 This is now officially our first pure health panel. Let's start off our week. So we have an hour here. I want to introduce myself. My name's Doug Judy. I'm a pediatrician and a public health professor at UC Berkeley. And I have the honor of convening this panel here. And I am the content leader for the health track here at SoCAP this year. And this first panel, as we title the Changing Landscape of Health, what it means for investors and entrepreneurs. It's really an opportunity here to bring several of the primary sponsors and both thought leaders and financial supporters within the health track here on stage to hear, to talk about what's going on in their institutions and in health in general. But first, to start out, what we're going to do is Risa Liviso More is the CEO and president of the Robert Wood Johnson Foundation. We're going to provide her an opportunity to speak by video. She couldn't be here in person. So Risa's been president and CEO since 2003, so fully a decade at the Robert Wood Johnson Foundation. And she's an interesting person because her background, she has an MBA from Wharton, as well as an MD and is a practicing geriatrician. So the combination there is really unique. So I think we'll tee up the welcome from Risa, and then I'll introduce our panelists. Welcome to SoCAP Health. I'm Risa Liviso More, the president and CEO of the Robert Wood Johnson Foundation. First, let me just say thank you. Thank you for wanting to make a difference and for believing that change is not something that we should wait for, but something that we should be willing to and daring enough to create. Robert Wood Johnson Foundation has spent 40 years believing that very same thing. As America's largest philanthropy dedicated solely to health issues, we've tackled tobacco, we've taken on child obesity, we've wrestled with the value, quality, and accessibility of health care, and we've done it because we know that the well-being of our society and the vitality of our economy depends on connecting purpose with action. In other words, we're your kind of people. I think I speak for everyone on this panel, and I say that we're all eager to help you connect with the communities and the networks and the innovative thinkers on the front lines. In fact, we can't wait to help you. As you heard earlier, many of the serious health challenges our nation faces today have little to do with what happens inside a practitioner's office and have much more to do with the everyday aspects of people's lives. Persistent gaps in income, education, housing, neighborhood infrastructure are damaging the health of our people and the potential of our country. In far too many cases, the length and quality of a person's life has as much to do with zip code as it does with genetic code. These disparities are moral issues, but they're also economic issues. For example, when you introduce a grocery store into an urban food desert, you're not just improving health and providing healthy fare to families. You're also creating jobs, tax revenue, and community cohesion. It's all connected. We know it and you know it. And at my foundation, we're working to create a national culture of health that enables all in our diverse society to lead healthy lives now and for generations to come. And we're doing it by bringing together agents of social change, arming them with evidence-based research, and then giving them room to innovate for the greater good. So we're thrilled to welcome you to that table. Let me leave you with the words of an African prophet. The best time to plant a tree is 20 years ago. The second best time is right now. So let's get to work. We don't have any time to waste. Thank you for your attention and have a great conference. So you can see why we wanted her here, even though she couldn't actually be here. She's an amazing speaker and a real inspiration. So the goal today is to talk a little bit about the changing landscape of health and healthcare in the country and how that is affecting the institutions we see here up on stage and what the opportunities are gonna be for innovation, entrepreneurship, and investment going forward. So I wanna just give a quick introduction of each of our panelists. My plan is to ask each of them a question once we've done introductions. They'll have like three, four, five minutes to give their initial thoughts. Then I've got a couple follow-up questions for the panel. Some may come up from the discussion. And that actually is gonna take a good portion of our hour. So I wanna make sure we leave about 15 minutes if we can at the end for questions from the audience. So be thinking about what you might ask our panelists as we go through, okay? So first to my right is Jim Marks. Jim's at the Robert Wood Johnson Foundation. He's gonna be speaking on behalf of RISA. He's Senior Vice President and Director of the Health Group and has been there since 2004, so a long time now. He retired previously, he was Assistant Surgeon General after serving as the Director for the CDC, the Center for Disease Control, not Community Development Corporation. The Center for National Center for Chronic Disease Prevention and Health Promotion. Next to him we have Carl Hoffman. Carl's actually a former ambassador to Togo and has been at the PSI, Population Services International since 2007, and brings our global perspective to our panel today. Next to him is Tony Eton. Tony strikes me as potentially the person with the most letters behind his name as a doctor or lawyer and a public health professional. And he served as the Director and County Health Office for Alameda County across the Bay for a number of years before coming to the California Endowment in 2009 where he's Senior Vice President for Healthy Communities. Kimberly Cornette is next. She is the Director of Social Investment Practice at the Kresge Foundation, which is based in Detroit. She's been there since 2009 and before that she worked for the Enterprise Community Investment Company, working in real estate investment for affordable housing and community development. And last we have David Erickson. David's at the Federal Reserve Bank of San Francisco. He runs the Center for Community Development Investment and is the Editor of the Community Development Investment Review, the journal there. And is unusual at the Fed because he's actually not an economist, he's a historian. So he brings a little bit of history and economic perspective to our panel here. So with that, we'll start with Jim. Thank you, Doc. So the question I wanna ask, aha, let's see if this is the question you prepared for. I'll find out if he was paying attention on our call. So what do you see as the three biggest changes occurring in health and healthcare in the United States now and what opportunities and challenges do these changes present for the Robert Wood Johnson Foundation? A little bit different way. I think we're at a real inflection point in health and healthcare. It is very clear that the healthcare system we have cannot be fixed with changes at the margin. It is so badly broken. We are investing an additional $100 billion a year than the previous year and we're losing ground compared to other countries. They are simply getting healthier faster than we are. So we've got to find a different way to create health. And what we're starting to see, I think, so one of the key changes is a much broader vision of what health is and where it comes from so that it begins, is nurtured, is protected and preserved in our communities. And that the likelihood of initially becoming ill or injured is practically unrelated to good quality medical care. It is really about where one lives, learns, works and plays. Whether one smokes, how active a person is. The food that they eat and how much of it. The toxins or microbes they're exposed to in their home or their workplace. Safety of a neighborhood. Things that are all outside of medical care turn out to be the biggest drivers of health, especially of a community. That means we have to look elsewhere for improving our health than medical care like we have. The second, I think, is the recognition about how central inequality is and disparity. In the lead up to this session, Doug showed a graph that the mortality among workers was four fold difference for those that were at the highest level positions versus those at the lower level position. What was missing from that graph was the mortality for those that were unemployed or uneducated, came from broken difficult families which would have been even higher. We're seeing that in this country, we're seeing that grow such that income inequality is an area getting the attention but make no mistake that really affects health of people and we've got to capture and turn that around. We're seeing it in differences between communities. We're seeing it in differences within communities. But for example, if you don't know, life expectancy among women has fallen in 43% of the counties in the US in the last two decades. Who would have thought it? Who would have thought it? We are now, our life expectancy for people under age 50 is so bad that we are further from the second worst developed country than the second worst developed country is from the best. We have got to change where we think health comes from. So what does that mean for you? It means that as we work to create a culture of health in our communities, businesses are starting to get it. So they're looking at where healthcare costs lower. How can they help a community become a healthier place? For example, VW built a new plant in Chattanooga, Tennessee. They went there not because of health, they went there because they got tax breaks and all of that, but they chose Chattanooga because it was among the healthiest places in that state. They built a 10,000 square foot facility for their employees, decided to open it up to the community as a whole as a place to be active. We're seeing more and more businesses include the healthiness of the community as one of the decision points in where to move. Civic leaders, mayors, and others are seeing this as the way to make a community an attractive place to attract business. Of course, the risk is that that makes an already disadvantaged community even more so. But if they don't know that this is what's happening, they won't be able to create the changes. So, we see incredible opportunity opening up to both create and harness what is necessary for our culture of health in our community because in fact, we're not able to do it within our medical care system. We've gotta do it outside of healthcare. Great, thank you. So now we're gonna go a little broader. We're gonna go international. So Carl, tell us what you can about the dynamics. What's going on in the global health space? And because a lot of folks here are in the business of improving lives, where do we see or where do you see the opportunities to cut across sectors and silos in this effort? Right, well thank you Doug. And also thanks for your leadership in bringing this health stream to be part of SOCAP, which I think is very important. Global health is really about the 95% of health consumers that live outside the United States. And in terms of the work that my nonprofit does and others in our space, it's really looking at the two billion people or so around the world who are, as you described a little bit in your opening discussion, are saddled with poor health situation, poor economic outlook, poor social outlook, are victims of underdevelopment and are not gonna escape that without some external assistance. You know, there's a lot of skepticism in the United States about what is often termed foreign aid or foreign assistance. But you had a statistic in your opening comment there about what a difference 1% improvement would make in terms of the savings in what the US spends on health care. And you know that 1% represents more than the United States spends every year on every aspect of our engagement outside this country. Every aspect, our diplomacy, our international development, our support for the UN, our support for international institutions, not the military, but every civilian aspect of what we do. So, you know, this is often seen as a much greater proportion of our budget, it's actually 1% of our federal budget. And it's achieved great things over the past several decades. Child mortality around the world has fallen dramatically. HIV and AIDS are now in many parts of the world a manageable condition as opposed to a death sentence. And even family planning, family planning which has languished for too long is now showing signs of progress in terms of meeting the unmet need for modern contraception that so many tens of millions of women around the world want. So there's tremendous progress that's occurred in global health. But there's also a lot of challenge right now. I mean, as we know as taxpayers, public funding is constrained everywhere, not just in the United States, but everywhere around the world. And the disease burden is shifting. So even in the parts of Africa where we work, those blue areas on your map where life expectancy is lowest, what's expanding the fastest? Non-communicable disease, cancer, deaths from cancer. The burden is shifting in terms of the health burden on the poorest and most vulnerable in the world is shifting. And it's a time when we really need new partnerships to try and address these challenges to create healthy communities, healthy societies, healthy countries. These are partnerships that transcend public and private. They're partnerships that involve developing country governments as well as donor governments. And organizations like mine, PSI, as well as other social marketing outfits have for many decades been using private sector approaches to reach these poor and vulnerable health consumers and help them make choices that allow them to live healthier lives. And we're using social marketing and social franchising as tools to allow us to do that. So social marketing, using private sector approaches, products and services to reach a target audience with a beneficial effect on the whole society. And social franchising, using the private sector to leverage that resource to reach the poorest and the vulnerable because they get, by the way, their health care from the private sector. So I would say there's tremendous success in the global health space. It's a moment of transition, like Jim described in the domestic environment. It's a transition as well overseas where new partnerships are really important, public and private, and particularly investors who are looking for that social rate of return, that return on health investment that you talked about at the outset. Can you say another word just in terms of the scope? Where all is PSI working and what are the specific focuses? Sure, so we've been around for 43 years. We work in 65 countries around the world. We have about 9,000 employees. We, through the large S and the support of taxpayers in Europe and in the United States and through the sale of products, we have annual revenue of about $550 million. And we are reaching tens of millions of health consumers every year and averting years of life that would have otherwise been lost to death or disease. So we use dailies as our performance metric. Great, great. And actually another panel later this week is gonna talk about the health return on investment and specifically a woman named Amy Radcliffe is gonna be talking about these dailies, these disability adjusted life years that PSI actually calculates and helps then determine where their investments go and measure your success, which is a very exciting. We're a non-profit but basically dailies are our retained earnings. Right, right. That's what we're aiming for. All right, Tony. So the California Endowment, and this is your particular piece of the California Endowment, has a 10 year strategic plan to invest in 14 communities in California and the health of 14 communities. So what changes in health and health care recently and into the future are gonna have the biggest impact in your work in these communities and your investment in these neighborhoods? Yeah, so first of all, I can't see anybody in the audience. People like to, are so bright and it's really always important for me to see people's faces and their reactions to get a sense of whether they understand what the hell I'm saying. So let me give you kind of a little bit of the bottom line of what we're trying to do. First of all, just imagine this. I have a dream job, it's like an incredible job because somebody gave me a billion dollars and said, I want you to take this billion dollars and over the next 10 years in 14 low income California communities do whatever it takes to improve the health status of the populations in these places. And by the way, don't invest too much in health care because that has proven not to be all that effective. And so I get to wake up and work with a lot of other people with this idea that there's something that we can do with a relatively small amount of money. It sounds like a lot, but it's not a lot. I sometimes refer to it as our little bag and nickels. To figure out how to catalyze, health status changes in 14 under-invested communities throughout the state, from rural to urban, couple of Native American reservations, some Central Valley farm communities. And we really don't have a textbook for doing this, which is why I'm very delighted to be here and wish I could see your faces because you are actually quite critical to helping us figure out how to do a lot of this work. Now, let me tell you a little bit about myself. I grew up in Canada. I am a Canadian and I'm proud of it. Oh, I'm also American, I'm proud of that too. But here's the story, when I first came to this country, I was in the East Coast community in Baltimore, Maryland, and was really quite shocked at the conditions in East Baltimore where I was in medical school and couldn't understand what I was seeing. And still to this day have a difficult time rationalizing it and know for a fact that there are no communities in Canada that look like that. And one of the things that struck me was that people in this country kind of have a tolerance for conditions that in other parts of the world would be intolerable, certainly in developed countries. And when you're poor in this country that you pay an enormous social cost of being poor. If you're poor, you tend to live in a neighborhood where you have to worry about crime. You tend to live in housing that is substandard, typically overcrowded, full of triggers for disease, and is unstable. You tend to live in communities where there are poor schools. And I could go on, but everything is stacked against you. The social cost of poverty in this country is extreme. You can be poor in Canada and live in a neighborhood with great parks, great schools, great housing. I went to university for free in Canada. So the issues that are facing people's health trajectory in this country are structural and they are man-made. And so what we need to do in our work is to enlist your brilliant minds in figuring out how to undo some of these structural impediments to people's life trajectories. And we've recognized that that work requires a deep understanding and a deep investment in human capital. We have to figure out ways to harness the talents of people who live in these communities and enlist them in the crafting of 21st century solutions around health that'll benefit all of us. And that's a fun job. Let me just tell you, that is just fun. What I think is typically not well understood is that health is really about opportunity. Health is about hope. Health is about having control over the future of your life. And to the extent that you lose that hope, that you lose that control, you tend to make much shorter term decisions. You're much more likely to smoke, you're much more likely to drink to excess, you're much more likely to drive without a seatbelt, you're much more likely to have unprotected sex. All of those things are much more likely to occur in populations that feel they don't have control over their future. So our work is really, I tell my staff, that you're really hope salesman. I mean, your goal is to really figure out ways to leverage the broader economy to actually invest in human capital and build hope. And that's why I'm excited to be here. I appreciate that. And I wanna highlight too that we do this idea of what we call platform communities. We have a session coming up later this week if you're interested, specifically thinking about, we have three or four different organizations that are working with communities and how would entrepreneurs, investors, work directly with these particular identified communities to bring out the best of both sides. Kimberly, my question for you, so you represent Kresge, national foundation that has not been traditionally a primary health, health has not been a primary focus. So what role has your foundation taken to address the changing landscape of health and healthcare? And what can you tell us about some of the recent investments that Kresge has made in this health arena? So I would say that Kresge, if you had to find an overall theme about the foundation is really about community development. And my job at the foundation is somewhat unusual in that I'm not a grant maker. I was brought to figure out how to build a financing practice inside the foundation that would complement the strategies that the foundation had prioritized. And one of the kind of low hanging fruit that seemed ready when I was trying to get my feet on the ground was the grant making that we were doing to federally qualified healthcare centers, healthcare centers that had a revenue stream and it occurred to me that there was an opportunity to use debt to build those new healthcare centers rather than to use grants. And some of that had been going on through CDFIs, particularly NCB Capital Impact, but it wasn't really at scale. And so that was kind of the first starting place for us. And I was not a health person. I really came from the housing world. But as I've learned more about health and its relationship to community development, health to me seems really kind of like the super vitamin for community development, if you will. Because through better health outcomes, you can get better educational outcomes. You get better employment outcomes. You get better earnings, which result in more tax dollars. And so I think the challenge that the foundation is trying to figure out is how do we not just isolate health within one program area, but how do we think about how health is really knitted into everything that we do? So we really started out with a very simple strategy of trying to push debt into the CDFI market and build an understanding about how that debt might build new federally qualified healthcare centers. And I think with several excellent partners, we've had some early success there. But I think the next and higher challenge for us is to really figure out not just how do we build more boxes of healthcare facilities, but how do we really influence what happens inside those boxes, not just on health outcomes, but also on cost and care efficiency. And probably maybe the third realm that we haven't gotten to yet is really how do we move other systems of community development to prioritize, measure and find metrics for the way that they can interact with health? Somebody said to me the other day at a meeting that I think we were at together. You know, like the American Association of Architects was calling, looking for standards, like how should they be thinking about health? Which sounds like, I don't know, a little puzzling to me. But I think that's really the frontier that we need to get to in the aspiration, which is that it's not an isolated group of the believers, which we all are, but really it's many different constituencies thinking about how health can be a part of their work on a day-to-day basis. Did you want to mention any particular example of, oh, I think she's maybe gonna adjust here. Did you want to mention the Healthy Future Fund specifically or any sort of one of the names of the investments recently? So we have done a number of debt investments through CDFIs. We did an interesting fund last year that was called the Healthy Futures Fund that was a partnership with Lisk and Morgan Stanley, which was a $100 million fund that used low-income housing tax credits and new market tax credits. It was kind of bifurcated in two pieces. The new markets was about building new health centers and the low-income housing credits was directed at projects that have health services embedded in them. I really think that's like a 1.0 version of where I hope we can go because this is really about having a visiting nurse come to a housing development. It's about a van service that takes people down to a clinic. That's really only, that's the beginning of where we need to go, but there is this large chasm that exists between houses and health providers and health providers and other service providers and some of those, and I think it's been a role that the foundation has played, is just helping people to get to know one another because we all know that we transact business better with people that we know and it's been shocking to me, I'll tell you a funny story. So when I was trying to figure out the whole healthcare landscape, I went to a developer friend of mine that I knew really well and they owned a home healthcare business and I said, Tom, what do you guys do with FQHCs? And he goes, FQ what? And I said, FQHCs? And he was like, FQ what? And I federally qualified healthcare centers. He goes, oh, he goes, all our patients, all our tenants, they're coming under Medicaid. And I said, I know, but where do they go? I mean, you're housing 50,000 people. And he goes, you know what? We really don't know. And I mean, it's just an example of even the most sophisticated among the housing developers up until this point, perhaps, haven't had a full understanding of where their patients are going. Probably our most recent investment, which I'm really pleased about is with the Colorado Coalition for the Homeless. This is an organization based in Denver that is not just a housing developer, but also an operator in FQHC. We've recently done a line of credit to that organization to allow them to expand their health services in advance of healthcare reform. We did that line of credit based on performance. So we set an interest rate on it, but that interest rate is going to decrease as the health outcomes of their tenants improve. And so we feel like it's a way as a social investor that we can drive an organization to a greater level of impact that they want to achieve and really monetize that in terms of a discount that they will benefit from. Yeah, the reason I like those examples is because it's carrots, not sticks. It's offering money that if you set your system up in a certain way, you'll get access to. And in the case of lowering interest rates by meeting certain thresholds, that's exciting too, because again, the opportunity for entrepreneurial activity to help these organizations meet these thresholds, what are those things? Is it a bus service to get them around? Is it having five folks visit them in their home? We don't entirely know, and that's partly why we're here because smart people are gonna think of the things we haven't thought of yet. All right, so David Erickson, Federal Reserve Bank, sitting here on a health panel at Socap. It's kind of a strange thing. I will though, to save you a little bit, the Federal Reserve has partnered with the Robert Wood Johnson Foundation now for three years on the Healthy Communities Initiative, which was really focused on bringing together community development and public health and to try to help increase the integration across those sectors. But can you tell us a little more about what is the Federal Reserve's interest in healthy communities, and how does that interest align with Socap, which brings you here to being on this panel? Sure, thanks Doug. Yeah, I'm starting to get a little bit of a complex because every time I go to a conference and I say from the Federal Reserve, everyone says, why are you here? Oh, like that sort of, and so let me see if I can explain that a little bit. You know, the Federal Reserve gets a lot of headlines for setting monetary policy, but we also are bank regulators. So one of the laws that we enforce and help with our two other sister regulators is the Community Reinvestment Act of 1977, which requires banks to lend back into the communities where they take deposits. And this is a pretty sizable amount of money that goes into these communities. And for those of you who aren't familiar with community development, this is really an industry that came out of the war on poverty. It focuses, over the years it has sort of morphed, it was kind of economic development, community empowerment, and sort of is morphed over time to focus more on building this sort of community amenities that would make a neighborhood more viable. So, and the subsidies that go into this are in the neighborhood of about $20 billion a year. The workhorse here is affordable housing development that's usually service enriched. So either it's for frail elderly or single parents, or people who are formerly homeless, people like that that need some services in addition to their housing. Community developers also build clinics, schools, grocery stores, or food deserts, a lot of these other amenities. But if you talk to someone like Nancy Andrews who runs the low income investment fund, she said, you know, we really thought that if we got the buildings right, we'd solve all the problems. You know, we could somehow just build our way out of this problem. We could build our way out of poverty. We'd reintegrate these neighborhoods back into the mainstream. And if we look at the statistics, we see that we're not making as much of an impact as we hope we would. So poverty is still going up. Even the number of people who are ill-housed is still going up. And so we thought, okay, we need more partners, right? We need to think differently about this. And so that's when we really started looking at some of the work that Robert Wood Johnson had done with their commission to build a healthier America where they really had hit this, I think, just world-changing insight, which is that your zip code is more important than your genetic code for your health. And you think about that. Like, think of all the times you fill out a form where you say, you know, is there heart disease in your family? Is there a history of cancer? None of that is as significant as your zip code. Like, how crazy is that? So that's when we started thinking, well, wait, we're in the zip code improving business. So let's get your friends together, our friends, and we've got a party, you know? And but what we find is, and part of the reason why, to get to the question or with the title of the panel, what does this mean for investors and entrepreneurs that is changing landscape of health? I think what's happening with this merger of health and community development is creating a new type of platform that's going to provide a lot of opportunity for social enterprises to come in and for investors to come in to make investments that have a social return to make a lot of money. So let me just repeat that. I think there is a chance to make a lot of money because there is a disruption going on right now that is so profound where increasingly that money, that 2.8 trillion that Doug talked about before that currently mostly going to pay for procedures is soon going to go to people who can keep people healthy. I cannot tell you how important that change and focus is. It's going to require an entire new set of skills, new enterprises, new institutions, and new investment vehicles like the Healthy Futures Fund that are gonna allow investors to come anywhere along the risk return spectrum and achieve some type of social return and their investing. So this is something I've been coming to SoCAP every year since it started and I always enjoy my conversations with Kevin after a couple glasses of wine. I very rarely understand what he says until it takes me about a year to catch up to what he's talking about. But he was today at the Federal Reserve talking about all of these different entrepreneurs that are using cell phone apps or smart phone apps or case, really interesting use of case-managed technology and bath mats that can help case managers manage people's type two diabetes. So you can start seeing how these entrepreneurs are glomming together with community developers and those who care about approving the health of low-income Americans with this changing landscape with pay for value in the healthcare system. You can see why we have David on the panel. He's a very positive thinker. You actually started to answer one of the questions I wanted to ask the panel getting to it. So one of the questions we discussed is the term you've used it before, David, actually, the Federal Reserve actually held a meeting earlier today in alignment with SoCAP focusing on community development, health, impact investing, and social entrepreneurship all mixed together in a room at the Federal Reserve Bank which is kind of exciting. But we talked about the health impact economy. So the question we talked about, and so if each of you maybe thinks just for a minute or two, or talks for just a minute or two, in order to create or move forward a health impact economy, who are the partners we need to have and how do the types of entrepreneurs and innovators and investors that attend this meeting fit into that calculus and also specifically for your own institution moving forward? Maybe I'll start, Doc. The way I see it is that there's almost no sector that doesn't have an influence on health. But most, oops, yes, there we go, there we go. Sorry, I have no control over it. There's almost no sector that doesn't have a real influence on health. But most of the time they haven't assessed that, they haven't used that to monetize and say, what's the cash flow or who gets the benefit from that? And we have a lot of interventions that are aimed at reducing the cost of illness but very little about capturing the value for health. And that's one of the things that you out there looking at how do you improve health and then how do you find the funding streams that benefit from that is what we need. But that is, whether it's in agriculture, whether it's in transportation, even in schools. And so when you look at community development, it's not just about housing, but it is about, is there a supermarket there? Supermarket that brings jobs. We know better jobs need to better help. Supermarket that brings fresh fruit and vegetables that even people of low income will buy more fresh fruits and vegetables if it's easy for them to do so. About a FQHC, a neighborhood health center that can provide quality care and perhaps help them get to other services they need. In fact, one of the areas where there's really good evidence is that if you build housing and then build services into it, connected to it, so that the residents who have their struggles can get those services, service enhanced housing, they do better. They do better for longer. Their families do better. And it is an added value for very little additional marginal cost to the housing. That's an area that's well known, well studied. So I think it's, there are opportunities there, but we just have got to harness them and understand how do we get the value for health and turn that into the monetary flows that you all will use. And your banker says there's a lot of money for it. Profit to be made. So Carl on the global stage, what's- Well, I would say, we like to think of ourselves as in the health impact business. This is our core business. And I think in the global health space, one of the perils is that this fantastic, technological innovation that you talked about, David, and the interesting ways in which new entrepreneurs are coming into the space, it's often assumed that that's the real obstacle that needs to be overcome when you talk about the two billion people that we are potentially working with. And although all of those things are crucially important, I think the reality is in our space, really what you need is partnership with people who are just core process-improvers. We are not looking for the new silver bullet. Many of the interventions already exist. The low-cost, simple interventions exist to save people's lives. It is simply a matter of getting it into their hands or getting them to the facility or getting the supply chain to work better. We, for instance, with funding from a foundation, we do a lot of work with mail circumcision, adult voluntary medical mail circumcision as an HIV prevention tool in Southern Africa. And ensuring that we could get the maximum impact among men who wanted that service was really what? It was a process improvement question. It was, how do we get the right services and the right commodities with the demand creation in the right places? And these are not highly, I mean, this is a many thousand-year-old business we're talking about. Not great technological innovation here. So, a lot of what happens in the global health space depends on simply making what seems boring better and faster. And that's how we save more lives in that space. Yeah, it's maybe because I've spent many hours thinking about content for this week, but I'm gonna plug another panel related to that. But that issue is really critical, and I wanted to make sure that here at this meeting that we don't think that technology is always the solution. That here in the U.S. as well, there are systems changes by sort of what I think of as people-oriented changes. We're gonna have a group called Health Leads speaking later this week. It's called Beyond the App, is the name of the panel, talking about how you actually allow a physician to identify, like I talked about earlier, a housing problem, writing a prescription, giving it to the patient or the family, they go to the front desk and someone there is trained and has the resources to actually connect them with housing resources. Something that I can't do as a physician, but they can do. That's a Google, that's simply having an iPhone, practically, it's not the technology of it, it's having a person there to really help close, as a case manager, which is what's missing. Tony, any thoughts about partners with the California Endowment and how, what the opportunities are there, or what you need? Yeah, so, you know, when you go through public health training, you learn these obscure terms like the social determinants of health, which basically just means the social causes of health, and you learn very quickly that the two most important ones are income and education. Everything else is basically derivative of income and education in this country. And if you talk about income in this country, changing income, redistributing income, everybody brands you a socialist and chased you out of the room. So you can talk about education, and people basically will give you a hearing. Now, when we're, I'm not focused on individual health, I'm focused on the health of communities, which is really about the structures and opportunities within a community that allow people to pursue opportunity. And when you map in this state, in this region, those communities that have the lowest life expectancy, you also see that those are the communities that have the least physical accessibility to opportunity. An opportunity to find is basically employment or education pathways that allow you to access employment. In fact, the recent study just looked at essentially low opportunity communities and high opportunity communities, and the fact that people can pursue social mobility more effectively in high opportunity communities than they can in low opportunity communities. So for me and my colleagues who are struggling to try to figure out ways to improve the overall health status of communities, the partners that we're looking for, the ones that can help connect a higher percentage of people. This thing's gonna blow down, isn't it? A higher percentage of people in these low opportunity communities with opportunity. And when you think about many of these communities, you don't have to think about it, and just look at the data. You see that things like the official unemployment rate may be as high as 30, 40%. And you know that those people that are counted as unemployed are surviving. Well, how are they surviving? They're operating in an informal economy. They may be going to flea markets and purchasing stuff and reselling them. They may be fixing stuff in their garages. They may be running a hair salon in their garage. And so we recognize that it's important to actually facilitate people's participation in that economy as well, because as they become more successful in that, as their income rises, their health rises. Their health improves. They have much more access to opportunity. So folks that can help potentiate or facilitate connectivity for people operating in the informal economy, microloans, all kinds of technological applications for bringing people together so they can access markets more efficiently, that's actually health improvement strategy at the local level. So we're very interested in hearing from meaningfully designed strategies to help connect people to make them more productive in the segment of the economy where they're most likely to access. Yeah, that's really great. I wanna note the time. We've got just about 10 minutes left. Kimberly and David, any quick comments and then I wanna see if we can get a question or two. We've been having some very interesting conversations with insurers who have a business reason to look at different strategies around wellness, preventing readmissions. And so we've been looking at some nascent partnerships between service providers, between housers, about how those entities, because they are touching people where they live and have a trusted relationship, can actually both be in a business relationship, so perhaps earn some economic value, but really trying, it's kind of an unlikely suspect that we haven't worked with before, but I think reaching across those lines, there's new partners to be found. That's really great. Any comments? Just really quickly, one thing I forgot to mention is that I am speaking for myself, I'm not the Federal Reserve, so that's, because of what I reminded you of that, because the next thing I was gonna say is that I think the status quo, my mantra lately is that it's unfair, dumb, and expensive, you know? And it's, we spend a lot of money, but on the wrong things. Prisons, emergency room visits, special education classes for kids that are so expensive, it's more expensive than the whole other class, a whole classroom, you know? So we can readjust how we spend money, but that's gonna take system change. And that's, everyone's on this panel has talked about system change and how important that is. One thing I'm gonna say if I can do this in like a minute and a half, but you know, everyone thinks about the Marshall Plan as being this great opportunity to sort of, this altruistic rebuilding of the European economy. But there really was, one of the theories behind it was, you know, we've come to Europe twice in a short amount of time to end the war between all these countries. And the condition for participating in the Marshall Plan was, you had to build, everyone had national industries. There was a Belgian steel industry, there was a German steel industry, there was a French steel industry. And in order to participate in the Marshall Plan, which is only about 3% of the European GDP, so not that much money. You had to say, okay, we're using German coal and French iron ore and we're gonna build it in Belgian steel mills. And we're gonna reorganize the European economy on a continental wide basis on the theory that they won't go to war together again if they're connected economically, right? And so you have what became the coal iron ore league that became the common market that became the EU, right? So these small changes, small amounts of incentives can really change systems. I think foundations need to lead the way in how they can create the prototypes that show the way. And then I think government needs to come in behind them and start changing the systems in policy. And that, I think then we can start seeing, then there's gonna be a rich opportunity for entrepreneurs and investors to fill in the gaps and fill out that new economy. Great, thank you. See a historian, we had to get a little historian. Yes, why don't we see if we have time for a couple of questions? Try to keep them short and question oriented, not long statements if we can. Got one right back here. Hi, yeah, hey. I have a really innovative strategy for public health and we've been researched by Arizona State and some other things. But one of the things we discovered was that the medical community has a certain set of metrics to say what success is. Are investors using the same metrics as the medical community for what success is to what they fund because if they did, it feels like no one would fund anything because it feels like the medical community, especially the public health, has a strict criteria. Yeah. Anyone wanna try that one, Jim? I think one of the things we've found is we've started to come together with community development is that in fact, there are different metrics or at least different ways of framing them and we've gotta find a way to build those bridges. One of the things I talked about is that we know about the prevention of the cost of illness but we've not talked about the value of health enhancement as a way we've gotta start to structure our dialogues and understand what each other brings to it. So for example, a community development work that creates a park likely will create increased activity, places for people to play if presuming that they're safe. That's not measured or counted as a health investment by medical care. And so under the Affordable Care Act, they no longer can count the clinical care that is charitable. They've gotta look for other investments. So that's another potential source of funding but also I hope will be one of those small changes that leads to the health care system being able to say, what are the investments in our community that will help help overall? But we're not there yet but it's a place where I think there's a lot of opportunity. The difference too between outcomes and output. So just the number of patients you see in your clinic is not as important as whether any of them actually got better. The same is true for housing. You can build lots of housing but if it's not quality housing, you've sort of defeated the purpose. So we have a question here. Oh, there we go, yellow. Hi, I'm Anders Ferguson and I'm one of your moderators and one of the panelists. Doug, thank you all. I've come to learn some things while you're being an intelligent moderator. So I think you guys have collectively made the argument that health isn't health care. And you've made the effective argument that the zip code determines our health and that it's all going in the wrong direction. And thanks to our Canadian American, we know that America doesn't care about poverty and poor people. Like, so the missing link that I don't understand out of all this is how are you gonna change that to change health care if we don't care about poverty and poor people? Historically or today. And collectively as a nation, we're getting poorer and so everybody in the food chain is fighting to get somewhere. Thanks. Yeah, go ahead, Tony. Yeah, so thanks for that question. And it's something we think about all the time. How do we get people to care about this? But there's sort of two answers to that question. One is that, and if you look back historically in this country, the historian could probably do a better job of this. People didn't care about civil rights. People didn't care about HIV AIDS. People didn't care about gay marriage. I mean, people didn't care about disability, but they were made to care by building the power of people who recognize this as a priority issue. So part of our work is to essentially, and I say this very openly, health is political. You actually have to build social, political and economic power in a critical mass of people in the communities that are most impacted by these outcomes so that they can actually take hold of the reins and change some of the priorities in those communities. I mean, that's really important. But the second piece that I think is in part what I'm hearing a little bit when I hear about the Federal Reserve's interest and some of the non-traditional health players' interest in this is that we are heading down a path just with chronic disease that is bankrupting local government, bankrupting state government, bankrupting the federal government, bankrupting the private sector. I mean, when you see people go on strike, it's typically not wages that they're arguing about. It's like who pays for health care? So, you know, there's all of a sudden all of this aligned interest and concern around this problem about escalating spiraling health care costs. And you can't get to a solution in the health care delivery system for that problem. You have to get outside the doors of the health care delivery system and look at community, look at community infrastructure and redesign the health care system as fully integrated in the community. And so that's a challenge for all of us. It's not just the health of four people that's at issue here, it's the health of all of us. I'll go ahead. Try it out a little bit. So what we're seeing here, and I hope that you are, you're entrepreneurs, we think that there's market opportunity in this area. When we looked at in the area of obesity, the companies, the food processing food companies that did the best, had the best stock market performance, the best reputation, the best profitability were those that were increasing the proportion of their product offerings that were better for you. So you don't have to do this only as a social good. There is market opportunity. Some of it may not be at market rates, but we think that there's a lot of opportunity there. The other is, frankly, like Tony said, we need a movement where health is a shared social goal. And then we say, we look to our decisions made in our various sectors and say, does it help health? If not, what does it take to add to health? And how costly is that for that added health benefit? But we've got to make that much more a conscious set of discussion and decisions. I'll just add one thing too. When Kevin Jones, who's one of the founders of SoCAP, spoke at the Federal Reserve Bank earlier today, he put it very bluntly and said, when the market sees that money can be made on poor people, meaning the delta, the change in health, the largest savings will be in those who are worse off, that will move money in a new direction. And I think that was a fascinating and very different perspective than I would have as a physician and a public health professional. But that's one of the main reasons we're here. So we've got one last question, I believe, back here. And then we'll wrap up. Hi, my name is Maria May. I'm from BRAC based in Bangladesh. My question to the panelists was that I feel that a lot of what I'm hearing is really refreshing to hear in the domestic context. But it's the approach that we've been using in global health for a long time. And so I wondered kind of what strategies you're using to learn from what's happened globally, particularly in developing countries and how you're planning to apply that here. Thank you. That's a very good question. One of the things that's interesting about that, the next generation of community health centers is really based on a South African model from before the apartheid government was the work of John Castle, where he basically said the clinic will adopt the whole neighborhood as its patient. And I think this is really important, that the ideas about how we make these changes shouldn't stop at the border, that we need this sort of borrowing from other countries to get the best ideas possible to make these changes. Yeah, Jim. Or Tony, yeah, go ahead. Yeah, I would, first of all, great question. Thank you very much for that question. We think about that a lot in our work. And if we had more time, we could talk a little bit about historically how the US has tried to influence global health thinking to try to kind of narrow the spectrum of what are the real determinants of health. The US is behind the rest of the world in terms of understanding what actually drives health, which is why we tend to invest so much in this damage control kind of system. But what we've learned from looking at other countries, both developed and undeveloped countries, is that this whole notion of sort of structural change, looking at trying to make critical multi-sectoral investments usually early on in the life trajectories of humans, tend to have much better ROI than the things that are later in narrow. Any last comments? Jim or Kimberly? A little bit to that. At the Robert Johnson Foundation, we have opportunistically or we've found ideas and applied them in the US or found entrepreneurs who've done that. For example, treating violence as a transmissible condition. How do you interrupt it? Much like you do directly observed therapy. You apply it in ways to stop the spread or early detection of mental illness. Something that came from Scandinavia, mental illness in adolescence where treatment is much more effective if found early. We are a domestically focused foundation but we just made the decision that we're gonna be much more systematic about looking for ideas elsewhere that we can try to apply here. And it may be the foundations who can lead in this space because when you talk about mobilizing federal dollars that prevention versus treatment problem that you cite, you know, the only place where you get the political consensus to mobilize the resources for all the investments in global health is around the treatment conversation and prevention is always an uphill struggle. It's always an uphill struggle. Kimberly, any last word? Nope, I think that'll do it. All right, good. Well, thank you all. We ran over a little but I wanna thank our panel and thank you all for participating and enjoy the week. I hope you like the sessions.