights only divides us but there are bridges in our debate and I think the bridge is probably most closely seen around the question of whether all lives have equal worth. People around the world are really inspired by that American ideal of that all are created equal and by that we mean that all lives have equal worth and that if you come into a hospital it doesn't matter who you are, you ought to be treated as if your life is worth dignity, respect, and the same chance as anybody else and I think that is the bridge that we can come back to and bring alive. That is a beautiful bridge and with that I thank you both for participating and I thank you as an audience for participating.