 Thank you Joe. Thanks for having me back for the seventh conference. There are a lot of people in this audience or people who have been here that I've worked with or known over the years but I do want to mention a longtime friend Dr. Richard Carmona who's the former Surgeon General and I thank the National Coordinator for Health Information Technology Dr. Don Rucker for being here and I know Congressman Ruda who is a number of Congress was here earlier. I want to thank all the people who are here but especially the patient advocates who have shared their personal and often painful stories and all of you who've been at this now for seven years. Since Joe first made that commitment in 2012 to me at the Clinton Global Initiative and I want to congratulate him at the end of this year he will celebrate his 30th anniversary since he founded Massimo as a young virtually penniless man and what he joked with a garage startup. I think the boy's gonna mount to something if he just keeps at it. I love coming here it's one of the great privileges of my year and I look forward to it every year but it's sort of ironic. I love talking to people who know more about the subject than I do. It seems kind of weird but I like it. I think it's somewhat ironic that of the three members of my family you could have invited to be here. I am the third most knowledgeable person about this subject in my family. One of the people in the photo line told me that he worked with Hillary when I was president on health care issues and I remember at least five different things he talked about and working on and my daughter has three advanced degrees in public health teaches public health at Columbia and co-wrote a textbook which is on the global health how it's funded and whether it does what it's supposed to do which is now in use in many of the medical schools around the world so you're stuck with me but I care a lot about this. I'm grateful that the movement just in the last year alone saved more than 90,000 lives. I'm grateful for the 4,700 hospitals at home and around the world that are part of this effort. I'm grateful that 89 technology companies have committed to share data to develop algorithms and predict dangerous trends and I hope there will be more. I'm very happy that this is increasingly a global effort. The patient safety movement now has 35 regional chairs leading local networks across 17 countries. I know enough just about America to know how much health care challenges vary from place to place. Not very far from here in the Coachella Valley. I started the first health matters initiative and it was a very interesting laboratory because the area is very diverse. It has one big good hospital. It is represented in Congress by a medical doctor who's a Hispanic American who went to Harvard Medical School, grew up in a poor family and went home to practice medicine and it has the richest and the poorest Californians in the same area. So I learned a lot in the years that we work with them. They aged out of the project. After five years, I think we've done all we can. But I learned how different the challenges were and we've gone to work in Little Rock, my hometown, and in Houston and in Jacksonville and in rural Mississippi and other places and it was amazing when we went to Jacksonville which had some really great projects but one of the things they asked us to figure out was what they could do about pedestrian deaths and it turned out that they had the second or third highest pedestrian death rate of any urban county in America. And when I went there and started looking at it, we figured out why because it's a city county government and it's not clear when you leave the city limits and then all of a sudden you're in the country and anybody that's on foot is in danger because people don't expect people to be out there where they think they can be driving 55 or 60 miles an hour. Anyway, you can multiply that manyfold by the variety of conditions that exist and challenges. So I think this is a really, really good thing. I'm going to keep my talk fairly short because Joe always has interesting questions and I find that when you're answering questions, even if people don't agree with you, at least you're talking about something they're interested in, but I think it's important before I do that to do what I can do as a lay person who's cared about this issue for well over two decades. It is really important that you continue to do this. The rate of increase in saving lives has slowed down some this year from last year and that is perfectly predictable because any sensible effort of this kind picks the low-hanging fruit first and then to really get the numbers down of avoidable deaths, you have to deal with diverse systems, diverse cultures and at least conflicting perceptions of economic and professional interests. So my most important message is, please stay active in this, please get more people active in it and don't give up. I've reached the age now when I'm the oldest man in my family for three generations. Every day is a gift to me and I'm trying to spend the rest of my life making sure that people younger than me don't die before their time and have a chance to live their dreams. And it's a big problem that 200,000 people still perish every year here who might not have to die. And the number of worldwide is much larger, of course, estimated almost five million. So I think this is important. I think the fact that you keep adding new topics is encouraging. I saw you dealt with the importance of embedded a curriculum on patient safety and all the major educational programs in the country. I think that is very, very important. I think it's important to address drug shortages of all kinds. It's bad now and I think the problem is likely to get worse because of the variety of mutations of bacterial infections and sepsis problems and many other things that are going to make it harder. When I first saw you were also going to add a study of delirium. I thought, my God, you're going to talk about the contemporary political system. Finally, he's picking. He's finally finally there's a subject I'm an expert on. But when I read it and I realized the differences that I can tell as a visitor to hospitals to people's reaction to severe surgeries, for example, by age and other variations, I think it's really, really important. Near the end of my second term in 1999, well, no, earlier than that, at the end of my first term, I established the Commission on Consumer Protection and Quality Care that produced a really landmark report for the time on patient safety. And then I issued executive orders to provide basic patient protections to everyone enrolled in any federal health care plan. That's Medicare, Medicaid, a children's health insurance program, the federal employee benefit program, the Veterans Hospital Network, and the US military systems. And at the time, it was about 84 million people, as I remember, in a country that at the time was at about at about a 280 million population. It was a big chunk of America. And I think it made a difference. Then near the end of my second term in 1999, to coincide with the release of the Institute of Medicines to Errors Human Report, it really brought for the first time widespread attention to this issue. We had a federal task force set up to issue very specific recommendations about how to improve health quality and patient safety. We required 300 plus private health clans that were participants in the federal employee benefit program to institute quality improvements in patient safety initiatives. And we reauthorized, believe it or not, in a bipartisan way, where the Congress then in the hands of the Republican Party and the White House in the hands of a Democrat, the Agency for Health Care Quality and Research to ensure that there would be a continuing multimillion dollar investment in research on this issue. So I have followed it all this time. I loved it when Joe Keane stood up for the first time and said his goal was to eliminate all preventable patient deaths. And if possible, do it by 2020. Like so many goals. It's easier to say than to do. Doesn't mean it's a mistake to have a goal. You just remember that it's whatever the numbers are this year and next year. In all probability, at least half of them would not have occurred had it not been for this intense effort that has been made by all of you for being part of this group and for working in the way that you work in your own lives wherever you live. Changing systems and cultures is hard. It's also hard to explain to build popular support for unless you happen to be someone who's lost a loved one in the hospital or in some other way that was entirely preventable. As a play on the 1999 report's name, I think one of Joe's greatest quotes was, to err is human. But not to put in place processes that can eliminate preventable deaths from human error is in humane. We need the patient safety movement. We need to bring people together who are stakeholders in every conceivable way. And everyone should care about it because it affects us all. Each one of us is bound to be patient at some point or our family members or friends or neighbors. Just in the last year, I've had two rather amazing examples of the simple power of an increased awareness of avoidable hospital infections. My brother-in-law at 64 lost his lung capacity and lost over the next 70 days, well, 85 days, almost 100 pounds in the hospital. And he was on an ECMO machine for 70 days at George Washington Hospital. The doctors told me they'd given up several times. They said they'd never had anybody his age and his condition. Stay on that machine for 70 days and live. One of the reasons he did was everybody including yours truly, that got in that hospital room, was their hands at least four times between the time they got to the hospital and they left. They were... And then the man who runs my home for Hillary and me in New York had to have a heart valve repair. And I went to see him twice and now the masks that I had to wear not only covers my nose and mouth but it protects my eyes and protects them from me and me from them. Little things. But somewhere in our country today, someone will not get an infection which will kill them if it hadn't been for protections like that. And that is very, very important. It's also important to say that when we stop people dying from preventable complications from sepsis or other health-associated infections, mistaken diagnosis, adverse drug reactions and other errors, we not only lift a life, we ensure the viability of our health care system. Couple of months ago, an article in Health Affairs suggested that we are in many ways still in the Bronze Age of medical error reduction. It's an interesting piece. I don't have enough professional expertise to know whether every assertion made in the article is right, but I do know this. As much money as we spend on health care, we ought to be able to reach the gold standard, not stay in the Bronze Age. Again, I want to say I want to thank the patient advocates who are here and those of you who've lost loved ones, particularly I want to thank you. A couple years ago now I had to speak at the Memorial Service here in Southern California for a friend of mine who was 53 years old and he did not die, I don't believe, of any hospital error, but he did contract an infection when he was in France. He came back here to the best health care and he died with the infection never having been identified. There are going to be enough problems like this as it is. We need not compound human mortality with our own errors and I think we need not start with finger pointing. A lot of you know my mother was a nurse anesthetist and I want to thank the anesthesiologists for their sponsorship of this effort too, but I could count on one hand by the time I went off to college and my mother retired, how many patients she'd lost on the operating table where a mistake by her or the physician could have played a role. She never got over any of them. She knew them all, she knew their names, she knew their family situation, she lived with it her entire life. Nobody gets up in the morning and goes to work not caring about whether someone dies because of an accident or an error. People want to do the right thing. They want, people get into this kind of work whatever your role in it is so that people can live longer healthier lives. So I appreciate the fact that the patient safety movement asked people to assume responsibility without pointing fingers. It looks at systems that fail, networks of communication that should exist but never have, silos that need breaking down and networks that need building up. In other words, better ways to cooperate. This is again easier to say than to do. I'm well aware of the concerns that are often cited as barriers, the cost of high-tech systems for hospitals, proprietary interest, liability, privacy issues, the ability to finance innovative research in the pharmaceutical industry, providing medicines in adequate volume at affordable prices. But the only reasonable way we're going to be able to deal with this consistently over time is to have both a legal framework which incentivizes good behavior and disincentivizes bad. But to recognize that denial and neglect is not an answer. That avoidance is not an answer. That you have to bring in all the stakeholders and we have to find a way to work together. If you do it, it may cause a little more in the short run but it would be worth it to eliminate liability concerns lower costs and maintain financial incentives for continued investment. And this is like a broken record. I've been saying this for more than 20 years now but I remember once I went to a Tina Turner concert and it was Tina Turner with an abused wife had been totally mistreated, had been receded into the shadows of American pop culture and she had a rebirth in the 80s which continues to power her today and she's nearly 80. But she sang all her new songs and then she got to the end and she was going to sing her first hit, Proud Mary and every time she got up to the microphone while the band was playing the introduction the crowd would cheer and she finally said, you know I've been singing this song for 25 years but it gets better every time I sing it. So I've been saying this a long time like a broken record. You can have all the separatist tribalism you want all over the world but in the end interdependence is not an opinion it's a fact. The interdependent eco structures and human behaviors of the earth are causing the climate to radically change. You can deny it all you want but if you look at what the insurance companies are requiring of coastal cities people that make a living measuring risk and are not interested in ideology or entrenched interests are telling us that they already know it. I'm about to go down to Puerto Rico to spend four days trying to help rebuild Puerto Rico the Virgin Islands and the little island of Dominica from the horrible storms they endured and and the only thing that works in an interdependent world is if you get all the stakeholders together much of the distortion of the American economy is rooted in the fact that beginning probably in the late 70s but in full force by the early 80s we developed an idea that was totally alien for decades in America which is that an American corporation owed its primary duty far and away only to the investors and that they were far more important stakeholders than customers employees and the communities of which they were apart. Worked out great for the people running the companies whose pay was tied for the to the stock price but it left a wake of slowly developing rage and that's part of what's causing a whirlwind all around the world with the level of economic inequality and social displacement and psychological isolation. So I will say again in an interdependent environment where divorce is not really an option the only decision is to define the terms of interdependence. Look at all this Brexit problem even if they passed the Prime Minister May's plan they weren't really getting a divorce they were redefining the terms of their interdependence and so you just have to decide but for me if you're stuck in interdependence it's much better if everybody's rowing together. I think notwithstanding the momentary political emotional and psychological rewards that came from the successful expression of resentment or whatever addiction is still better than subtraction and multiplication is still a hell of a lot better than division and in the end we will either do what we have to do or we will put our whole species in peril. So I believe that even though it's going to be difficult for you to explain most of this to a popular audience we are now told that the average attention span of somebody for an item on the evening news is eight seconds. Butterfly limit is nine seconds. We're laughing but it's true isn't it we all want to do something else. I love the TVO program so I don't have to watch the ads. I mean just anything to speed it up whatever it is just speed it up. Sometimes we need to slow down take a deep breath and analyze. What's the problem what are the constituent parts who can fix what what are we going to do in what order. You know that's hard work and hard work is boring if you think that contests should be entertaining. A lot of the Romans like to go to the Coliseum and watch people eating by lines. It was only entertaining unless you were one of the people being eaten by the line. But if they hadn't stopped it sooner or later they'd have run out of people. When people come together in common cause they don't always reach a hundred percent success rate human nature being what it is and the problems being intractable but it's always better than it was and I don't want any of you to get discouraged. And when you're dealing with a complex health care or education challenge or an economic challenge there is almost always a way to make things markedly better and make it better economics. I'll just give you an example I got started when I left the White House. There was no funding for AIDS except what governments appropriated on an annual basis. United States was giving 300 million dollars a year and I left my last budget had 600 million and that was more than 25 percent of what the whole world was spending at the time to give poor people medicine which was much more expensive than it is now. And since there was no money Nelson Mandela and I agreed to co-chair this group of former heads of state who freed from the bonds of politics and go around and tell everybody else what's good for them. But we did it and we rattled a tin cup and we raised some money but I thought there's got to be a better way so I went to five different countries beginning with Ireland and Canada and got them to promise me that they would allocate 20 million more dollars a year to provide AIDS medication and care and countries they could choose and that I didn't want any of the money I just wanted to let me turn on or off the tap. And then I went to countries that wanted it and I got them to sign a no corruption pledge and then I went to the manufacturers of the generic medicine most of whom were in India with constituent elements in the medicine mostly coming from China and I said look you're charging $500 a year we're paying $10,000 a year at my age clinic in Harlem just around the corner from my office but so 500 sounds like a little bit of money but I said if you live in a country with a per capita income of less than a dollar a day and a heavy AIDS population and no real revenue base for your government it's not very much money. I mean it's not it's a lot of money and there's not very much capacity to pay for it so I said I would like you to consider changing your business model. These guys looked at it and I said so what do you mean? I said you're charging 500 bucks I said how much is an extra pill cost you? I said what if you could sell 10 times 20 times 50 times as many medications how much would you sell them for? I said you're running this like a small-town jewelry store. A global health epidemic you know I used to buy my mother a little Mother's Day presents when I was a little boy and the family that owned the jewelry store always had tough kids could buy it cost a buck or two take home to their mothers but I looked around in the jewelry store and they always had more watches than they could ever sell more bracelets than they could ever sell diamonds what do you do if somebody returns the engagement ring? You know think about it you have to have a big inventory so you have to have a big markup because you're a small independent business person and people start defaulting on the payments and you're not in very good shape I said that's why you're running this because the payment business is so uncertain the supply chain is not very efficient even some of your manufacturing processes could be better suppose we had a good supply chain and you had automatic prompt payment and you increased your volume then you should run it like a big grocery store a big food store we have huge volume and low per unit profit margins so we started and we went from 500 to $190 to $160 and got it all the way down to $90 the children's age drug started at $600 with fewer elements because the volume is smaller we got it all the way down to $60 and I gave them my word and at the time I had done a lot of work in India they took it I said I promise you if you don't make more money I'll change the contract you have to make money because it's not sustainable otherwise then comes the global fund and PEPFAR and one of the funny stories of my breakthrough and my relationships with the Bush family which became legendary with the passage of President George HW Bush we were all going to the post-general both the Bushes and me and the younger president Bush said tell me what you're doing with AIDS so I told him and he just passed PEPFAR and he said well my god tell me it's generic medicine doesn't work I said oh yeah it does I said their most extreme claim was that it's only 60% is effective but since their drugs are more than 10 times more expensive than ours will still save more lives if we do it my way I said I'll make you a deal I will take every drug we sell put in any human body anywhere in the world to give it to the American FDA if they approve it will you I said I don't want any money I never take any American government money I said if they approve it will you say to these countries it's okay with you if they buy the medicine he said you got a deal immediately the FDA approved 22 of the 24 drugs so then we were off to the races now now today there are 27 million people on antiretrovirals in developing countries up from 200,000 in 2002 we started 20 million and a significant majority of those people are alive on contracts negotiated by the clinton health access initiative and even more important it became morally and economically impossible to maintain a massive price differential between what they were charging us and everybody else so it collapsed the whole price structure and they're all making more money and it's got to be a way to do that Joe and I were talking before we came up here about this shortage of insulin we have in America at a time when the life expectancy of people in middle America it's still dropping because of the combination of opioids alcoholism suicide and the consequences of obesity especially especially type 2 diabetes but we have to find things that we can do together because if including protecting intellectual property for a reasonable amount of time under reasonable circumstances but because you you can't we got to find a way to do the things that work for more people and we got to really make up our mind every one of us especially when it comes to transparency and other uncomfortable subjects that we're going to go from the Bronze Age to the gold standard and prevention and so when you go home that's what I hope you'll think about will we go to the Bronze Age to the gold standard I hope you will commit to all 17 of the actionable patient safety solutions if you're from one of the companies that signed the open data pledge I thank you look this transparency again it's easy to be for as long as you're talking about somebody else taking their clothes off I remember in the campaign Hillary and I gave 38 years of our tax returns up and the foundation we decided we would tell everybody in the world every person who had ever given us any money and exactly what the money had been spent on all of it every year and you know this stuff can be misused all of a sudden I learned that the Secretary of State gave appointments to 10 people who had given me money in the Clinton Foundation obviously a terrible thing two of them were Nobel Prize winners they won the Nobel Peace Prize and all the others are people that any secretary of state of either party at least so far would have seen for good and sufficient reasons so if you're transparent you can get white but somebody's got to take and fly and leap if you want to reach the larger goal so that's my pitch I know it's hard work to change systems but I know if you do it it is the most rewarding thing in the world and think how you will feel particularly those of you who are younger 20 years from now I've looked into just before I came out west I faced time with our two grandchildren and I thought I thought about coming here and I thought you know if if before I die I could just know that my grandchildren they might have a plane crash they might have a car wreck they might develop some terrible unknown illness but at least they would never die in a hospital because of preventable error I would be much more at peace at least they would have their chance to live their dreams smartest person in my family when I was a little boy was probably my great uncle who had a sixth grade education and when he was in his 80s he could still remember the names of the bird dogs he'd owned 60 years earlier he could still go corn higher than my head and when his wife was fourth out of their home because of her Alzheimer's for several months she knew who she was for 15 minutes a day and she lived in this little adjunct set of apartments we had that was connected to our hospital it was a great thing for the little town I was born in and how the 11,000 people it was really nice and she would call him and say we've been married 56 years and you've left me over here in this dump I never seen this place before get over here and take me home my uncle by the way it had a lung removed in the 1970s and was one of the 15% of the people that survived lung cancer back then so every day he would get in the car and he would drive to see her and every day for two months the time he got there she didn't know him anymore but he did it my uncle was so smart one day when all this was going on I was a young governor I went to see him and it got dark and I said buddy I got a home go home I got to take Chelsea to school in the morning and I got some work to do tonight and he walked me to the door and usually we were just joking and he was telling me jokes and telling me stories and filling me in on the latest gossip in this little town where I was born and he grabbed me by the arm and I turned around the only time in my life he lived to be 91 years old the only time I ever saw him cry he had big tears in his eyes and I said this is really hard isn't it he said yeah but I signed on for the whole load and most of it was pretty good with the best statement of love I've ever heard but also the best statement of being able to accept the rhythms of life it's passing quick enough as it is we shouldn't get in our own way anymore than we absolutely can't avoid and there's still a lot that we can avoid thank you