 But thank you all very much for coming. Just one quick point of order before we get started. If you haven't noticed, we have a very packed stage here and an hour to talk. So we are going to play Q&A a little bit by ear, and we hope you'll bear with us on that. So if we have time, we would love to take your questions. If we don't, we would love to take them after the formal panel ends. But feel free to engage one way or another. So this panel is about health, and there's really two stories about health. So the first is one of discovery and invention, eradication. There's statistics that are quite impressive. For the last 20 years, life expectancy has risen steadily. The under five mortality rate has declined by 41 percent worldwide, and maternal deaths have declined substantially. That's good news. The second story of health, as many of you know, is a strained and inequitable system. Problems including climate change that are extremely large in scale. Chronic disease is outpacing infectious disease worldwide. There's a healthcare worker shortage to meet that need. And social and environmental determinants of health matter. So we know that food helps make people healthier, and pollution helps make people sick. And most of those needs are not addressed by the system. So this story of health is one where low income countries are, we can talk about whether we call them low income or not, low income countries are still overwhelmed by lack of infrastructure and access to basic care, which we'll hear more about. High income countries fight over who should get insurance and who pays for healthcare. But the central issue is just the same, which is the global system that we have today is not comprehensive enough to tackle 21st century healthcare problems. It's a really formidable challenge. So as I'm sure if you're in this room, you care about health, we could sit here and talk about everything that's wrong and paint a pretty terrible story. So we decided to take a different tack and talk about bright spots. So this is a panel full of representatives from organizations that are achieving quite a lot despite those challenges and proving that those needs can be met and those challenges can be overcome on a large scale if implemented correctly. So as you saw, the title of this panel is about delivering health, and that's really what you're going to hear about today. We hope that you will leave here with a sense of what's possible and how we might be able to grasp that possibility and potentially change this system. So, big challenge, right? First, what we're going to do is actually just go down the caterpillar here. So you'll meet people one by one. So Rebecca Oni is CEO of Health Leads. Rebecca, can you tell us about what Health Leads does? For the record, we're all terrified of these chairs, by the way. So if we fall off, someone should feel free to come help us. So Health Leads was born of conversations that we had with physicians in the mid-90s at Boston City Hospital, then the big public hospital in Boston, in which they basically told the same story again and again where they would say every day we have patients that come into the clinic. Child has an asthma exacerbation and as a physician can prescribe a controller medication, but I know that the real issue is that this child's living with 13 other people in a dilapidated brownstone with asbestos. It's the middle of the winter and the heat just got turned off. And of course, they're running out of food at the end of the month. But the doctors would say, but I don't ask about those issues because there's nothing I can do. I have 13 minutes with each patient. Patients are piling up in the clinic waiting room. I wasn't trained to do this in med school and we don't have the capacity to be able to address these needs. So even today in that same clinic, there's two social workers for 24,000 pediatric patients, which is pretty typical of the clinics where Health Leads works. So this kind of story, I think, has been, we at Health Leads have heard it now hundreds of times since. The Robert Johnson Foundation a couple of years ago did a survey about 1,000 primary care physicians and pediatricians across the country. Rural, urban, suburban, in which 85% of them said that they considered patient social needs essential to their health. And at the same time, 85% also said that they did not feel comfortable addressing these needs. So the bifurcated approach that we see in practice is either this kind of don't ask, don't tell approach, which is literally how physicians and other healthcare providers will often talk about it. Or those same providers in fact do tackle those needs and become subsumed with them. So at Bellevue Hospital in New York, the physicians report that they spent on average 9.2 minutes of every 15 minute patient visit on their patient's social needs. So Health Leads was sort of born of this conundrum and the model is actually quite a simple one when patients come in to the doctor's office and the physician or nurse or social worker identifies any of these unmet resource needs that will have an impact on the health of the patient. The provider can prescribe those resources the same way she would medication. Patients then take their prescription to Health Leads desk in the clinic waiting room. And we now have a core of about a thousand well trained college students who work side by side with those patients to help connect them to the existing landscape of community resources and public benefits. I think in my mind the kind of key piece of Health Leads work is that for us it's actually not really just about serving the next patient but trying to use the work that we do with our clinical partners as an opportunity to refute all of the reasons that are given for why health care is not focused on health, right? So patient's lives are complicated. We're trying to do this electronic medical record thing and we don't have time to do this. Poverty is messy. We weren't trained to do this. We don't have the resources to do this. This is going to screw up our patient flow and to really try to convincingly demonstrate that this can be seamlessly integrated and frankly made like any other subspecialty referral. So I can refer my patients to the cardiologist. I can refer my patients to the utilities company to get their electricity turned back on. And those are both a core part of health care delivery. The one quick final I think case study that I'll just share on this around what this transformation can look like is Health Leads launched about a year ago in a large academic medical center in Boston into adult internal medicine clinics that had by their own account studiously practiced this don't ask, don't tell policy. And the clinic really resisted screening patients for their unmet resource needs. We pushed back and ultimately now the clinic has embarked on routinized screening of patients' needs. And I think what's so significant is that although only 20% of the patients in the clinic receive care through Medicaid, when we started screening patients, 54% of the patients present with at least one significant unmet resource need. So that's food, housing, utilities, assistance, education, or employment. And that was frankly shocking to the leadership of that clinic. And when you think about a clinic that's trying, for example, to reduce the incidence of diabetes in the patient population but don't know that 30% of patients are running out of food at the end of the month, it's really hard to imagine how you get the gains you need to from a care delivery perspective and from a clinical perspective if you're not accounting for the realities of patients' lives. Part of what Health Leads has also really worked on is how do we not just demonstrate that patients' social needs can be an integral part of care delivery from an operating perspective, from a care delivery perspective, but also from a financial perspective. And so one of the things we started doing in these same clinics was actually texting patients when they finished their work with health leads. And essentially measuring a net promoter score for health leads, which was at about 78% with the industry average in health care being about 33%, but also found that the patients were 56% more likely to recommend their clinic to others because health lead services were available. In other words, we were simply providing more value to the patients in their clinical visits than would otherwise happen. And it was that that actually allowed the funding of health leads there to move from the community benefit budget of the institution into the operating budget, which was actually the first time that any initiative had ever made that migration in that institution. So I'll stop there. I think, to Kim's point about kind of what's the bright spot in this, what's been really exciting is that over the past couple of years, we've actually had 1,000 expansion requests from hospitals and health systems across the United States. And I think this represents, of course, just the beginning, but nonetheless, a real shift to recognizing that if health systems are going to successfully transition into the new reality of healthcare in this country, they are going to absolutely have to make addressing patients' social needs and integral part of care. And the question is kind of how do we begin that journey with them? So Gary is CEO of Healthcare Without Harm. Gary, why don't you tell us about your work along the same lines of what Rebecca just said? Thanks. So our birth story goes back to the mid-1990s when the Environmental Protection Agency was identifying medical waste incineration as the largest source of dioxin emissions in the country, dioxin being linked to cancer and reproductive toxicity and learning disabilities and a whole host of other issues, and also identified mercury contamination coming from healthcare as a significant source of contamination in the environment, mercury being linked to damage to the developing brains of children in the womb and in the first couple years of life. And so the realization was that healthcare, which is almost 20% of the economy in this country, represents all the contradictions of an economy that's built on fossil fuels, toxic chemicals, and industrial agriculture. And so our strategy was to bring the latest environmental health science and research to the sector of the economy that has healing as its mission and to get them to clean up their own house. And so some of the movement around that has been, when we started, there were about 5,000 medical waste incinerators in the country. Now there's less than 60. Healthcare has also figured out how to reprocess medical devices instead of throwing them all away. And now there's a market that's $500 million for reprocess medical devices. Hospitals are saving money. When we started, mercury thermometers were the gold standard for measuring temperature. And now they've been completely eliminated in the United States. No more pharmacy chains sell them. No more hospitals use them. There was legislation passed in Europe to ban them. And then we took it to a global level. And just a few months ago, we were able to win a global treaty, phasing out mercury from healthcare globally by the year 2020. Those were the early wins to reach large scale change. But subsequently, we said, well, what about the chemicals that are used? And so working with Kaiser Permanente and other systems, we're able to transform the market for IV bags and tubing, changing what kids are exposed to in the neonatal intensive care unit, creating a design strategy for hospitals that put occupant health at the center of green building, that then became the core lead for healthcare. Getting healthcare to address its own addiction to fossil fuels, because we understand that climate change is going to be felt by people all around the world, fundamentally, as a public health issue. And if we can transition away from fossil fuels, healthcare can lead by example, by adopting energy efficiency, by becoming early adopters of renewable energy systems. And then finally, another example is food. And how can we get healthcare to transform their food purchasing practices that could support local and sustainable agriculture so that they can both be supporting the local and regional economy that can be more sustainable, as well as serving healthier food for their patients and employees, and actually reducing levels of obesity and diabetes. And now there's 700 hospitals around the country that are transforming their food purchasing practices and being anchors for a more sustainable regional economy around food system development. So the ultimate strategy is to say that, you know what, in this 21st century, healthcare has a much broader healing mission beyond healing patients, that its role is to heal communities and it's to heal the economy and it's to heal the global planet which sustains all of us. And if we can, as we have done, sort of aggregate the purchasing power of the healthcare sector, it can be a driver for a renewable energy, clean energy economy. It can be a driver for safer products. It can be a driver for sustainable agriculture. And so that's the journey we've been on. Kaiser Permanente, Gene here sitting next to me, has been our partner for 18 years where they've been their early adopters and then together we've said how can we socialize this into the entire sector, not just in this country but globally. And so the work has been to actually build a movement inside of healthcare for sustainability and environmental health. Thanks, Carrie. So we can see with both health leads and healthcare without harm that they are transforming what care is being provided, so what the product of healthcare is. We're hearing about different kinds of providers and we're hearing about different places where it's being provided and we're starting to build a different story of a broader definition of care. Gene, you are, I want to make sure I get this right, director of community benefit for Kaiser Permanente in Northern California. How does Kaiser Permanente think about this? You represent a very large health system. How is it from your vantage point? Thank you very much. It's really fabulous to be here with all these partners and I'm feeling like well they're telling the story really well on our behalf. So I don't know how many of you have had experience with Kaiser Permanente. It's the nation's largest oldest integrated healthcare nonprofit delivery system. So those are a lot of words. What that means the longer I work within the system I realize is that the incentives are structured so that we're really able to fulfill our mission which is two fold is to provide high quality affordable healthcare services to our members and in Northern California there are about three million people but the same number in Southern California. So in any given community you can have between 40 and 50% of the insured population who are our members. So we are our communities in many places. But the second half of our mission is really to improve the health not just of our members but of the communities that we serve. And so we do that really through employing all the assets of our organization and it includes everything from the community benefit work that we do where we build partnerships, long standing partnerships. We work to address issues such as healthy eating, active living as well as working with our safety net providers where we don't just provide grants because those are kind of transient they come when they go but we work to help them learn how to spread best practices so that now we've got about 35,000 people in Northern California and 50 different clinic sites who are practicing the same level of care that we do for our members through a program for chronic care management called preventing heart attacks and strokes every day which means there are 30% fewer cardiac incidents happening in the clinic's populations. So there's work that we're able to do that really builds on our commitment to clinical excellence and managing the health of populations. But really I find what I find very exciting is that we really understand that what creates health is not really what happens in the clinic walls, what creates health are the conditions in which we live, the communities in which we live. And so to some extent the purchasing power that we have is being absolutely focused on sustainable purchasing on working to support diverse providers and manufacturers as well as to be able to really make a difference in the communities in which we work. We're supporters of the association of family farmers so that the healthcare services folks when you're in our facilities, you're able to eat organic and healthy foods and then when you walk outside there are farmers markets. So really we're attempting to really embody what we call total health. So it is an upstream model dealing with the health of populations, their physical health, their spirit, their body, their mind but also partnering very intentionally with institutions. I guess the last example I would leave you with is the longstanding partnership that we have in Oakland Unified School District where we work with them not just to provide support so that they've expanded access to school-based health centers which is very important to be able to reach kids where they're at but also we've worked with them to help support the African-American male achievement work so that they have changed the whole culture of their schools. African-American men and boys are no longer being suspended at the same level and they're really staying in school and they're able to transform their lives and when I've talked about this actually with some other healthcare institutions they're like, help us under, what's the connection? And I have to say the connection is very obvious to us that if you aren't well educated, if you aren't invested in your communities then you can't be healthy. That really puts a point on it. Thank you very much. Definitely hearing more themes of broadening the definitions of care. So Cassia, you are chief partnership integration officer at Partners in Health and chief of staff to Paul Farmer, the founders of Partners in Health. Tell us what PIH does and how is it different in the settings that you work in? Is this different from what you're hearing these guys talk about? Thanks, Kim. I think yes and no, of course. So Partners in Health has been working for almost 30 years now, starting in Haiti in the squatter settlement of Conge which was a community of people displaced by a hydroelectric dam project. And we work to provide high quality healthcare to the poor. And we work closely in partnership with Harvard Medical School and Brigham Women's Hospital in Boston to deliver the fruits of modern medicine to the people who need them most. And I'm reflecting that this is a big panel and it's the first time I think that I've been on a global health panel with exclusively non-clinicians. And of course we all have many clinicians with whom we work closely, but I think this reflects one of the biggest needs we see in global health which is this implementation gap. We have all of these wonderful diagnostics and therapeutics, lots of tools. We know a lot about how to prevent disease, how to treat it, how to cure it. In less than a generation, HIV has gone from being a death sentence to a manageable chronic infection. And yet we're failing to deliver these tools to the vast majority of the people who need them. And I think in this context, in our context, it can be easy to feel like we're doing a reasonably good job of delivery. Although I would say that in every city, including this one, there are pockets of vulnerable populations that we are failing. We are failing to reach. And with projects like Health Leads, that's getting better. But the majority of the world's populations still lacks access to even the most basic tools to ensure health. So partners in health has been working to prove what's possible in healthcare delivery. We especially like to challenge notions that things are too expensive or too difficult, that settings are too complex, that patients are too complex. And we're very proud that in some of these so-called complex settings, in Haiti, in Lesotho, in Rwanda, in Malawi, the Navajo Nation, we are able to document patient outcomes that are as good or better as those in what we think of as the traditional bastions of academic and medical excellence. So when we have patients walk into our clinic, a traditional funding structure in global health is money for HIV prevention, or money for a cancer treatment program, or a new program to help address child malnutrition. But of course, people don't walk in with one thing. There's not a broken arm prevention program. And when you're working in a city, or in a setting that has a lot of services, you can run a vertical program like that. When you're working in Nano District in rural Malawi, patients come in with a whole array of needs, many of them clinical, many of them not. And even if they start with a clinical need, what's the first concern of patients when they start to get better? They need food, they need food for their families, they need a safe place to live, they need access to clean water, and then of course a job and school for their children. So we have in each of these places been working to build partnerships where we can and to try to figure out how to address these needs where there aren't partnerships available, but we see very clearly this spectrum of needs as connected to patient health. And our expertise and our focus is on the delivery of healthcare, but that is not ultimately enough. It's as we say in medicine, necessary but insufficient. So I'm delighted to be here with these partners. This is part of an ongoing discussion we've been having over the past couple of years about how our organizations can work more closely together to address the spectrum of patient needs in each of our patient communities and also to advocate more broadly for a broader understanding of and approach to health needs. Amy, you are Chief of Staff to the Director of Global Health Sciences at UCSF. It's a mouthful. You're helping to launch something called the Institute for Global Health Delivery in Diplomacy at UCSF. Tell us about that and why you're doing it. Well first I wanna congratulate everybody in the audience. I've been to a lot of SOCAPs and I was at a bunch of panels yesterday and at most panels at SOCAP you hear about people who are just starting something, who just have a new idea and they're trying to figure out how that can work and they get really excited about it. This panel is full of people who did that 20 years ago and they're here to tell you the stories of how do you get to 20 years? So please, when you leave here, tell somebody about what you heard because all the folks that decided to eat lunch probably should be here so that they don't make the same mistakes that we all made five years ago. And one of those mistakes is what I'm trying to work on with Eric Goosby at UCSF and that is we focused on shiny objects. We focused on the science and we've gotten really good at those things but as everyone has said, we are failing. We are failing to deliver things that we understand the solution but we just can't get it to the people who need it when they need it. At a price point they can pay for it through a sustainable method that will last after our project is over. And so what we're trying to do is answer the question of why and come up with some frameworks and tools and processes and products and people who are able to answer those questions and do it. If we don't stem the tide of doing project by project work that are building parallel pieces of a system, we're never going to get to a place where the system itself is sustainable. And we've done those things for good reasons. The Ministry of Health in most of the countries where we work isn't particularly strong and in order to deliver care in emergency situations instead of trying to fix that, we've built something new. But we've done that for long enough and it's time now for us to go back to the system itself and strengthen it in a way so that it is able to deliver the care that all of these organizations are doing in pieces right now because we'll never be able to do it all globally. That's why we do partnerships and that's why we talk about models and that's why we hope that other people want to replicate the kinds of things that these organizations are doing. And that is part of what we're trying to build as a good repository of what that information is and then a movement around it so that instead of coming up with a new idea that we can get people who are excited and enthusiastic about solving the world's biggest problems to solve it using the answers we already have. Thank you, Amy. So Cassie, you kind of foreshadowed this and Amy, you pulled it together talking about partnerships. Gary and Rebecca, you guys have been spearheading some of this effort that Cassie was talking about with fellow health practitioners along the lines of what Amy was just describing about implementation and pulling together the experiences of folks like yourself who have had these deep and scalable experiences. Can you talk about the framework that's emerging and what you hope to do about it? Sure. So initially it came out of a number of organizations that were all grantees of the Skoll Foundation based in Palo Alto and we kept coming together and realizing that there was a framework that was emerging out of all of our work that united us even though we had different pieces of the healthcare solution. And we sort of boiled down that framework to be these four components of transformation. One was how can we transform the healthcare product? And in some cases the product may be an app or the product may be a prescription for fruits and vegetables that goes to the clinic to go get healthy food and sustainable food. How can you transform the provider so that we have a much broader army of people that are going out into the community to address the upstream social and environmental needs of people? So that's product and provider. The third was the place. And so instead of seeing the acute care hospital as the place in where healthcare delivered, that may be the place of last resort and that we wanna move healthcare upstream into communities so that the place for delivering healthcare may be the Oakland Unified School District, it may be the library, maybe the fire station, it may be the nursery so that we're moving it into the community. And in fact, yeah. And then the fourth, which is the most important is actually the payment structure. And how can we move away from paying for procedures to paying for prevention so that we're incentivizing people to stay healthy as opposed to incentivizing healthcare providers to do more tests and to do more interventions? And so when we looked at those four P's, we realized that whether you're working in Malawi or you're working in Missouri, those things stood. And so what we've been trying to do is to take that model and say, how can we start to insert this broader transformation framework in the institutions either at the national level in the United States through Medicare or at the international level through the World Bank and multilateral loan organizations to change, to transform healthcare along these four lines. And that's the kind of creative collaboration that we've been growing to figure out what are those levers that we can press together that can actually transform healthcare? And I loved, Amy, what you were saying about this is more than the work of an organization. I think, you know, part of the pattern recognition that we did across these 20 or so social entrepreneurship organizations working both globally and domestically functionally against these four P's that Gary was talking about wasn't just the objective transformation, which are the P's, but also the way that we think about approaching the transformation. So these are organizations and partners in health is among them as well, that it's not about kind of growing our footprint or securing additional capital, but it's actually around understanding, Gary has this great language around how can we be the intel inside of larger actors within health systems in the United States and globally and really cause them to have the tools that they need to be healthcare providers, not medical care providers. And so part of what we've really been intentional about each of us as individual organizations, but now as we've come together collectively is choosing our partners carefully. And it's not a coincidence that both health leads and healthcare without harm are working with Kaiser Permanente. Part of the whole notion of this is to say, there are key actors in health systems and in the healthcare sector, both domestically and globally that are kind of these ripe beds of innovation and the places where we can demonstrate the achievability of a radically new approach to care delivery. And I think Kaiser, certainly in the case of health leads, and I know this is true for healthcare without harm, has been a place that has been in some ways just profoundly willing to reconsider the four P's and to think far more expansively around the product of healthcare. So health leads now has a partnership where when patients come into the KP Richmond Clinic, not far from here, they are now routinely asked, do you have enough food at home? Are you worried about paying your utilities bills? And those are questions that have, in just a few months, become an integral part of how that clinic's functions. Again, with the idea of saying, this isn't just about the next KP member and it's not about more health leads, it's really around saying we can demonstrate that this approach to care is imminently achievable. And so I think a lot of the work of this community of social entrepreneurs, frankly, has been looking beyond ourselves and really trying to understand how do we arm these institutions like KP where others go to learn to be able to really fulfill their own aspirations around their commitment to their patients and to their communities. So we all know that what gets paid for gets done. So I wanna shift us a little bit to talk about the funding environment. We've talked about implementation with this framework of the 4P. So we're talking about broadening what it is that we're implementing. And in an international context, it's kind of doing it for the first time in many cases. In the domestic context, it's a big web, isn't it? So Jean, talk to us about the Affordable Care Act. So what is, things are supposedly changing here in the United States. So what does that mean for how we look at healthcare delivery and how is KP thinking about that? Small question. It's a small question before lunch. The Affordable Care Act has just been tremendously powerful and transformative and I think that everyone should be very clear that it has already been a success. There are millions of people who now have access to high quality medical care and they didn't have it before and it was a source of great consternation for families as well as literally for poor health. So it's very powerful and I will also say that a lot of people are still very confused. People are confused about how to gain access. There has been a big push at least in the state of California to get folks enrolled but as you start to do that enrollment very much as Rebecca was saying, become clear that actually healthcare is not frequently people's most preeminent need. It's really access to food and housing. So we have seen that it's been a great opportunity to really to join with others who are doing grassroots advocacy and education to reach folks where they're at and get them connected to all of the resources that they need including healthcare but not only not isolated to healthcare. I would also say that it has done a lot to really focus people on prevention, on clinical care prevention which then leaves the opportunity for more upstream prevention and to focus on evidence based care to give payment based upon what works and payment based upon outcome as opposed to just the number of widgets that you produce and I think that's very important. I was hoping I wouldn't be the Debbie Downer but I have to say that there are still a lot of people who are not eligible for coverage under ACA and certainly again in the state of California that represents really hundreds of thousands if not millions of people and so we have to be attentive to the need to support those providers who do provide care to these people. Both hospitals and clinics as well as safety net providers, community health centers and they have a real challenge with payment and their payments really does need to be reformed and they need to be able to take risk. They need to be able to serve a population and not just serve people based upon individual visits and right now there are real constraints. People know it's very important to be able to provide access to services to serve the whole person but currently in community health centers you're able to, they're limited with the number of services you can provide in a given visit which is really counterintuitive which really creates barriers to the integration of behavioral and mental health care services with primary care. So I would say there's tremendous cause for optimism and simultaneously the health care providers absolutely have got to address affordability. Health care takes up too much of our nation's resources and so we have got to do a lot better with a lot less resources. Can I just ask you to also talk quickly about I mean Kaiser Permanente is a great example of having different pools of funding to pull from. Can you just, I mean you've been able to execute partnerships with organizations like Healthcare Without Harm and Health Leads and how does that payment model work? How can you actually embed some of this stuff in your approach to what gets paid for? I think it's a great question and we're a prepaid model, right? We're capitated. So our basic incentives are aligned that it is in our interest to work with our patient population to keep them healthy and so because we don't bill fee for service, we don't have to worry the way I see a lot of our partners, community providers who are, they would love to be able to have people in the clinic who can do outreach. They would love to be able to do counseling but they don't get paid for it and so I would say that that's another element of ACA that should be considered is not just ACOs which are very exciting as ideas but I do think that the capitation incentivizes folks to do the right thing in the right place at the right time. And on the question of payment and incentives I'm sitting here reflecting that if you don't charge for your services at all that's another way of steering clear of these perverse incentives is the case in our work. But you had mentioned this question of domestic and global delivery and I think that's been another interesting impact of the ACA is that it's really opening up a lot of discussions about what's worked in other settings, what's possible, what the real evidence space is and we've gotten a lot of questions and started a lot of interesting conversations with people who are interested in what's worked in partners and health models so to use a small example we rely extensively on trained, paid, supported community health workers that's a fundament of the model and we've seen with using CHWs to deliver care especially for chronic diseases like HIV and TB that requires daily therapy we've seen terrific outcomes and as I said in some cases we see better patient outcomes and higher rates of adherence than we do at some of the top medical centers here and we developed that model not because it's a lot cheaper than using clinicians for every visit although it is of course and not because there aren't enough clinicians in these settings to deliver care directly although that's also true but because we believe it's the highest standard of care for chronic disease having someone that you know from your community come to your home every day help you take your medication and also check in on the other things that might be barriers to receiving care or getting healthy is I think most of us would agree a better patient experience than getting yourself to a clinic waiting to see a clinician touching only on this narrow scope of things so that's been an exciting I think impact of ACA and I hope as a side note that we can you know this is often described as reverse innovation bringing Haiti to Harvard as we say I hope we can get rid of the whole term reverse innovation I think it's time has come it made sense when it was coined to describe a echocardiogram that was developed in India for GE and then manufactured here but I think the notion that an innovation that comes from the developing world and arrives here is somehow backwards or the reverse of anything is over Did you want to? Yeah, yeah, yeah I think what's interesting to Cassia's point is you know is the whole notion of kind of how do you deliver excellent care in resource constrained environments in ways that are actually the right way to approach care and for so long in the US we haven't viewed ourselves as a resource constrained environment and you know I think both because of the ACA but frankly just because healthcare is now 19% of GDP there is this recognition that on the one hand while there is mind boggling amounts of money that are deployed in and around healthcare functionally this has become now a resource constrained environment and the power of that I think is actually quite exciting because it allows us to get back to some of the most logical and fundamental ways to deliver care in the first instance and I think that's part of what's been so exciting about this group of social entrepreneurs you know kind of beginning to articulate that these four P's of transformation is to say we are actually returning to the way care should be delivered and having the opportunity to source best practices and bright spots and insights across global models and that's just I think a profound opportunity of this moment in time. Well and let's talk more about that I mean Amy and Cassia you've both spent your careers in global health and many people seem to think this is an opening in that setting as well international aid is changing people have you know from USAID have different expectations of what national governments should be doing I mean how does that fit into all of this? Well we're also at a profound time of convergence the Lancet just came out with a big series of articles this spring talking about what the economics and how that's going to change the health care environment as well and as we are becoming we're not becoming resource constrained we're becoming acknowledging that we're resource constrained countries that have been called low income are also changing we're seeing huge GDP growth and as that happens countries will be more responsible for paying for their own health care systems and as philanthropists get less excited about solving the problem again and again and again the philanthropic dollars are decreasing so there's going to be a shift that happens very soon in who's responsible not just in name but responsible in terms of the money and if that doesn't happen at the same time as the management responsibility and the control and power and agency over what's happening in their systems we're going to end up having a mismatch in a pretty dire direction so I think that that's one wave that's coming along with that just like the ACA we're hearing lots of news about universal health care and this is becoming a new goal for us globally how on earth are we going to be able to provide health care for everyone and then isn't it just a ridiculous thing that I'm asking that question because how can't we? Both of those things working at the same time is going to have a macro change in the way that all of us are thinking about this work and as we look outside I have a tendency to try to ask you guys to do things this is us asking you to be taking a stand in it as well all of us who are working in this space need to start recognizing how we fit into the overall puzzle we're not really transforming into a new way it's kind of like leg warmers like we're going back to leg warmers most people aren't even old enough to know what that means get ready leg warmers are pretty exciting and it just means we have to go back to the fundamentals and apply the basics of how you do care and how we think about healthy people and then be logical about how we build the systems to do it. It's really funny because in my head I really wanted to talk about Ebola and now we're going from flash dance to Ebola this is amazing I just wanted to say we've been talking on somewhat of a systems level and I want to bring it back down to how does stuff get implemented I mean everything you guys have been talking about today depends on a person who's paid and trained to do something that's measured and influencing the system so and we're talking about how there's the lack of that in so many situations so Cassia talk to us about Ebola you're really involved in a lot of this but you know breakdown what is missing here? Three things staff, stuff and systems right so the real crisis of Ebola is not an outbreak of a hemorrhagic fever which is actually fairly hard to transmit it's easier to catch tuberculosis than it is to get Ebola and can be managed and contained if there wouldn't be a massive outbreak of Ebola here because we have health systems and barrier nursing and isolation rooms and masks and gloves and the things that healthcare providers need to take care of patients safely so the crisis is an acute one of Ebola but the real crisis is the chronic lack of the underlying systems and the staff and stuff we say in shorthand the commodities, the supply chains and the trained workers to support them so it's a grim one not one anyone would wish for or ask for but this is an opportunity both to increase the awareness of the really dire lack of these systems and to do something about it I'd like to congratulate my fellow panelists because not only have none of us fallen off of our chairs yet but it's been probably half an hour and no one has said the word sustainable I think I'm pretty sure that's a record for five social entrepreneurs on a panel right so what is not sustainable about the lack of a healthcare system is that we're gonna see more and more of these crises like Ebola which will become and stay crises because there's no way of managing them and we really really need to invest not only in the systems but in supporting the public sector systems you know a group like Partners in Health or any other healthcare delivery organization that's a non-profit can't confer rights only a government can do that and so there is I think a lot of good policy and plenty of lip service around strengthening these national public systems but we're not really seeing that happen in practice the investments aren't there and the notion that inviting a government official I'll use a real example from Haiti after the earthquake right so we go to there are a lot of NGOs in country everyone's gonna have a what's called a cluster meeting a health cluster meeting where officials often the leaders of various NGOs get together to try and coordinate and work in partnership and you get there and someone says well where's the government of Haiti why aren't they there why aren't they here and there's grumbling about you know government of Haiti didn't show up and someone says well we invited them and what that typically means is that someone sent an email which would be very hard to receive for an official who has no computer no electricity no access to the internet and if they had gotten the email in post earthquake Haiti they may well not have had a vehicle gas to put in the vehicle money for gas to put in the vehicle money to pay a driver to drive you know so we have to be more pragmatic and more realistic about what real inclusion means and what real support of a ministry means it doesn't mean inviting them it doesn't mean making them the titular head of a committee it means actually figuring out what the barriers to their participation are and helping to address them I just need to add a couple of things Ebola this is not the first time we've seen this this is not anywhere near the first time we've seen this and it is it is abhorrent that we're letting it get even this far because this is how HIV started this is how SARS started this is not the first opportunity we have to see that there's a systematic problem we are ignoring something that cannot be ignored anymore and yet we're going to it is one of the things that gets me up in the morning and makes me shake because how can this be happening again but it is and so we have to solve the problem writ large it can't be about Ebola it has to be about how do we not let these things happen again and that means it can't be about the next shiny object it can't be about the next social entrepreneur winning a new award of $5,000 to get their idea that lasts for the next 30 days it needs to be about groups coming together like this group and doing things that move the entire chess board and if we don't all get on board those of us who already are seeing this happen there's no chance we're gonna get everybody in the other rooms to see it as well so again, here's your call to action you guys have now heard it and you probably believed it because you wouldn't have been in this room or stayed this long if you didn't but it's something that we have to start a movement around and these folks are amazing leaders in it but so too are all of you in the audience so I just wanted to add another dimension I just came back from a conference set up by the World Health Organization it was the first global conference on climate change and health and there were health ministers from 30 or 40 countries all talking about how they've seen the spread of malaria and dengue they've seen flooding they've seen this epidemic of asthma related to the overuse of fossil fuels and so one of the important themes that came out of the conference was how can we build in at a global scale the resilience that's needed in the healthcare sector so that they are the last building standing so that there's onsite power when the grid fails as we learned in Hurricane Sandy and Hurricane Katrina the hospitals that failed had all their backup systems in the basement they didn't have any onsite power and people they had to be evacuated so some of there's some really interesting innovations and technology that are simple and at appropriate scale for many many places around the world to bring solar power to clinics to have solar refrigerators that can keep the medicines refrigerated in the event where there is no electricity that can have onsite water filtration systems that can prevent cholera and the spread of diarrhea in flooding conditions there's even technologies that basically it's called a solar suitcase so that it's a solar powered suitcase and you open it up and so when a midwife or a physician is in somebody's hut where there is no electricity they can have light in which to help deliver babies so there's some really interesting strategies where I'll use the word environmental sustainability meets climate resilience and that's another dimension of what needs to be kind of built in and there's all sorts of opportunities for investment in that space where health ministries can be adopters of this at scale I feel I've failed in my, you're charged to me to mention Ebola and I would just give you all something to think about as I'm sure the coverage will be certainly not slackening and perhaps increasing over the next couple of weeks and one of the tropes of this coverage is how virulent Ebola is this high mortality rate over 50% and I would suggest that that is a measure of the weakness of the underlying health systems not of the strength of the virus so I think more realistic or even a target mortality levels probably sub 20% so it's just another example of the way that evidence base is thin and one story might carry the day and the coverage is all about this very scary, it is a alarming disease it's a hemorrhagic fever and causing a lot of mortality and again I would just suggest that we all interrogate what's behind those numbers and why it is that the mortality is so high So Atul Gawande has this great quote from one of his New Yorker articles where he said in medicine good ideas still take an appallingly long time to trickle down and I think so much of the discussion today is that it's actually not at all it's profoundly not about the new idea it's about how do we make those ideas real and I think that's we've taken on that as our charge and as Amy said, how does this audience think about that challenge? You stole the words right out of my mouth obviously the point of today was to talk about practical approaches but practical approaches that can address large problems and this is as we've talked about these four P's about can you change how we think about the product and the provider and the place and the payment of healthcare as a way to move it upstream broaden what we mean by it but essentially at the end of the day strengthen the system that provides it by broadening that system and being very practical about it we need gloves Okay, well thank you all very much for attending again this is an interesting hour for a panel and we appreciate you all being here obviously if you have any questions or wanna ask anybody anything afterwards come on up and as they said we're talking about a bit of a trying to create a bit of a coalition so if you are interested and have anything to add please do let us know thank you so much for your time