 I've been asked, what is a doctor doing here at SoCAP? What am I doing up here on stage? The short answer is that health and illness are not what I was trained that they were. I took my first job following my pediatric training in East Palo Alto, which for those of you who know, it's a small town in South and San Francisco. It's one of the poorest communities in the Bay Area. It's mostly first and second generation Mexican-Americans now. And after 25 years of training, medical school, residency, college, I took an extra year of residency just to make sure I knew everything. I was really ready and excited to be a doctor in the community. So it was a little bit of a shock when I realized that medicine is not what I thought medicine was. So I was there, I gave vaccinations, I checked for anemia, I checked lead levels, I screened, eyesight, and hearing. But it turns out that that's not the issues that were facing my families. The families I was working with were facing financial issues, insurance issues, language issues, immigration issues, nutrition. Often the cheapest, most filling meal for a family was the McDonald's across the street from the clinic. Transportation was an issue. My families, I get them an appointment at Stanford to go see a specialist and they'd miss the appointment because their friend who had a car broke down or the buses weren't running on time. Housing, I found myself as the doctor in the clinic writing letters to landlords to get windows fixed for kids with pneumonia or to get the carpets replaced for kids with asthma. Families were homeless. These were the issues that were really facing them and I had not been trained in any of this. So the first thing I want you guys to remember today is health is not healthcare. We tend to conflate those things here in the United States. We use the terms interchangeably and often replace them with one with the other. Healthcare is really medical care. In fact, I often tell my medical students that if you're healthy, if you're not sick, by and large you don't need to see a doctor. You don't need to interact with the medical care system. So what are the actual causes of illness? There was a study done a few years ago, about 10 years ago now, looking at what we call the actual causes of death. So what they did is they looked at death records and said, well, let's not just look at whether it was a heart attack or pneumonia. Let's look at what it led to the heart attack and led to the pneumonia. And what we found was that medical care really only accounted for about 10% of the total illness. The real issues were the things that I had been seeing. Social circumstances like poverty, not enough family support, physical environment, toxins in the community or in the home, behavioral choices, drinking, drugs, whether you stay in school, those sorts of things. So what is health? One definition, which actually goes back to 1946 and credibly is quite good. It's from the World Health Organization. They define health as the state of complete physical, mental and social well-being, not merely the absence of disease and infirmity. Another way of thinking about it is that your body is the sum total of the opportunities and challenges you experience through your life. And that is what adds up to health. One of my mentors and colleagues at UC Berkeley has described this as being a road in the mountains, a curvy road with lots of bumps and potholes and sometimes you're watching the road and sometimes you're not and there's sharp turns. And there's a particular spot where people often don't slow down quite enough and go careening off the cliff. And the car ends up in the bottom of the valley. Terrible wreck, horrible injuries, happens over and over again. Finally, the community at the bottom of the valley says this is too much, we can't take this. So they build a clinic to help the people who are wrecking their cars. Pretty soon they say that's not enough. Let's get a hospital, so they build a bigger hospital. They bring in specialists, they bring in ambulances, let's get them more quickly to the new emergency room we just built. Let's bring in MRI machines and CAT scans and technology. This is effectively what we've done in the United States. We've built a hospital at the bottom of the cliff. Now it's true that in the developing world, although the road is as curvy or curvier, they don't even have the clinic at the bottom. So there really, there is some variation across the domestic and global sense of health and healthcare, but the road is the same. So the question is if medical care is the hospital at the base of the cliff, what's making the road so difficult to drive on? So the second thing I want you to remember is the term social determinants of health, okay? This is a term we use in public health and it attempts to define what it is about life that makes staying on the road so difficult. So the World Health Organization had a commission a few years ago to try to think about this and they acknowledge that healthcare and access to healthcare is in fact one of the social determinants of health, sort of as we talked about, but the real causes of illness are the conditions in which you are born, grow, work, and age. So what are those things? It's kind of a crazy picture here, but it kind of gives a range. It's the things the families I was seeing in East Palo Alto were dealing with on a daily basis. It's not good enough job, not enough income, unstable family, maybe a single parent, low quality education, lack of transportation, violence, racism. These are all the things in the daily life that influence you. And in fact, the reason I like this particular image is because for two reasons. One is it's a baby and we know that the social determinants of health are much more, have much more impact early in life than they do later in life. They always have an impact, but children are particularly vulnerable. The second issue is these arrows look like they're actually going into the child. And there's, that's really a very recent idea that these social determinants of health actually enter the body. We say it gets under the skin. This is the idea of toxic stress. Okay, and you've got a couple of images there of different sort of types of stress, sort of situational. Toxic stress is not the kind of stress we experience choosing between two job offers or that a pilot or a surgeon might experience or someone might experience standing on stage talking about toxic stress. This is the kind of stress. It's all those situations, you have some control over why you're there, how prepared you are, whether you want to make that choice today or tomorrow. Toxic stress is the lack of all those things. It's a real lack of control. You can again sort of see those picture of the children there. You don't, your day to day life is irregular. There's no consistency. This builds up in the body and wears you down. And it actually alters your biology. This is what we're really beginning to learn now. So the immune system is affected. The ability to fight off infections. The ability to fight off cancers. The causes inflammation. So asthma is an inflammatory disease. Cardiovascular disease, so heart attacks are related to inflammation. Neurological development, so mental illness, children's learning, their ability to concentrate, their ability to modulate their emotions, their ability to make decisions are all influenced by these early toxic stress. And you can imagine those skills, those learning skills are really important for school and for jobs. And if those don't develop properly, you're set off on a bad trajectory. So the third big thing I want you to remember, there's no test. I do want to point out though, if you thought you were leaving here without a graph, you know, I am a professor. So we have to have at least one graph. So this is the idea of gradients, okay. That's because toxic stress affects all of us. So what we have here, this is a study that was done a while back. I forget how long, 15 years ago now. And was looking at a guy named Sir Michael Marmot. He's a knight now, in part because of this work. British guy was looking at government employees in Britain. And he was looking at the highest paid, what they call administrative, which is the CEO, president level, okay. And comparing them to the semi-skilled and unskilled. You might think of a janitor or a gardener. I was looking at the likelihood of dying prematurely. And what you can see there, is there's a fourfold increased likelihood of dying before 65 for the lowest status of jobs. That's pretty remarkable. What's more remarkable, what shocked everybody was this professional and executive class, just one step up from the highest. Those are doctors and lawyers. They have double the likelihood of dying early. Double the likelihood of serious illness. The clerical staff, that's secretaries, managers, double that likelihood. So what's going on there? We know it's not having a job. These people are all employed. It's not having health insurance or medical care. They have universal health care in Britain. It's not nutrition. It's not housing. It's not transportation. Presumably their homes are decent. These are, again, these are all employed people. What we believe is that it's stress. It's this toxic stress. They initially said, well, it must just be the British. They're different. So they read at the side of the United States, same thing. They did it in other countries, same thing. They said, well, maybe it's just mortality. Maybe that's the issue. Or maybe it's cardiovascular disease, it's heart disease, because that's the main cause of death. All diseases. They said, well, maybe it's age. Well, this is the same story in children. In this case, the lower income kids are on the left side. You can see these nice gradients go all the way down, okay? The important thing here is that toxic stress affects all of us. And it affects across the socioeconomic spectrum. It goes across countries and goes across communities. And the result is to health disparities, okay? So on the global stage, and many of you would have seen this before, you can see in Sub-Saharan Africa is the blue. That's a lifespan of 40 to 50 years, okay? That's the inability of these communities to be able to tolerate, to have the resilience, to have the financial and social resources to deal with the day-to-day stress. You can see in the dark green, Australia, Europe, Japan, Canada have much, much higher lifespans. Again, because of government policies and family policies and family decisions. But if you think we're getting away from that in the U.S., you're wrong. So here's a map of Washington, D.C. So in downtown Washington, D.C., or central D.C., the life expectancy is 72 years. That's equivalent to Morocco or El Salvador. Out in the suburbs, Norway, 15 to 30 miles away. You see a nine-year lifespan difference. New Orleans is even worse off. Central city, the life expectancy is 55 years. That's equivalent to Zambia and to Aganda. And yet out in the suburb, in other parts of the city, it's higher than the national average. And another issue is this is not just these cities have histories of entrenched racism and social issues. We can look at St. Paul and Minneapolis, one of the wealthiest and healthiest cities in the country. This is actually a nice map. Shows the interstate system. These are exit ramps. Lifespans are different exit ramps. And you see right here, the lower left, three miles apart, 13 years difference in life expectancy. In fact, 83 is higher than any country in the world. So people in Minneapolis who live in that neighbor or that exit ramp live longer than people in Japan do on average. So why does this bring us to Socap? Well, first, Socap addresses social injustices. Going back to that same WHO report, they said pretty frankly, social injustice is killing people on a grand scale. This is one of the most serious social issues that we face as a species, really. Right now, it's unfair and yet true that where you're born, be it East Palo Alto or Lagos, Nigeria, is more important to your life health and your life chances than anything else about you. Second issue is Socap already does health. So I spoke at a panel last year and it was really impressed by the work that was being done to make communities better places to make families more stable, to provide income to mothers in villages around the world. All of those things lead to health. And yet I never heard the word health uttered last year while I was at the conference. So this is a health ROI, return and investment that I think is not being adequately incorporated or addressed or considered in the work that many of you are doing. And I think it's something that we want to try to focus on this week. Third, Socap thrives on disruption. And in the U.S., we are being disrupted quickly. Three reasons I just listed here. One is the current cost of health care. $2.8 trillion a year and we don't even get the best health care or health outcomes in the country or in the world. The middle class swede lives longer than the wealthiest American on average. And although we've seen already with things like the sequester head start being taken away, sort of lefty liberal feel good stuff, head start, maybe some food stamps. At the rate we're going, we're gonna start seeing aircraft care is removed, all cancer research, crop subsidies, things that matter across the aisle as they like to say. There's gonna be no avoiding it. The flip side of that though is think about the opportunities in there. If you shave off 1% of $2.8 trillion, I had to do this calculation a couple of times, $28 billion, just 1%. Health care system wouldn't even recognize it, right? And yet that is $28 billion. It's already being spent that could be spent somewhere else. We're not talking about new money. We're talking about money that is already being spent. Second one is the ACA, the Affordable Care Act, Obamacare. This big change is coming. There's going to start really looking, hospitals, insurance companies are really gonna start trying to keep people healthy. People are gonna stick with their insurance long term. This is a dramatic turnaround and it's gonna have a whole new range of health players, health care players, are going to start focusing on new things. And this is where innovation is needed from all of you because these players don't know how to keep people healthy. They're only good at keeping people, curing people once they get sick. And the third is demographics. The aging population in the US, one more graph, I couldn't resist. We're gonna see a doubling of those over 65 in the next 40 years. And a tripling actually of those 85. And as a colleague of mine at Berkeley said to me, he goes, if you think the healthcare system is stretched now, wait till there are 100 million retirees. It's simply unsustainable. So what we really have to do is focus on getting people healthy, keeping people healthy, keeping them out of the hospital, keeping them needing as few medications for as long as possible. High quality life until the end of life. And as we saw with the social determinants of health and toxic stress, a lot of that ironically has nothing to do with medical care. It has very much to do with changing the daily lives that all of you work on improving. So with that, I do wanna welcome you all. I also want to say that over the next few days we have I think at last count 27 health related panels. It's the largest track this year. Many of them are cross listed with other tracks. We've got some on investment, both global and domestic, looking at infrastructure, looking at innovation. We've got panels looking at highlighting entrepreneurship, looking at technological solutions. Also systems change. Not all solutions are gonna be technological. And we have some overview. The next panel this evening is in health at least, is looking at long-term changes in the health system. We have an ACA panel, an Affordable Care Act panel tomorrow. We're looking at big data. We're looking at what health ROI means. So with that, I wanna welcome you all and thank you for hearing me out and hope we'll see you in some of the health panels this week. Thank you.