 It gives me great pleasure to introduce our speaker this afternoon, Paul Wise. Paul Wise is a professor of pediatrics here at Stanford, but he's also the Richard Berman Professor of Child Health and Society. He's the Director of the Center for Policy Outcomes and Prevention. He's also a core faculty member at PCOR and Freeman Spogli, and also at the Centers for Health Policy. Paul has an interesting career. He did his training at Cornell. He did his undergraduate in Latin American Studies. He did his MD training at Cornell. And then he went on to do a Masters of Public Health at Harvard and stay at Harvard for quite some time, where he did his residency training at Children's Hospital and then moved over to be the Director of Emergency and Primary Care Services at Children's Hospital and the Director of the Harvard Institute for Reproductive and Child Service, and the Vice Chief of the Division of Social Medicine at Women's in Brigham, which many of you know is the academic home for partners in health. So Paul has done quite a bit of work with partners in health. His interest is very eclectic, but very focused now on governance and instability and how do you deliver health care in times of instability. And so that's what he's going to talk to us about today. Thank you, Dr. Weiss. Thank you, Dr. Berry. It's a pleasure to be here. I'm going to leave time for discussion, and I really do invite discussion, particularly because we have some experts in the room and certainly contribute to this conversation. When people talk about health care delivery in politically unstable areas of the world, particularly at a resident level, the sort of usual response is to think of the kind of challenges that we face in these areas as very similar to dealing with complex humanitarian emergencies. That you're dealing with trauma, you're dealing with questions of security, logistics, you're working in settings like this. And it's absolutely true that there are components of care that are very similar to what you would work in a post-natural disaster, quote, unquote, kind of arena, where you're dealing with immediate surgical needs and immediate humanitarian relief. However, that's not what I'm going to talk about today because in my view, this is not the central challenge of providing health care in areas of political instability and civil conflict, that it is not the same thing as providing care in a complex humanitarian relief operation, that there are other challenges that are far more profound and ultimately have far greater impact on the health and well-being of the people we're worried about. And what I'd like to do is to go beyond sort of the usual conversation about this to where I would submit the real action is, the real challenge and the real potential to make a difference. Now, in dealing with complex humanitarian emergencies, we've got these kinds of issues to deal with. Planning and training, certainly planning, training, and many of you have received training, particularly those interested in global health, in working in these kinds of situations, logistics, communications, coordination. These are all really important things to do. However, my suggestion is that what we really are talking about is the impact of political instability more on civilian population. And that takes us to a whole new kind of landscape that we're going to try to navigate. And when we think about the impact of political instability and civil conflict on civilians, we think about the direct effects. And the direct effects being very similar to what you would find in a complex humanitarian situation. When you have trying to provide health services in situations like this, you have the direct effects, immediate effects of combat situations on civilian populations. And you also have immediate implications for mental health and other kinds of things that are quite dramatic in these kinds of situations. And the most profound, starkest impact is on mortality. Direct combat, what people might call collateral damage in certain circles. You have direct effect on civilian populations ending in immediate mortality. Places like this where civilians are almost always caught up in crossfire, places like Syria currently. You also have significant issues with morbidity and disability, where you have large numbers of wounded civilians that are not reflected in a frank mortality rate. And people have used dailies to address the concern about morbidity, injury in terms of direct effects in these kinds of situations. And just the definition of a dailie is up here. And it's basically a way to assess the impact on people, functional impact, not associated with mortality. So it's just a measure of how many years you live with a disabling condition in addition to any mortality, years of life lost that is measured in mortality. All implications are that the dailies are far higher than the deaths in most situations. Approaching 10 to 1 in terms of injured, disabling conditions as a ratio to death. So morbidity in these situations is quite traumatic and anybody's worked in these areas knows the burden on the health care system to what, to the extent that it exists due to disabling conditions in these areas. Also mental health issues are significant. And these are what we basically would classify as direct effects. However, there's something else that's going on in these situations as well. And that is the direct mental health effects are often hidden. This is work that we did during the Bosnian War in the 90s where we basically interviewed and tested children in refugee camps that were very close to the area of conflict. And what we found was just enormous exposure to potentially debilitating mental health problems that basically more than 50% of the kids experienced the death of a family member due to combat. Witnessed violence, killing, and exposed to combat, extremely high exposures. Never underestimate the kind of exposure you get in civilian populations in areas of ongoing civil conflict and combat. The impact that we found on PTSD was profound. About 75% of the kids in this study showing frank science significant PTSD. The kids were then lost to follow-up as the war moved on so we don't know what the long-term implications have been. But the mental health effects, the dally effects, the mortality effects are quite profound. Now, how do you protect people, civilians, from the direct effects? This is where just war theory becomes important. It's not, maybe the first time it's discussed in a resident lunch conference, I don't know, tell me. But it's the primary means by which the world tries to protect civilians in combat, in civil conflict areas. And it's useful to understand what it basically implies. Just war theory goes back to early Christian theology as well as it's there in the counterinsurgency doctrine that was rewritten in Afghanistan and Iraq. It is the fundamental, it's the centerpiece of the protection of civilians in areas of conflict. And you have sort of pre-war situations and just war theory tells you when you're allowed to go to war and what kind of war based on the potential impact on civilian populations of noncombatants, how to act during the war, what kind of collateral damage is considered acceptable and what is not and how those decisions should be made. And then you have post-war and it tells you about responsibilities for reconstruction. And this is basically the kind of approach that most people take, the counterinsurgency leaders who are active currently in Afghanistan as well as the moral philosophers like Michael Walzer, they still base much of what they are suggesting as being critical here based on just war theory. There are also things that have been generated by just war theory that have come to mean vehicles for global response. And there are international conventions, the Geneva Convention is an example. You also have international criminal proceedings. The United States is very concerned about falling within the jurisdiction of the international criminal proceedings in the context of war and generally does not sign on to many of these conventions and international conventions and criminal proceedings because of the concerns about what it does in making combatants, US military vulnerable to international criminal proceedings associated with combat operations, but they do exist and most other countries in the world tend to embrace them. And these are the kinds of things that are in place to protect civilians in areas of civil conflict. But we also have indirect effects and indirect effects can be shown in this slide and we all know about the violence in Darfur. At the height of the violence in Darfur, the vast majority of the deaths occurring in the Darfur area were not due to combat, were not direct effects. In the eastern Congo, in the Kivus, a study was done where they looked at under five kids, under five young child mortality and found basically the same thing, the vast majority of the excess mortality taking place in the Kivus just like in Darfur were not associated with direct violence. They were not direct effects. They were what generally would be classified as indirect effects. This pie graph looks almost exactly the same as the pie graph you get in other parts of the Congo, in northern Uganda, in virtually all of the poorest areas of developing world. The only thing that changed was the gain was turned up. All of these levels were elevated, but the distribution of the mortality was basically the same distribution as it always had been, that when you look closely at what the data are suggesting, is that the impact of civil conflict on civilian populations, particularly the most vulnerable, has nothing to do with the direct effects, where all the focus on civilian protection tends to be. That in fact it's taking place in this arena, not in immediate surgical requirements, but in malaria, measles, neonatal mortality, diarrhea, dehydration. Now the implications of this kind of epidemiology my suggestion is pretty profound. And when people look more closely, they find a series of expert panels were put together as part of a Lancet activities in the early 2000s, found that that distribution of under five mortality, the majority of all those deaths are preventable with interventions we have now. We don't need Stanford or Gates Foundation to develop new technologies or interventions necessarily. With interventions we have now, the majority of those indirect effect deaths are preventable with things we have now. Now the implications of this I think are important. That when you look at just war theory as a mechanism, as a framework for protecting civilian populations in areas of civil conflict, it raises real questions. That in fact the reality is that it doesn't really look like pre-war, war, post-war. In fact what you get is a churning. That many of the post-conflict areas of the world are, as far as anybody can tell, pre-war. That there's a churning that goes on. Is the Eastern Congo post-conflict? When do you declare it an area of chronic political instability in civil conflict? There's been fighting off and on for 20 years. What do you call Guatemala? That just war theory breaks down very quickly when you look at the epidemiology. That the medical epidemiology is challenging the traditional way war needs to be conceived, particularly its impact on civilian populations. So when we're in situations like this, places like this, we need to recognize that there are issues of chronic insecurity, chronic displacement, changes in the health infrastructure that never get re-put back together. That the indirect effects are associated with these kinds of issues. The challenge is profound. What has been our response? Well, this is a map of the geopolitical world as most of you have grown up thinking about it. This is a map of the world based on health care expenditure in each country. Notice there's a rather obese United States there. Welcome to our world. What happened to sub-Saharan Africa? It's virtually gone. This is under five mortality. This is a map of the real world in the areas that we care about. And you can see that there is clearly a disproportionate investment in health throughout the world. Again, this is not going to be striking news to most of you. But if you look at where global investment for health is going, this is a map of development assistance for health per all-cause dally. Again, dally is an indication of need. So it's a kind of health investment per unit need. And I'll just call your attention. Namibia lights up because there aren't many people in Namibia and you sort of get an artifact there. But let me call your attention to the light blues and the light greens where there's relatively little development assistance for health. Development assistance for health is Gates Foundation, USAID, Global Fund, all the big funders. So look in Angola, the Congo, Nigeria, Sudan, Somalia, Zimbabwe has turned light blue. There's something about these places that is important to recognize. And when you plot development assistance for health per capita by under five mortality rate, you get a plot that looks like this. You get a pretty nice relationship. Botswana, Namibia, Rwanda, Malawi, Zambia, Ghana. What's down here? Very high child mortality and very little development assistance for health per capita. Angola, Chad, the Congo, Somalia, Sierra Leone, Mali, Nigeria, Central African Republic. There's something special about these places. These are areas of poor governance and political, chronic political instability. Most of these could be considered post-war, post-conflict situations, but that is not a helpful way to think about it. They're basically churning areas of chronic instability. What is Somalia? Post-conflict, the DRC, Nigeria, particularly in the north and the east, Central African Republic, Angola. I think you can begin to see the message that the places that light up as light blue and light green are areas of ongoing civil conflict and very poor governance. Those are the places that get the least amount of global attention and global funding. Where do the NGOs go? Where do programs that send residents and faculty, medical school faculty, to areas in the developing world? They tend to go to Botswana, Zambia, Tanzania, maybe Kenya, Costa Rica. It's very unusual that there is significant engagement in the areas that are politically unstable. It's understandable, but it's not acceptable. When you look at the indirect effects of civil conflict and poor governance, we know that the impact is profound and yet our focus and engagement tends to be in places that need at least. This is all under five deaths in Sub-Saharan Africa. For Michelle and me, it's like thinking some things we saw Saturday night in college, but this is each country a piece of the pie. This is Nigeria, the DRC, Ethiopia, Sudan, Angola. In other words, what we have is a dramatic contribution in absolute terms such that in most years the majority of under five deaths in Sub-Saharan Africa are taking place exactly in the places that NGOs and education programs won't go, where the developmental assistance for health is leased. So it's not just a question of, in my view, it's not just a question of, well, the DRC, yeah, it has needs, but it's complicated. Yeah, well, Tanzania is a good place because you can make efficient use of the funds that you invest. And in northern Nigeria, it's hard to say it's going to be efficiently used. I get it. I understand. But the reality is that you will not be able to make a substantial reduction in under five mortality in Sub-Saharan Africa unless you engage the places that are characterized by political instability and inadequate governance. There's no way around it. The epidemiology doesn't lie. Now, this program here is one of the few that actually works in areas that have some political instability, particularly in Zimbabwe. I'll talk about that in a minute. But that's very unusual. So then the question is, well, what happens? Why is this taking place? Why do you get all these indirect effects in these areas? Well, this is the pediatric immunization schedule for the United States. Actually, a few extra things got added last year. Okay? This is the DRC. This is the Congo immunization schedule. So when you're talking about preventable, vaccine-related diseases, the disparity between what you, the lives you save with this kind of a protocol versus this kind of protocol is almost by definition profound. So by policy, the DRC immunization schedule is committing hundreds of thousands of kids to be vulnerable to diseases that kill little kids for which we have very efficacious vaccines. By policy. And now the question is for us, and I wanted to leave plenty of time for a discussion, is how do you begin to address these indirect effects in areas of unstable governance? As clinicians, as physicians, as public health people, the time that we allow ourselves to basically say, well, we're going to focus our attention in places that are relatively safe to work with relatively good governance, not so corrupt, those days are over in my view. If you're sitting around waiting for the global security people to fix everything, good luck. My suggestion and our commitment in this project that we have here at Stanford is to say the health people, the global security people, the political scientists need to get together to come up with integrated strategies that are attentive to the requirements of providing efficacious health services in these areas, but also attentive to the political requirements of provision. That what we need is to create new strategies and a sense of new field that integrates the technical requirements of health with the political requirements of provision. And we're doing that through linkages between medical school, between people like Steve and Michelle, David Relman, myself and pediatrics, with global security experts and political scientists, they're some of the best in the world at this stuff, or based here at Stanford. To try to create an integrated series of strategies. And the way we're thinking about it is how do you operate in areas that are not secure? How can you create mechanisms of provision? Now if you're going to build health centers and you're going to put docs in there and you're going to have a big infrastructure, forget it. It's not going to work in these areas. You can rely on doctors without borders all you want. But the thing about doctors without borders is that they almost always leave at some point. Not always. Some places they stay on. But also the scale of their operations tend to be relatively small. So how can you rethink the delivery of health services in areas that remain relatively insecure? Places where you're basically working in places like this. This is the Congo. When you're providing health care in places where you're very likely to meet militias and non-state actors who are going to make life difficult. How do you deliver pediatric care in border areas of Mexico? Now a lot of our work is done in places like Guatemala. Post-conflict? Well maybe. Again a churning kind of political instability. But in El Salvador in 1984 in the midst of a brutal civil war they declared a truce to immunize all the kids in the country. On one side of the road guerrillas were immunizing little kids. On the other side of the road the army was immunizing kids. It also took place in some of the conflict areas of Uganda. There are other examples. Now these are not easy to do and I'm not saying that this is not at all a panacea but what it says is that there may be creative strategies that allow us to provide certain kinds of health interventions that can move into an area deliver the services quickly and then move out. There's no real need for infrastructure. Maternal mortality reduction through C-section is not going to be very amenable to this kind of approach. But immunization? Moving in every six to twelve months into an area? Maybe. You'll never do that in a million years unless you're working with the global security people and the political scientists who understand how to build the truce how to make sure the truce is going to stick, who to talk to. This has to be a very integrated approach but there may be certain technical things that we know require very little from the political environment that the political scientists wouldn't have a clue. They don't know what it takes for certain kinds of immunizations particularly those that don't need cold chain. They don't know what those political requirements are. They need to hear from us. But could you see yourself trying to immunize kids in the midst of the Salvadorian Civil War as a health team alone? Impossible. These things have to be done in an integrated fashion. Another area that we're very concerned about that we think we have something to offer is in areas affected by geopolitical sanctions. And this is welcome to Zimbabwe. Most global funding will not go to the Zimbabwe government to the Ministry of Health because Mugabe has been declared a leader that should not receive any external funding that would support his regime. So a patchwork of sort of NGO approaches of parallel systems has been created but we're very concerned that those systems will almost always be inadequate. And what you can see is a deterioration in the health indicators in Zimbabwe, a deterioration in the capacity of what used to be one of the jewel medical schools to train people to keep people in country have deteriorated terribly. That's why the program that Michelle has created in Zimbabwe may involve some of you is so important because it begins to address the failures of the sanctions regime. It's not a failure, it's actually a successful impact but in our terms it's a failure because it has undermined the Ministry of Health's capacity to provide adequate health services to the people who need it most. And we're working with political scientists who are active in Zimbabwe to alter the sanctions regimen to permit certain kinds of medical technology, medical services and the funding associated with that to move forward at scale through the Ministry of Health. To do that we're going to have to have certain political insulator effects to ensure that the funding supports what it's supposed to be supporting but also that the political consequences of improving health services is not reaped by the Montgomery regime. It's a hard thing to do but it's not impossible and that's what we're working on now. USAID is the primary mechanism for foreign aid, foreign assistance for the U.S. State Department in the world and this is its logo I came across this last year in a particularly complicated political environment and this as you can see it's part of the graffiti wall and this is the security barrier, the Israeli security barrier that goes to the West Bank. This is Bethlehem. Now think about what it would be like to try to develop high quality systems of care in the West Bank, in Gaza because particularly in Gaza because Hamas is under geopolitical sanctions and we have, as I hear, is a global expert on these kinds of issues and my hope is that it contributes to the discussion afterward but when we looked at the data for Gaza and the West Bank we saw glaring epidemiologic evidence for system failure almost directly related to the sanctions regime. Is there no better way to institute a sanctions regime that may still be effective geopolitically but somehow salvages that component that could support the provision of health services to the neediest people in the region? Sanctions regimes that are currently used are blunt instruments but it's going to take people and technical requirements for providing health care services in these areas to help alter the sanctions regimes politically to allow for the delivery of health services in these areas. There are many other areas in the world that are living under sanctions. We also deal with terrible corruption in these areas. This is actually a town where we do a lot of our work in Guatemala where judicial murders are common. Why? Because the judicial process is non-functional. So if you are considered a thief and you get arrested because somebody caught your red-handed the likelihood is that somebody is going to buy their way out of going to jail. There's no confidence because of corruption that the judicial system is going to function. The response of the local people all over Guatemala, not only in this area, is extra-judicial killings. So somebody is considered a chronic thief or a drug lord. They wind up dead. And how do you work in a situation like this where corruption is so bad that you wind up with things like this going. Now, people worry about corruption. The global fund money was robbed or money from World Bank to build a dam. Most of it went into somebody's Swiss bank account. Those are real issues. But the biggest impact of corruption in the areas we care about is that it undermines local collective action. That people will not take a dollar a month for a community health program because if somebody is walking around with a bag of money collecting money for your community activity, the expectation is that that person is going to send you a postcard from Texas. That the impact of corruption is local and it undermines community organization and community solutions. Now, can we address these kinds of issues? Well, our approach is to begin to develop integrated health delivery strategies that take into account the political aspects that are required as well as the technical health related aspects. But in addition, we're also saying to the design community and there's obviously a very important one, very capable one here at Stanford. Fine, you're going to design a new hip joint or you're going to design a new technology that relates to something that's needed in a hospital. That's great. We all need low cost, very high quality hip joints and other kinds of things. This is not a critique. But why can't you design a technology that addresses the political barriers to the provision of services in these areas? Can you come up with technology that evades corruption? That works even in the most insecure areas. That you're attentive to the design of the new technology and the new technology systems are attentive to the political barriers of health care provision in these areas. And so, we are working in places like Guatemala to develop systems of health care delivery and to a certain extent new technologies that actually address the political barriers, the political obstacles to addressing the indirect effects of civil conflict in these areas. And this is a community health worker program and nutrition surveillance that's going on in about 25 villages in the region. These are two health promoters and this is called growth monitoring. We basically take a fish scale and we have about 5,000 kids under surveillance in the area now. However, there are a lot of nutrition programs and growth monitoring around the world. What makes this different or at least attempting to be different is that the community health worker program extends itself into community action and community organization. That the community health workers are not just focused on weighing the kid, graphing them and getting supplementation. That they see their role as much larger in addressing collective action in these areas. And because of the program and its association, new housing developments have gone in, land distribution has occurred and people for the first time have titled to their own homes. They didn't get land for agricultural purposes. Their incomes stayed the same. But we had a Stanford medical student who's now a resident in Boston who looked, we had data on kids' growth before they moved to their new homes and then after. And we found that the communities that moved, their growth improved. Incomes exactly the same. But because of improvements in water and sanitation, housing, but particularly because of improvements in community organization that we saw the kids' health and nutritional status improve. We have political scientists working with us. We have global security experts working with us. And increasingly, we have you working with us in these areas. That the reason I jump at the opportunity, well, if Michelle asked me to do anything, I'd jump anyway. But the expectation is, and my great confidence is, that we are training a new generation of clinicians, of physicians, of health workers who get it. Who understand the political implications and the political requirements of health care provision in the developing world. And these are Harvard and Stanford students doing door-to-door TB surveillance in the Highland, Guatemala, in these areas, but always with community health workers in a structured environment and trying to develop systems of care that can function in these kinds of environments. Also, the provision of clinical care, getting experience of working in these areas is important. Some of you may recognize Sherry Blowett, who is a medical student here who went on to do rehabilitative medicine. She was also a champion marathoner, won the New York and LA Boston wheelchair marathons, who continues to be active in this area working on rehabilitative medicine. And of course, mental health services as well in this context are critically important. And increasingly, working with mobile technology, people of medical mobile, the Global Health Research Foundation here locally to create technologic systems that can evade predatory governance, that can evade traditional corrupt practices that have always undermined the ability for these communities to develop well-functioning systems. And I can go into more detail of what that technology is really beginning to look like, but the point is that we are extremely active and committed to creating integrated approaches to address the indirect effects of unstable governance and conflict, which requires a far more comprehensive, a far more integrated approach. That in the end, our hope is to develop new strategies that will in fact be able to create new mechanisms of provision while confronting directly the brutal at times and often subtle at times political obstacles to equitable provision. So let me stop there and see if you have comments, particularly some of the other experts in the room. Questions, comments? Yes, Steve. Well, first of all, thanks a lot. Does everybody know Steve Lubey is relatively new, although we're not going to be able to say that for much longer. Does everybody know Steve Lubey who's joined Stanford, works very closely with Michelle and the Woods Institute and Freeman Spogli and anybody else that gets their hands on him, but is a world-renowned researcher on young child's infectious disease in general, but particularly water sanitation, child development, diarrhea, many years working in Bangladesh and in areas of significant political instability. So he's an amazing resource that we now have at Stanford, so sorry about that, but they should know who's talking here. Oh, and I was going to make a comment on your font size. Whatever, I'll take it. This is a, it's a very compelling presentation precisely because of your focus via birth of disease and birth of disease and childhood. And the idea both that we have access to mortality and that mortality is preventable. I am interested as you think about this gradation between what we think of as preventable in a more stable low-income country environment versus what is preventable in the setting of chronic conflict. And of course that is likely a continuum too. You have talked specifically about immunization as being something that you might be able to parachute in or do with less infrastructure and you can think about maybe deworming vitamin A maybe in that same category. Those would be good. But some of the other responses in terms of clean water provision or the kind of community organization that you're working on in the highlands of Guatemala, that's not going to be as applicable in the least stable settings. So I guess what I'm trying to conceptualize or would like your opinion on is do you see this as a flexible proportion of what is preventable and if you're a little bit more realistic in fact is your preventable fraction have to be adjusted given the context. I was with you until you used the word realistic because my view is the response is well, be realistic, you can't work in any of these areas. So I just want to... What's realistic is we don't know what's realistic because we haven't tried to do these things in these areas. But clearly there's going to be considerable both quantitative and qualitative barriers to provision because of the political requirements of provision. Putting in a water system or creating C-section capabilities is going to be a much more complicated, more difficult thing because of the technical requirements. So it puts a larger burden on the political side because of our technical needs. Immunization, you sort of zip around with the refrigerating, it's not that easy, but it's a lot different than reducing maternal mortality through the maternal mortality C-section, putting in water systems. That's true, but I wouldn't write off any arena of health provision as being unrealistic. I would say that the challenges are more complex and maybe more profound, but there may be opportunities we don't know until we do it. I think this is a wide open field that has not been explored. So I wouldn't write off any part of that 63%, but recognize as you point out that our approaches may have to be different and may be far more difficult to approach that. But the other, the flip side is it also tells you something about the role of technological innovation could play. If all of a sudden maternal mortality reduction wasn't so technically complicated, misoprostal is a technical intervention that has been around for a while but is now being developed for direct utilization, off prescription in areas with a lot of maternal hemorrhage, postpartum. Well, all of a sudden you took something that was unrealistic to deal with because how are you going to deal with postpartum, you have no transfusion, what are you going to do? All of a sudden, boom, you turned into something that's relatively easy to do, even in a politically complicated environment. So it's very dynamic and that's why I wouldn't write off anything but embrace it and hit the wall, explore it and there may be ways that new design, new technologies, but also new political approaches may liberate the technical parts and ways that we can foresee right now. Paul, you talk about integrating politics with health and so I'm going to play a little bit of a flipside and MSF is famous for trying to not integrate politics with health and could you comment a little bit about how we managed to integrate politics with polio vaccination with the Osama Bin Laden assassination and now we're seeing what happened. Right, okay. There are two separate things I would say. One is the issue of can you really develop health care provision in these areas without taking into consideration political barriers. The second is as health workers should we remain neutral politically in order to protect ourselves and the services we provide. I see that as two separate things. In fact, the statement about neutrality is in fact a response to the prior category of engagement where you know enough about the politics to say we need to be neutral because otherwise we're going to run into trouble. What Michelle was mentioning was that I don't know if you've seen Zero Dark Thirty or any of the other million movies that were made about going after Bin Laden but the allegation is that the CIA tried to get DNA material from people living in that compound in Abadabad by a doctor going in doing immunization campaign and to get DNA that way. And of course when it was found out or at least when it was alleged it put a hold on all the immunization programs in the area. In fact, in some measure it has helped to generate actual killings of immunization workers in parts of Pakistan and Afghanistan. MSF and others always try to remain neutral and in many areas they've been very successful and it permits health workers to act somewhat protected. However, it also fails a lot as well just a couple weeks ago in the Lancet there's a whole series of articles on protecting health workers in politically unstable areas. Raje, I hope you talk about this a minute dealing with implications in the Arab world for health care workers in areas with a lot of civil conflict. And in general it's basically been a useful approach. However, it may be when you look carefully at that it's more legend than reality about how protective it really is. And it's again worthy of consideration but in the end it may be the best strategy to protect health care workers and solutions in areas that are politically unstable. I don't know, Raje, you had a comment? Yeah, sure. So I mean overall the theory of change that I think you're operating with is in situations of unstable governance you can avoid working through these governments that are either non-functional or not concerned about their population by taking interventions that somehow promote local collective action. And sometimes that means community intervention sometimes it means using technology and that's how I understand the theory of change. The one major obstacle I think to that is that a lot of times especially in conflicts that have higher level powers involved in them the degree of surveillance that's involved is what really limits local community action. And I think we've seen that in a number of settings and I think probably not yet in Guatemala the interventions work there but throughout the Arab world what you see is the main limitation on local community action doctors going to help people where they otherwise would is they're afraid that their government is following them is tracking them and puts them at risk and they're using sophisticated technologies to do that. In other settings like in Gaza which you mentioned in Pakistan where there were forties recently helpful on that you're seeing that the use of drones surveillance drones is what's actually limiting community action local collective action everyone keeps themselves cloths themselves off and that leads to help people fall apart and really no local collective action to replace the total governance failure and so I know the part of what you're trying to do is use new technologies to get around that but I also wonder about interventions that either shut down or eliminate some of these surveillance technologies that are the problem in the first place. Right, I didn't mean to imply that the secret ingredient is local community organization that's why we're working on sanctions and much broader governmental approaches that would include discussions about drones in areas increasingly number of areas that are being affected as well as a whole variety of other activities that should be discussed really at governmental levels at state levels but I also feel that there are a lot of non-state actions that particularly in the healthcare arena that could also be operating that we need a comprehensive a heterogeneous pluralistic approach that recognizes this is a very dynamic activity so I totally agree and that's why the sanctions are up there and why I even raised Gaza as an issue however I think that the world is changing very fast and a lot of places around the world are evading governance failures or coercive governments through new technologies that particularly places like Stanford can begin to make a difference while we'll still have to be working on the protection of civilian populations through just war theory and related mechanisms but there's a whole new world operating particularly at the level of the provision of healthcare services that are also worthy of consideration I think we're sort of at time now but I want to thank Paul for very provocative and hot topic in global health thank you very much