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They would
you speak who was at the business school?

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But now you set up a new gig.

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You're going to have to tell him about it,
because I never left.

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But Peter does really cool stuff

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in social entrepreneurship
in low income countries.

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He also

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illustrates
how to give an amazingly cool lecture.

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And I just love watching life
and learning stuff from you.

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I'm going to let you introduce
because I'm going to get

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get it wrong, cause
I never memorized that paragraph.

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That was just my heart.

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Thanks for,

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Hey, everyone, great to be with you.

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Hello to those of you who are online.

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My name is Peter.

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Feel free.

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Let me just say, first off,
we have a good chunk of time.

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We won't necessarily use it all.

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I want to respect the fact
that you've been in class all day.

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But we can be a little bit relaxed,
and so please feel free to interrupt.

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Ask questions.

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You know, slam me with, critiques,
whatever it is,

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including you folks online as well.

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So I am a, a doctor by training,

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pediatrician, internal medicine
and practices and public health.

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And I've spent most of my career
doing global health work,

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and we're going to talk about
a lot of that today, really doing systems,

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building health equity work in places
like Rwanda,

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Malawi, Ceuta, rural Haiti,

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Lima, Peru, Siberian prisons,
inner cities in the US, etc..

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And we're talk about one
specific example of that.

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And the social entrepreneur thing
sort of happened by accident.

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It was just trying to, you know, be
useful, and help address problems.

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But, but I did go on with some colleagues
in Rwanda to, to found a university,

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there called University of Global
Health Equity,

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which you should all know about
and I will talk about as well.

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And after several years of doing that,

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and kind of getting it off the ground and
handing it over to a much more competent,

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vice chancellor,
I moved here and I ran the school center

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for social Entrepreneurship, which is what
took me to the business school in 2017.

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Ran that for a little over six years,

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had a little sabbatical, and then started
this new gig that I just mentioned.

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And we can talk more about Crucible later
if you're if you're interested.

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I think there's some interesting parallels
between the health systems work

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and now the kinds of the needs
and strengthening education systems,

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and that's

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why it's been attracted to me to sort of
get out of my comfort zone again.

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Just like being a global health
social justice doctor and

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turning up in an elite business school,
like I had no business being there.

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It was was weird.

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My first lecture, at Sade in 2017,
I was talking about equity,

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which you'll hear about today,
and the first couple minutes.

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Everyone's face is screwed up
and it looks so confused and I was like,

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you guys okay?

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And I thought I was talking
about the financial person

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securities and things like that.

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I'm like,
oh, I'm totally in the wrong place.

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This is amazing.

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And it was great, actually, to be
in a different discipline and in a milieu

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we're not.

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I sort of thought the same way
and saw the world the same way,

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and got to spend a lot of time
with amazing MBAs, many of whom are impact

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driven and actually quite a number
from health care, etc.

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and are using MBA as a masters
in getting stuff done.

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That's what the school center
does, is try to bring together

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folks from across disciplines, across
sectors who are trying to solve big,

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hard problems, sustainable development
challenges and things like that.

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So, it's been a it's been a weird ride.

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For me for sure.

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And then every once in a while,
like every no, ten years or so,

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I seem to sort of get restless and decide
to do something completely different.

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That's what I'm doing. Yeah. And as of
this is just as of January. Right.

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So it's all brand new.

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We don't even have a website yet,
but we can talk about that later today.

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We're going to talk about system
entrepreneurship,

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and I understand that you've been talking
about and thinking about

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and working on complex systems
problems, already today in this week.

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So hopefully you'll be really,
really primed for this.

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And I'm going to come at it
from the angle of,

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how we frame social entrepreneurship
at the school center.

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And I'm going to talk through sort
of my experiences,

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over about ten years in, in Rwanda,
which is one of the most remarkable,

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country level transformations,
not only in health care, but sort of

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social and economic, that,
you know, that I've ever seen

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and in fact, you know, the statistics
kind of bear this out as well.

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I'll acknowledge
that at the moment, Rwanda is is engulfed

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in, a really messy and tragic
situation, involving DRC.

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That's really a conflict
that's gone back 20 years.

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It's a complex place
and it's a complex neighborhood.

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Happy to talk about that.

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But there's a lot to learn from
what is probably

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the most entrepreneurial countries
and one of the most interesting

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places, to be doing this work in
the world right now.

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So 2025

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has gotten off to kind of a crap start,
right?

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It's like not been the best year.

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I'm also American,
as you could probably tell on my accent.

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I'm not Canadian.

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Not from the 51st state. So.

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I didn't mean that, of course.

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But, you know, it's been it's been rough.

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And, I'm

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speaking to a group of small business
leaders in the UK at the business school

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next week,

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and we kind of talk about each year
I come and talk about the kind of big

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global trends.

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And, and I think the watchword for 2025
is uncertainty, right?

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We just don't know what's happening
right now.

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We don't know where we're going.

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How sort of one guy has been able to throw

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so many things into, into question
and in a rapid fashion

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has been pretty remarkable
for those of us working in global health.

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You know,
like USA is an important institution,

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but they don't do everything everywhere.

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But what turns out happens,
as I'm sure many of you know

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and have seen, was that the kind of,

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sudden shutting down

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created so much uncertainty
that it just rippled

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throughout the entire global
health system.

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So W.H.O.

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stopped working.

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Basically, they stopped hiring.

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They put a whole bunch of projects
on hold.

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Ministries of health have stopped

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because they're not sure
if money's ever coming through

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and if they're going to have to repurpose
funding for this nutty other thing.

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So of course, projects are being shut
down, jobs are being lost,

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lives are being lost.

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But it goes way beyond that.

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One single institution
is affecting the entire system

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in a pretty catastrophic way.

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And of course, those things
are being replicated, unfortunately,

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in lots of other places.

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And I don't want to depress you by talking
about all the things that seem to be.

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That he's going to do that tomorrow.

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Oh, good, good,
good going wrong in the world.

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But where's all this coming from?

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It's coming from the fact
that the challenges that we're facing are

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this we sometimes called wicked problems
have based in Boston for a long time.

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So it's wicked in the Boston sense,
which means messy,

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really hard, really terrible problems.

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We're living in a world
that is interconnected and entangled in

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so many ways. Our systems are entangled,

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etc., etc.

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and, what we mean by wicked problem
is, is a problem

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that is not just complicated, but complex,

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where not only do you not know

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a cure, a whole group

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of smart people thinking about this
probably don't even agree on the cause.

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They may not even agree on
whether there's a problem at all.

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And these are the big kinds of challenges
that we face today.

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We saw a lot of this during Covid.

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We see a lot of this kind of conversation
with the climate crisis, etc..

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And so the way I think about
social entrepreneurs are that social

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entrepreneurs are the ones
who try to entrepreneur wicked problems.

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And so that's what
we're going to talk about, today.

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So you've talked a lot about systems.

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I don't know if you've confronted
the work of, Janella meadows,

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who is, you know, a sort of,
you know, a major intellectual figure

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in, the rise of systems
thinking for social change, right?

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You probably know that, systems
theory has come

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from many disparate disciplines.

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In many ways,
a lot of that has come together in

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almost what seems like a new ish way
in trying to understand how systems

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thinking can help us address complexity
in terms of social systems, basically.

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And, and so what she said or wrote is
the world is a complex.

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I'm going to read this
for the benefit of the recording.

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The world is a complex, interconnected,
finite

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ecological, social, psychological,
economic system.

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It's one big system.
It's all connected, right?

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We treat it as
if it were not as if it were two visible,

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separable, simple and infinite.

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Our persistent intractable
global problems, wicked problems

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arise directly from this mismatch. Right?

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We've made a lot of progress in the world

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through kind of, you know, reductive

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thinking and breaking things down
into their component pieces

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and teaching systems
thinking for the last eight years or so.

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One of the interesting things I've learned
is that there is an inverse

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relationship between someone
sort of age and career status,

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and their ability to,
like, psychically handle systems thinking.

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What I mean is that when I'm talking
to kids or secondary school

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students, they intuitively grasp
what we mean when we talk about systems.

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The idea that things don't move in linear
cause and effect, A

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to B to C,
but that they move in kind of cycles.

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For example.

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And when I was teaching systems
thinking to executive in

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Vas to the Masters
in Global Health Leadership,

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over at the

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business school as well,
we're talking like mid career

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C-suite, super accomplished, successful,
high powered people.

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They hated it. Right.

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And one guy at the end of the module,
the exec MBA one, stood up and he said,

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I'm speaking on behalf
of, of the entire cohort here.

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This was to to myself and my colleagues
on the one week program on Monday.

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We hated you
and we didn't know why we were here.

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And on Friday, you change the way
we see the world at least a little bit.

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And that's great.

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But we, you know,
we get through life like.

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Right?

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You've been successful people,
your problem solvers, right?

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You take a problem, you want to tackle it.

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You want to find a solution.

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You want to say, okay, what's going on?

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I'm going to break it down
into pieces, into steps and, and do this.

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And then we're going to do this
and then we're going to do this.

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I think about the way you work
in development with things like log

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frames, you know, inputs,
outputs, outcomes, that kind of stuff.

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It's totally linear and that works really
well for a lot of hard problems.

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For complicated, hard problems,
it doesn't work well for systemic problems

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because the interactions are too messy,
they're too interconnected.

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And so doing something over here
can cause a second

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or third order thing over here and
a totally different part of the system.

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And oftentimes that's what we call
the speculative law of unintended

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consequences.

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I called Thomas Merton from 1936
the unintended consequences

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of proposed social action.

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It means you can go into a situation
and do something

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with the best of intentions
and with a lot of rigor,

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and still mess everything
up and make it worse,

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because you're only looking at this one
narrow thing.

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You're looking at addressing one disease
in one community

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or one little part of the system,
and actually not understanding that,

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you know, that the benefits
that you're distributing

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without much education, cause
you're trying to do it faster at scale,

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are not being used properly,
and they're being resold as fishing nets

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and choking off fish and clogging up
waterways and things like that.

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Or starting a frozen fish factory
at Lake Turkana in Kenya.

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In, you know, the north of Kenya
as an economic development project

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for the locals, but not actually investing
in stable electricity

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like a power infrastructure.

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And then all of those fish
don't get frozen

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because the power goes off
all the time, etc..

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You know, like the history of the late
20th century

235
00:11:43,068 --> 00:11:46,443
is littered with well-intended projects
that have gone amok.

236
00:11:46,693 --> 00:11:47,755
Right.

237
00:11:47,755 --> 00:11:50,193
And a big part of it
is because you're actually not looking

238
00:11:50,193 --> 00:11:51,943
at the, at the entire system.

239
00:11:51,943 --> 00:11:56,630
So my view and what I submit to you
is that systems thinking,

240
00:11:56,755 --> 00:12:00,692
the kind of stuff you've been working on
this week, is, is a kind of a super power,

241
00:12:00,817 --> 00:12:04,504
is a kind of an edge
because it allows you to see things

242
00:12:04,504 --> 00:12:07,504
and new ways to step into other shoes,

243
00:12:07,879 --> 00:12:11,316
see problems in new ways,
see them as different kinds of problems.

244
00:12:11,878 --> 00:12:16,691
And from that you can see opportunities to
make change that maybe others don't see.

245
00:12:17,003 --> 00:12:19,690
And that's kind of the essence
of entrepreneurship, as

246
00:12:19,690 --> 00:12:22,690
you'll see
when I talk about the work in Rwanda, what

247
00:12:23,503 --> 00:12:26,690
what's sure looked and felt
a lot like a medical problem

248
00:12:26,690 --> 00:12:30,877
when I started as a young doctor,
in rural Rwanda at the time,

249
00:12:30,877 --> 00:12:34,627
and it was 2004
on what was essentially an HIV project,

250
00:12:34,627 --> 00:12:38,501
you know, funded by the Global Fund
and all of the new, vehicles

251
00:12:38,501 --> 00:12:41,501
that were bringing resources
to the global Aids, fight.

252
00:12:42,126 --> 00:12:45,938
What I realized was that it wasn't an HIV
problem, wasn't even a medical problem.

253
00:12:45,938 --> 00:12:47,876
It was a poverty problem. Right?

254
00:12:47,876 --> 00:12:49,313
There were structural problems.

255
00:12:49,313 --> 00:12:51,375
There were other things that were driving
this, actually,

256
00:12:51,375 --> 00:12:54,375
the forces that determine who gets sick
and who doesn't,

257
00:12:54,750 --> 00:12:59,125
who gets access to care
and who doesn't or not biological right.

258
00:12:59,125 --> 00:13:02,124
Their political and their social
and economic other other things.

259
00:13:02,187 --> 00:13:06,749
And so once I was able to understand it,
this wasn't like, I figured it out.

260
00:13:06,749 --> 00:13:09,874
This was having the good fortune
of amazing mentors,

261
00:13:10,624 --> 00:13:13,186
that actually were dealing
with different kinds of problems.

262
00:13:13,186 --> 00:13:14,936
I understood that as,

263
00:13:16,123 --> 00:13:18,248
one of our patients in Haiti once said,

264
00:13:18,248 --> 00:13:21,373
taking your antiretroviral medicines
or HIV medicines

265
00:13:21,373 --> 00:13:24,373
without food is like washing your hands
and drying them in the dirt.

266
00:13:25,435 --> 00:13:26,935
So yeah, the pills are cheap.

267
00:13:26,935 --> 00:13:29,060
You can get the pills, to people.

268
00:13:29,060 --> 00:13:32,310
But unless you understand
the entire situation, not actually going

269
00:13:32,310 --> 00:13:36,059
to be creating the kind of value you want
and having the impact that you want to.

270
00:13:36,059 --> 00:13:39,371
So this is the kind of system stuff
I'm getting ahead of myself already.

271
00:13:39,934 --> 00:13:40,809
But great.

272
00:13:40,809 --> 00:13:44,121
Another aspect to addressing
complex problems that's important.

273
00:13:44,684 --> 00:13:47,558
You guys have heard of tragedy
of the Commons, right?

274
00:13:47,558 --> 00:13:51,558
The idea that, you know,
we're all in the same boat together,

275
00:13:51,620 --> 00:13:54,620
but we tend to each stay in our own lane

276
00:13:54,620 --> 00:13:57,745
and do what is in our self-interest.

277
00:13:57,745 --> 00:14:00,057
That could be myself
and my family or our community.

278
00:14:00,057 --> 00:14:02,120
That could be our organization.

279
00:14:02,120 --> 00:14:05,307
We do a great simulation called Fish Banks
that was developed at MIT.

280
00:14:06,307 --> 00:14:08,057
Which basically puts a bunch

281
00:14:08,057 --> 00:14:11,056
of people in a room
like you and you're all,

282
00:14:11,119 --> 00:14:13,181
fisher people,
you're running fishing businesses,

283
00:14:13,181 --> 00:14:15,431
and you're all fishing
out of the same scene,

284
00:14:15,431 --> 00:14:19,743
and your job is to build your business
and get as profitable as possible

285
00:14:19,743 --> 00:14:24,430
and make money and buy more ships
and do more fishing, etc., etc..

286
00:14:25,118 --> 00:14:26,305
And what happens?

287
00:14:26,305 --> 00:14:28,055
You are fishing from the same sea,
which is in

288
00:14:28,055 --> 00:14:30,117
some ways a closed resource, right?

289
00:14:30,117 --> 00:14:34,180
So if each of you or each of your teams
are acting in your own

290
00:14:34,180 --> 00:14:37,304
individual self-interest, what happens.

291
00:14:38,679 --> 00:14:40,054
Is he gets overfished.

292
00:14:40,054 --> 00:14:43,054
The sea gets overfished,
and then there are no fish left.

293
00:14:43,491 --> 00:14:45,554
And then you go under
and you all go under.

294
00:14:45,554 --> 00:14:47,616
And the amazing thing about this
simulation is,

295
00:14:47,616 --> 00:14:50,678
like at the time that we explain it
to you, you figure this out.

296
00:14:51,366 --> 00:14:54,740
So you come into the situation,
knowing what we have to do

297
00:14:54,740 --> 00:14:56,303
is figure this out together.

298
00:14:56,303 --> 00:15:00,240
Otherwise we're all going to,
you know, fish all the fish out of the sea

299
00:15:00,365 --> 00:15:03,365
and go bankrupt and lose our livelihoods.

300
00:15:03,740 --> 00:15:05,677
But every single time it happens anyways.

301
00:15:07,739 --> 00:15:09,239
Because

302
00:15:09,239 --> 00:15:12,177
of this fact, the tragedy of the comments,
like, I still have a goal

303
00:15:12,177 --> 00:15:15,614
and I'm trying to make a balance sheet
and I'm trying to get my employees paid.

304
00:15:15,926 --> 00:15:17,926
I'm trying to feed my family.

305
00:15:17,926 --> 00:15:20,863
And by the way,
if I'm the first one to blink

306
00:15:20,863 --> 00:15:23,863
and even one other person
doesn't go along with it

307
00:15:25,113 --> 00:15:27,113
and I'm going to lose
and they're going to win

308
00:15:27,113 --> 00:15:29,925
and I'm sacrificing for nothing, right?

309
00:15:29,925 --> 00:15:32,675
And so in the end, best of intentions,

310
00:15:32,675 --> 00:15:35,675
we still mess it up most of the time.

311
00:15:35,675 --> 00:15:37,924
It's kind of what happened
during Covid, right?

312
00:15:37,924 --> 00:15:40,924
If you think about this right,
think about the right.

313
00:15:40,924 --> 00:15:43,237
We have an example of,

314
00:15:43,237 --> 00:15:44,111
you know,

315
00:15:44,111 --> 00:15:48,111
one of the one of the greatest examples
of sort of rapid scientific cooperation,

316
00:15:48,111 --> 00:15:49,236
probably in our lifetimes, right,

317
00:15:49,236 --> 00:15:51,861
in the development of Covid vaccines
here and around the world

318
00:15:51,861 --> 00:15:54,236
and getting them
through regulatory approvals

319
00:15:54,236 --> 00:15:56,860
and finding ways
to finance them, etc., etc.

320
00:15:56,860 --> 00:15:58,985
we didn't do as great a job
at getting them

321
00:15:58,985 --> 00:16:01,548
into the arms of the people who need it
the most.

322
00:16:01,548 --> 00:16:05,172
I know spends a lot of time doing Covid
related stuff,

323
00:16:06,047 --> 00:16:09,047
and but mostly talking about it.

324
00:16:09,359 --> 00:16:14,922
But I know that in 2021, you know,
which was the year that the vaccine

325
00:16:14,922 --> 00:16:19,171
rollout really happened in earnest
by the end of 2021, Canada

326
00:16:19,546 --> 00:16:22,358
had purchased
six times more Covid vaccines

327
00:16:22,358 --> 00:16:25,296
than they could ever possibly need
for their own population

328
00:16:25,296 --> 00:16:27,920
because they were trying to leverage
against the different types and have

329
00:16:27,920 --> 00:16:29,795
whichever ones would be most effective.

330
00:16:29,795 --> 00:16:34,545
And Malawi had still not been able to
vaccinate its frontline doctors, nurses.

331
00:16:35,607 --> 00:16:36,232
Right.

332
00:16:36,232 --> 00:16:39,232
You designed
a system, you would never do it that way.

333
00:16:39,420 --> 00:16:41,669
And, you know,
we thought at the beginning that like,

334
00:16:41,669 --> 00:16:43,044
this is like the alien invasion.

335
00:16:43,044 --> 00:16:45,544
Finally, the global threat
that can bring us all together

336
00:16:45,544 --> 00:16:47,169
like a Will Smith movie, right?

337
00:16:47,169 --> 00:16:50,169
And like, we can work together
and we can conquer it.

338
00:16:50,169 --> 00:16:51,356
And this is going to be great.

339
00:16:51,356 --> 00:16:53,793
This is the way we can figure out
how we're going to start to cooperate

340
00:16:53,793 --> 00:16:57,543
as a society for world scale problems,
and climate change is next, right?

341
00:16:57,856 --> 00:17:00,480
This is my naive optimism in 2020.

342
00:17:00,480 --> 00:17:02,105
And it didn't go that way.

343
00:17:02,105 --> 00:17:04,668
And again, because of sort of narrow,
narrow self-interest.

344
00:17:04,668 --> 00:17:07,667
So the way Antonio Guterres put it,

345
00:17:07,667 --> 00:17:09,730
a couple of years ago,
the secretary general

346
00:17:09,730 --> 00:17:13,104
of the UN, we faced the greatest
cascade of crises in our lifetimes.

347
00:17:13,104 --> 00:17:16,167
And yet solidarity is missing
when we need it most.

348
00:17:16,792 --> 00:17:21,104
And you'll see, as we talk about system
leadership and system entrepreneurship,

349
00:17:21,854 --> 00:17:25,916
how important it is for
you as leaders to be doing

350
00:17:25,916 --> 00:17:28,603
the work of building relationships
and bringing people together.

351
00:17:29,603 --> 00:17:32,228
That's it really important
in the global Aids movement that I came in

352
00:17:32,228 --> 00:17:35,978
sort of at the tail end of
when you think about what had to happen

353
00:17:36,477 --> 00:17:39,102
to go from,

354
00:17:39,102 --> 00:17:43,227
let's say, 1997,
I was a like a young university

355
00:17:43,227 --> 00:17:48,039
graduate who went to work as a volunteer
for a Tanzanian NGO called Kuleana

356
00:17:48,039 --> 00:17:51,164
that was doing children's rights work
and particularly working

357
00:17:51,164 --> 00:17:54,226
with homeless kids and shelters
and things like that.

358
00:17:54,601 --> 00:17:59,101
And so I happened there,
to try to be useful as a 21 year old

359
00:17:59,101 --> 00:18:02,538
who didn't know very much about anything,
at the height of the Aids crisis.

360
00:18:02,538 --> 00:18:03,100
Right.

361
00:18:03,100 --> 00:18:06,913
And 2000 kids in one shelter,
all of them had lost their parents

362
00:18:06,913 --> 00:18:11,600
and their families to to the Aids
pandemic and ended up from small villages

363
00:18:11,600 --> 00:18:15,474
in a city in terrible circumstances
and situations and suffering immeasurably.

364
00:18:15,724 --> 00:18:20,411
And I once got sick with malaria and
went to the hospital, to Kondo Hospital.

365
00:18:20,724 --> 00:18:24,724
And it was like the worst place I've ever
seen, you know, for people to a bed.

366
00:18:25,099 --> 00:18:26,348
Nothing was working.

367
00:18:26,348 --> 00:18:27,973
There were just people lying in hallways.

368
00:18:27,973 --> 00:18:30,723
There was suffering everywhere.
The system was totally overwhelmed.

369
00:18:31,911 --> 00:18:34,910
I knew that if things didn't go well,
I could get out.

370
00:18:34,910 --> 00:18:36,723
Why do I deserve to get out of nothing
else?

371
00:18:36,723 --> 00:18:39,597
Right?
This was the conversion moment for me.

372
00:18:39,597 --> 00:18:44,535
But then from there to 2003, 2005,
somewhere in there,

373
00:18:44,847 --> 00:18:48,659
we suddenly saw the creation
of the President's Program for Aids relief

374
00:18:48,659 --> 00:18:53,096
in the US, for the Global Fund to Fight
Aids, TB and malaria, billions of dollars

375
00:18:53,096 --> 00:18:56,659
of investment, and a whole bunch of things
that brought drug costs down.

376
00:18:56,659 --> 00:18:59,158
And suddenly everyone was like,
yeah, Africa with Aids

377
00:18:59,158 --> 00:19:01,533
deserves a shot of treatment
and we're going to do stuff.

378
00:19:01,533 --> 00:19:03,408
So how did that happen?

379
00:19:03,408 --> 00:19:04,470
It didn't happen that quickly.

380
00:19:04,470 --> 00:19:08,220
Of course, this was activism and advocacy
and social movements

381
00:19:08,220 --> 00:19:10,657
and other kinds of things
that happened over 20 years.

382
00:19:11,845 --> 00:19:13,470
But ultimately, there was a

383
00:19:13,470 --> 00:19:18,344
time in which Aids activists
who had been throwing blood on politicians

384
00:19:18,344 --> 00:19:20,657
and pharmaceutical CEOs for years

385
00:19:20,657 --> 00:19:23,344
had to sit down at the table together
with them and said, let's try to figure

386
00:19:23,344 --> 00:19:26,406
this out together, along with doctors
and other kinds of folks,

387
00:19:26,656 --> 00:19:30,468
so people who don't see the world
the same way, who don't trust each other,

388
00:19:30,531 --> 00:19:32,031
who don't like each other,

389
00:19:32,031 --> 00:19:33,843
have to find a way to see that
there's something

390
00:19:33,843 --> 00:19:36,343
that they share in common
in terms of their interests.

391
00:19:36,343 --> 00:19:36,968
Right.

392
00:19:36,968 --> 00:19:40,780
And the people who were able to broker
those kinds of relationships and those

393
00:19:40,780 --> 00:19:45,030
kinds of conversations are the ones
that can change the trajectory of things.

394
00:19:45,030 --> 00:19:45,655
Right?

395
00:19:45,655 --> 00:19:48,654
That's what we call system leadership.

396
00:19:50,092 --> 00:19:50,592
Okay.

397
00:19:50,592 --> 00:19:53,092
So I want to talk about
social entrepreneurship briefly,

398
00:19:53,092 --> 00:19:56,716
because that's sort of the
the angle at which, I come from

399
00:19:56,966 --> 00:20:00,466
and at the school center, I'll say we
even though I'm not there anymore,

400
00:20:00,903 --> 00:20:03,591
it's a very expansive definition
of social entrepreneurship.

401
00:20:03,591 --> 00:20:08,278
So many people think of social enterprise
when you hear social entrepreneurship.

402
00:20:08,403 --> 00:20:09,153
And that is true.

403
00:20:09,153 --> 00:20:13,652
Social enterprises are businesses that try
to create positive impacts, right?

404
00:20:13,652 --> 00:20:16,152
And they often do that
by generating some revenue

405
00:20:16,152 --> 00:20:17,965
for sustainability
and getting some grants.

406
00:20:17,965 --> 00:20:19,464
And breaking even, etc.

407
00:20:19,464 --> 00:20:22,902
that's all good and that's all fine, but
it's just one little piece of the puzzle.

408
00:20:23,839 --> 00:20:25,839
So let's start with entrepreneurship.

409
00:20:25,839 --> 00:20:26,714
What do you think of

410
00:20:26,714 --> 00:20:31,151
when you think of entrepreneurship,
or when you think of entrepreneurial?

411
00:20:31,151 --> 00:20:32,713
What kinds of words come to mind?

412
00:20:32,713 --> 00:20:34,963
You can you can share a definition
if you've got one in mind.

413
00:20:34,963 --> 00:20:37,213
But what what comes to mind, child?

414
00:20:37,213 --> 00:20:38,463
Things that.

415
00:20:38,463 --> 00:20:40,338
Like get rich quick, people.

416
00:20:40,338 --> 00:20:42,338
Get rich quick, people. Okay.

417
00:20:42,338 --> 00:20:44,275
Should I take a personally millionaire?

418
00:20:44,275 --> 00:20:45,650
Oh that's right.

419
00:20:45,650 --> 00:20:50,899
Think like, willing to take risks,
but ultimately chasing profit.

420
00:20:51,024 --> 00:20:53,024
Yeah. Okay. Big risks.

421
00:20:53,024 --> 00:20:55,337
In search of big opportunity.
But in this case, big profit.

422
00:20:55,337 --> 00:20:58,774
And of course, we as a society
kind of lionize, right?

423
00:20:59,024 --> 00:21:00,086
Or fetishize.

424
00:21:00,086 --> 00:21:03,336
The heroic entrepreneur
is usually like a middle aged

425
00:21:03,336 --> 00:21:06,711
white guy in a black turtleneck
or wielding a chainsaw or whatever.

426
00:21:06,711 --> 00:21:09,148
Right. But but those are
the success stories that we think of.

427
00:21:09,148 --> 00:21:11,773
It's like the heroic entrepreneur.

428
00:21:11,773 --> 00:21:13,398
Great. What else?

429
00:21:13,398 --> 00:21:14,148
Yeah.

430
00:21:14,148 --> 00:21:17,147
So like a structured problem
solving process.

431
00:21:17,397 --> 00:21:19,897
Step one would be
see a problem set to solve it.

432
00:21:19,897 --> 00:21:22,709
And then step three scale
your solution. Okay. Awesome.

433
00:21:22,709 --> 00:21:23,397
Yeah.

434
00:21:23,397 --> 00:21:25,772
I also spent around
40 years on Kendall Square.

435
00:21:25,772 --> 00:21:28,459
So I think of like biotech startup.
Yeah yeah.

436
00:21:28,459 --> 00:21:29,334
Yeah. Amazing.

437
00:21:29,334 --> 00:21:35,208
So but that's really about,
you know, leveraging new technology to,

438
00:21:36,771 --> 00:21:38,583
to drive value, right.

439
00:21:38,583 --> 00:21:39,646
To, to speak broadly.

440
00:21:39,646 --> 00:21:42,958
And that could be solving problems
and saving lives and making money.

441
00:21:43,020 --> 00:21:45,145
Hopefully both of them. Right. Yeah.

442
00:21:45,145 --> 00:21:48,207
Pioneering. Pioneering. Fantastic. Right.

443
00:21:48,270 --> 00:21:50,895
So doing stuff
that maybe nobody's ever done before

444
00:21:50,895 --> 00:21:53,707
or doing things in a way that no one's
ever done them before

445
00:21:53,707 --> 00:21:56,707
or doing them in a place
where it hasn't been done before.

446
00:21:57,207 --> 00:22:01,331
Sometimes it's about bringing things
like the fruits of modern medical science

447
00:22:01,706 --> 00:22:05,206
to market sort of communities
that have been excluded from the system.

448
00:22:05,581 --> 00:22:08,581
What else?

449
00:22:10,893 --> 00:22:12,330
Come on new, you got more ideas?

450
00:22:12,330 --> 00:22:14,705
Work with me here.
Try to keep you all the way.

451
00:22:14,705 --> 00:22:15,768
Oh, it's kind of in line with labor.

452
00:22:15,768 --> 00:22:18,142
I mean I think creativity. Yeah. Great.

453
00:22:18,142 --> 00:22:23,017
So creativity, pioneering, taking risk,
solving problems.

454
00:22:23,017 --> 00:22:23,829
Absolutely.

455
00:22:23,829 --> 00:22:26,142
All of these things,
all of these things are true.

456
00:22:26,142 --> 00:22:27,704
Going big right.

457
00:22:27,704 --> 00:22:29,704
Yeah. It could be. You know,
I want to be a billionaire.

458
00:22:29,704 --> 00:22:30,454
We could just be like,

459
00:22:30,454 --> 00:22:33,454
I want to build something massive on
and do something massive.

460
00:22:34,391 --> 00:22:38,703
So the classic definition,
a classic definition of entrepreneurship.

461
00:22:38,703 --> 00:22:41,891
This is a guy called Howard Stephenson,
I think back in the 80s,

462
00:22:42,515 --> 00:22:44,328
at Harvard, the pursuit of opportunity

463
00:22:45,390 --> 00:22:46,515
beyond the resources

464
00:22:46,515 --> 00:22:49,515
currently under your control.

465
00:22:50,265 --> 00:22:54,077
And I share this because entrepreneurship

466
00:22:54,077 --> 00:22:57,827
is not about starting a venture
necessarily.

467
00:22:58,889 --> 00:23:01,889
It's about the pursuit of opportunity

468
00:23:02,451 --> 00:23:07,701
beyond what seems possible right
now, beyond the resources that we have.

469
00:23:08,013 --> 00:23:12,013
And that could mean leveraging or
introducing new products or technologies.

470
00:23:12,263 --> 00:23:16,263
It could be leveraging networks
or relationships and new ways of coming

471
00:23:16,263 --> 00:23:20,762
together or new markets,
like I say, trying to bring technologies

472
00:23:21,012 --> 00:23:25,762
or the fruits of medical science
or whatever it is to new markets, right?

473
00:23:25,762 --> 00:23:30,012
The people who figured out how to address
the market failures of Aids, drugs

474
00:23:30,012 --> 00:23:33,011
that were $10,000 per person per year

475
00:23:33,386 --> 00:23:36,386
and said we could rejig this whole thing

476
00:23:36,386 --> 00:23:40,136
and they could be produced
for less than $100 per person per year.

477
00:23:40,511 --> 00:23:42,511
And the volume would explode.

478
00:23:42,511 --> 00:23:44,823
So we can go to pharmaceutical
companies and say, hey,

479
00:23:45,885 --> 00:23:48,885
you can make just as much money
as you're making right now,

480
00:23:48,885 --> 00:23:52,760
maybe more by dropping your prices 95%.

481
00:23:53,197 --> 00:23:55,885
And we'll give you a guaranteed market
to hundreds of millions

482
00:23:55,885 --> 00:23:57,759
of more people for life.

483
00:23:57,759 --> 00:24:00,947
Your margins will be small,
your shareholders will still be happy,

484
00:24:01,572 --> 00:24:04,134
and activists
won't be throwing blood on you anymore.

485
00:24:04,134 --> 00:24:05,321
That sounds good, right?

486
00:24:05,321 --> 00:24:06,884
So that's an entrepreneurial kind

487
00:24:06,884 --> 00:24:10,821
of solution to bringing a technology
into a new market.

488
00:24:11,133 --> 00:24:14,196
So we think of entrepreneurial
entrepreneurship

489
00:24:14,196 --> 00:24:16,258
as entrepreneurial ism, right?

490
00:24:16,258 --> 00:24:21,133
So it's people in groups that are acting
the way that you guys are talking about

491
00:24:21,508 --> 00:24:26,257
being creative, seeing new possibilities,
thinking big, thinking differently,

492
00:24:26,257 --> 00:24:29,257
trying to pioneer stuff,
trying to solve problems,

493
00:24:30,132 --> 00:24:32,882
trying to create opportunity
where there is right

494
00:24:32,882 --> 00:24:37,069
entrepreneurs see opportunity,
where others see challenges and problems.

495
00:24:37,506 --> 00:24:38,444
And we talk about social.

496
00:24:38,444 --> 00:24:40,194
Oh, sorry, it was already there.

497
00:24:40,194 --> 00:24:44,881
The sort of the technical term is primacy
of social environmental value creation.

498
00:24:44,881 --> 00:24:46,318
So it defines,

499
00:24:46,318 --> 00:24:49,380
the entrepreneur that you were talking
about from a social entrepreneur

500
00:24:49,568 --> 00:24:53,318
is the social entrepreneur says,
we may be in a for profit venture,

501
00:24:53,318 --> 00:24:54,692
we may be a not for profit,

502
00:24:54,692 --> 00:24:59,692
we may be in government,
whatever our primary purpose, our primary

503
00:24:59,692 --> 00:25:03,754
and the reason we exist and are doing
this work is to make the world

504
00:25:03,754 --> 00:25:05,129
better in some way, shape or form.

505
00:25:06,504 --> 00:25:07,754
So that's addressing a

506
00:25:07,754 --> 00:25:10,754
social problem or an environmental problem
or what have you.

507
00:25:11,066 --> 00:25:14,128
And you know, in many cases,
being profitable

508
00:25:14,441 --> 00:25:18,003
or making money might be a way
to scale your impact, right?

509
00:25:18,003 --> 00:25:20,128
Because nobody wants to rely on donations
forever.

510
00:25:20,128 --> 00:25:22,440
There's usually a ceiling to that,

511
00:25:22,440 --> 00:25:25,690
or a duration, you know, after
which it's going to be difficult to do.

512
00:25:25,877 --> 00:25:26,502
That's fine.

513
00:25:26,502 --> 00:25:29,002
That's the business model.
The business model is separate.

514
00:25:29,002 --> 00:25:32,002
It's about being entrepreneurial
and focusing on problems.

515
00:25:32,502 --> 00:25:36,439
The second thing
that I want to emphasize about this,

516
00:25:36,439 --> 00:25:39,876
if you buy my argument
that this is about entrepreneurial ism,

517
00:25:41,126 --> 00:25:44,688
you don't have to be
someone who's starting or helping to start

518
00:25:44,938 --> 00:25:45,813
a new venture.

519
00:25:45,813 --> 00:25:49,001
So classically, right, an entrepreneur
is someone who builds something

520
00:25:49,001 --> 00:25:52,063
new, starts an organization, starts
a venture, etc.

521
00:25:52,875 --> 00:25:58,062
an entrepreneur is someone who is being
entrepreneurial, but working inside

522
00:25:59,375 --> 00:26:00,375
of an existing

523
00:26:00,375 --> 00:26:03,374
organization that says system here,
but I would say organization.

524
00:26:03,687 --> 00:26:06,687
So that could be someone
who is working in a big company

525
00:26:07,937 --> 00:26:10,686
and actually saying we could do things
differently

526
00:26:10,686 --> 00:26:13,999
and leverage
the incredible market share and power

527
00:26:13,999 --> 00:26:17,373
and influence and all these other things
that this company has.

528
00:26:17,873 --> 00:26:19,186
It could be someone like

529
00:26:19,186 --> 00:26:22,248
the Minister of Health during the period,
or one that I'm talking about,

530
00:26:23,060 --> 00:26:25,623
one of the most social entrepreneurial
people I've ever worked with.

531
00:26:25,623 --> 00:26:29,372
She was a sitting minister of health,
but she acted like an entrepreneur

532
00:26:29,372 --> 00:26:31,810
because she was never accepting
the status quo.

533
00:26:31,810 --> 00:26:33,747
She was always looking for
new opportunities.

534
00:26:33,747 --> 00:26:38,247
She was always pushing to do better
and more and faster and bigger,

535
00:26:38,559 --> 00:26:41,434
and was the one who really drove
this kind of transformation.

536
00:26:41,434 --> 00:26:44,434
And she did it from within
a government bureaucracy.

537
00:26:44,621 --> 00:26:46,183
So it can happen anywhere.

538
00:26:47,433 --> 00:26:49,058
Maybe
not in the University of Oxford, that

539
00:26:49,058 --> 00:26:51,496
maybe the only bureaucracy impervious.

540
00:26:51,496 --> 00:26:53,870
I'm just kidding.

541
00:26:53,870 --> 00:26:57,620
And then the third kind,
which is sometimes called extra preneur,

542
00:26:57,808 --> 00:27:00,995
are the ones who entrepreneur
at the systems level

543
00:27:01,557 --> 00:27:04,057
that sort of
go beyond single organization,

544
00:27:04,057 --> 00:27:07,932
whether it's a startup or an incumbent
existing organization, and say, actually,

545
00:27:08,369 --> 00:27:12,181
you know, the kinds of problem
that we're wanting to address here

546
00:27:12,244 --> 00:27:15,369
is the sort of thing that no single
organization can solve on its own.

547
00:27:16,244 --> 00:27:19,243
We have to get a whole bunch
of different actors

548
00:27:19,368 --> 00:27:22,681
orchestrated in a way
that's going to help address this problem.

549
00:27:22,681 --> 00:27:25,993
We have to find people
in different parts of the system

550
00:27:26,368 --> 00:27:29,743
that have the right leverage
in the right place to get stuff done.

551
00:27:29,992 --> 00:27:33,992
We need the activists
and the pharmaceutical companies

552
00:27:34,180 --> 00:27:39,117
and the, you know, really cutting edge,
implementation doctors like Paul Farmer

553
00:27:39,242 --> 00:27:43,991
and the political leaders,
which included George W Bush.

554
00:27:44,116 --> 00:27:44,491
Right.

555
00:27:45,929 --> 00:27:48,803
All pointing in the same direction.

556
00:27:48,803 --> 00:27:51,178
And that system, entrepreneurship
is another term for this.

557
00:27:51,178 --> 00:27:53,053
So this is what

558
00:27:53,053 --> 00:27:54,553
the actual purpose of this talk is.

559
00:27:54,553 --> 00:27:57,178
Now we're 30 minutes in
and I'm just getting to the point.

560
00:27:57,178 --> 00:27:57,865
But here we are.

561
00:27:57,865 --> 00:27:59,865
So I want to talk about systems
entrepreneurship.

562
00:27:59,865 --> 00:28:03,177
I take all the things that I've said
now and give you an example.

563
00:28:03,365 --> 00:28:06,365
I'm not going to spend a ton of time
talking about

564
00:28:06,365 --> 00:28:09,552
systems thinking and systems change
and the really technical stuff.

565
00:28:09,552 --> 00:28:12,552
I'm hoping it sounds like
you've already had some of that.

566
00:28:12,614 --> 00:28:15,114
So. But feel free to ask questions
if anything isn't clear.

567
00:28:15,114 --> 00:28:18,301
What I'd rather do
is kind of show you by example

568
00:28:18,301 --> 00:28:21,988
and try to bring this to life,
because what I've learned is that systems

569
00:28:21,988 --> 00:28:25,988
change is really easy to talk about,
and it's really hard to do.

570
00:28:26,425 --> 00:28:29,675
And a lot of our research work at the
school center was really focused on like,

571
00:28:29,675 --> 00:28:32,800
what are practical approaches
to trying to shift systems for the better?

572
00:28:32,800 --> 00:28:33,800
How do you do it?

573
00:28:33,800 --> 00:28:36,362
If you're starting out at the beginning
of a journey, where do you start?

574
00:28:37,550 --> 00:28:39,237
And it's just not that easy, right?

575
00:28:39,237 --> 00:28:41,987
It's like it's like intangible, almost.

576
00:28:41,987 --> 00:28:43,424
And so we and lots of others

577
00:28:43,424 --> 00:28:46,424
have been engaged and trying to figure out
sort of how that works.

578
00:28:47,049 --> 00:28:49,111
So when I talk about system
entrepreneurship,

579
00:28:49,111 --> 00:28:51,111
here's just some bits of definition.

580
00:28:51,111 --> 00:28:53,673
There will not be a quiz.
You'll have these slides.

581
00:28:53,673 --> 00:28:57,236
I know your brains are tired person
or organization

582
00:28:58,173 --> 00:29:01,548
that facilitates
change to an entire ecosystem.

583
00:29:02,360 --> 00:29:06,172
By addressing and incorporating all the
components and actors that are required.

584
00:29:06,235 --> 00:29:07,110
Not all of them,

585
00:29:07,110 --> 00:29:10,422
but all that are required to move
the needle on a particular issue.

586
00:29:10,922 --> 00:29:15,484
So we could do this in the context
of a health system or an education system,

587
00:29:16,171 --> 00:29:19,171
or an environmental or an energy system,
etc..

588
00:29:20,859 --> 00:29:24,921
System entrepreneurs
move beyond delivering solutions

589
00:29:25,983 --> 00:29:26,296
and think

590
00:29:26,296 --> 00:29:29,295
about and influence
the architecture of the system itself.

591
00:29:29,358 --> 00:29:32,733
One tool that we use a lot in systems
thinking is something called the iceberg

592
00:29:32,920 --> 00:29:33,608
model.

593
00:29:33,608 --> 00:29:35,920
Some of you are probably familiar
with that.

594
00:29:35,920 --> 00:29:37,857
You know,
like if you think about the iceberg,

595
00:29:37,857 --> 00:29:41,544
right, you've heard tip of the iceberg,
this little bit that's above the water

596
00:29:41,544 --> 00:29:45,419
is represents only a very small piece
of the mass of the entire thing.

597
00:29:45,419 --> 00:29:47,856
That's why the Titanic sunk. Right.

598
00:29:47,856 --> 00:29:51,544
And so beneath the surface,
that's where a lot of the action is.

599
00:29:51,544 --> 00:29:55,168
And so an iceberg model of a level
that's above the surface is called events.

600
00:29:55,418 --> 00:29:58,418
These are the things that are happening
that we can see and observe.

601
00:29:58,418 --> 00:30:01,293
And then you have three levels below
the surface is kind of a root

602
00:30:01,293 --> 00:30:02,793
cause analysis.

603
00:30:02,793 --> 00:30:06,105
So first you look at the patterns ways
you can measure trends

604
00:30:06,105 --> 00:30:09,105
and things like that
to see what's happening over time.

605
00:30:09,230 --> 00:30:13,854
Below that you have the structures
what are the laws and the policies

606
00:30:13,854 --> 00:30:15,479
and the economic factors

607
00:30:15,479 --> 00:30:19,041
and the power dynamics
that make things are the way they are.

608
00:30:19,229 --> 00:30:21,291
What are the rules of the game?

609
00:30:21,291 --> 00:30:24,666
And then even deeper than that, you have
the mental models are kind of shared

610
00:30:24,666 --> 00:30:26,228
ways of seeing the world

611
00:30:27,603 --> 00:30:29,103
and what we think of as normal.

612
00:30:29,103 --> 00:30:32,478
And obviously not everybody shares
the same mental models about everything.

613
00:30:33,228 --> 00:30:35,915
But that is the sort of deepest level
of the system.

614
00:30:35,915 --> 00:30:39,665
And so what I would say is that
what social entrepreneurs want to do

615
00:30:40,915 --> 00:30:43,415
is not to,

616
00:30:43,415 --> 00:30:46,414
address the problem superficially,

617
00:30:46,602 --> 00:30:48,789
just treating a patient in a clinic.

618
00:30:48,789 --> 00:30:50,601
Very good and very important.

619
00:30:50,601 --> 00:30:51,476
Tom. Shoes.

620
00:30:51,476 --> 00:30:54,789
For those who are American,
you buy a pair of, like, cool canvas shoes

621
00:30:54,789 --> 00:30:56,976
and they give away a pair of shoes
to somebody in need.

622
00:30:56,976 --> 00:30:58,038
Somewhere in the world.

623
00:30:58,038 --> 00:30:58,851
I was working in Rwanda.

624
00:30:58,851 --> 00:31:01,163
They call us up every year
or two and be like, hey,

625
00:31:01,163 --> 00:31:02,850
can we send you a 40ft container of shoes?

626
00:31:02,850 --> 00:31:04,850
Would you help distribute them?

627
00:31:04,850 --> 00:31:06,725
We'll be like, yeah, no, that'd be great.

628
00:31:06,725 --> 00:31:08,163
There's a lot of
people who need shoes here.

629
00:31:09,287 --> 00:31:09,850
But I'd always

630
00:31:09,850 --> 00:31:12,850
have this gnawing sense that, like,

631
00:31:12,912 --> 00:31:15,724
is this really fixing anything?

632
00:31:15,724 --> 00:31:17,724
Because, like,
the shoes are going to wear out

633
00:31:17,724 --> 00:31:21,536
and the kid who couldn't go to school
because they didn't have shoes today

634
00:31:22,099 --> 00:31:25,599
might not be able to next year
unless like, Tom shoes comes along again.

635
00:31:25,724 --> 00:31:29,723
Why can't we understand and think about
why we're living in a world

636
00:31:29,723 --> 00:31:32,223
where kids can't go to school
because they don't have shoes

637
00:31:32,223 --> 00:31:35,223
in the first place, and address
those underlying root causes?

638
00:31:35,223 --> 00:31:35,848
Right?

639
00:31:35,848 --> 00:31:38,598
That's what we're talking about
when we talk about systems thinking that's

640
00:31:38,598 --> 00:31:39,785
what kind of the iceberg does.

641
00:31:39,785 --> 00:31:41,285
So it's really going deep

642
00:31:41,285 --> 00:31:45,410
and trying to understand what is the
architecture of the status quo.

643
00:31:45,722 --> 00:31:49,784
Why are things the way they are right now,
and why is it so hard to change?

644
00:31:50,222 --> 00:31:52,721
Because of status quo? Is is
rigid. You know what I mean?

645
00:31:54,159 --> 00:31:57,096
People don't want it to change because
often times they're benefiting from it.

646
00:31:57,096 --> 00:32:00,096
So systems entrepreneurs
think about that kind of stuff

647
00:32:00,283 --> 00:32:03,283
and act as a as a catalytic force.

648
00:32:03,721 --> 00:32:06,970
What that means is
it's not always about doing the thing,

649
00:32:07,720 --> 00:32:12,032
like providing the service
or the intervention or the product

650
00:32:12,032 --> 00:32:15,282
or whatever it is about it, and creating

651
00:32:15,282 --> 00:32:18,282
the conditions that enable change.

652
00:32:18,594 --> 00:32:22,032
Sometimes that is bringing the right group
of people together.

653
00:32:22,282 --> 00:32:27,344
Sometimes that is a policy change
that, maybe incentivizes action

654
00:32:27,719 --> 00:32:31,656
or increases the cost of inaction
or something else.

655
00:32:31,843 --> 00:32:33,718
You're doing something that shifts

656
00:32:33,718 --> 00:32:36,718
the dynamics of the whole system,
that allows things to happen.

657
00:32:37,718 --> 00:32:38,218
Okay.

658
00:32:38,218 --> 00:32:41,968
So we're wired to think about solutions,
right?

659
00:32:42,093 --> 00:32:42,905
We see a problem.

660
00:32:42,905 --> 00:32:45,967
We want to fix it in the systems
thinking course

661
00:32:45,967 --> 00:32:49,342
that I taught
to all of the MBAs and MBAs for six years.

662
00:32:50,592 --> 00:32:52,154
They you work in teams on

663
00:32:52,154 --> 00:32:56,216
like a sort of big sustainable development
channel at different stages of a year.

664
00:32:56,529 --> 00:32:59,404
What I would tell them
is that only 20% of your final

665
00:32:59,404 --> 00:33:02,466
mark is based on the solution
that you come up with.

666
00:33:02,778 --> 00:33:07,590
80% of your mark is based
on your understanding of the system

667
00:33:08,153 --> 00:33:11,153
and what's going on there,
and your ability to articulate that.

668
00:33:12,153 --> 00:33:15,152
Because if you just jump to the solution

669
00:33:15,152 --> 00:33:18,152
in ways we all want to do,
you'll usually get it wrong.

670
00:33:19,027 --> 00:33:21,527
Or you only get one piece of the puzzle.

671
00:33:21,527 --> 00:33:24,214
And so let's cash,
we would say like strike

672
00:33:24,214 --> 00:33:27,464
the word solution from your vocabulary
for the next two months.

673
00:33:27,464 --> 00:33:29,901
And every time you have an idea,
oh, we could do this.

674
00:33:29,901 --> 00:33:31,464
Write it down on a piece of paper
over here.

675
00:33:31,464 --> 00:33:32,588
That's your parking lot.

676
00:33:32,588 --> 00:33:33,651
And now let's go back to

677
00:33:33,651 --> 00:33:36,088
trying to understand
what's actually going on in the system.

678
00:33:36,088 --> 00:33:37,901
Right.
So it's it's a different way of thinking.

679
00:33:37,901 --> 00:33:40,338
That's why those exact MBAs were going

680
00:33:40,338 --> 00:33:43,650
berserk and really struggling with this
at the beginning, because they're,

681
00:33:44,650 --> 00:33:46,400
you know, they're action oriented people.

682
00:33:46,400 --> 00:33:47,212
So it's different.

683
00:33:47,212 --> 00:33:48,212
It's different. Right.

684
00:33:48,212 --> 00:33:51,212
Then we talk about systems thinking,

685
00:33:51,524 --> 00:33:53,149
we've seen this.

686
00:33:53,149 --> 00:33:55,274
It sounds like, right.

687
00:33:55,274 --> 00:33:59,024
We see the parts of the system
that were most proximate to.

688
00:34:00,024 --> 00:34:03,399
So if I'm a doctor,
I think about a problem,

689
00:34:03,399 --> 00:34:08,023
a health care problem from the level
of patient care in a clinic or a hospital.

690
00:34:09,086 --> 00:34:11,023
For example, somebody else

691
00:34:11,023 --> 00:34:14,023
might be a pharmacist,
somebody else might be a policy person.

692
00:34:14,210 --> 00:34:16,210
For patients, it's
going to be completely different

693
00:34:16,210 --> 00:34:19,147
for community health workers
going to market,

694
00:34:19,147 --> 00:34:20,710
for somebody
halfway around the world, it's

695
00:34:20,710 --> 00:34:22,959
going to be totally different
because their context is different.

696
00:34:22,959 --> 00:34:25,147
We tend to see what's
right in front of us,

697
00:34:25,147 --> 00:34:28,147
or we tend to focus on the part
of the problem where we have expertise.

698
00:34:28,646 --> 00:34:29,959
You know, I started this.

699
00:34:31,146 --> 00:34:32,521
Some of you must be medical, right?

700
00:34:32,521 --> 00:34:35,083
You know, medical training is like years.

701
00:34:35,083 --> 00:34:37,083
I did three specialties
in a public health degree.

702
00:34:37,083 --> 00:34:39,583
I was like in my mid 30s before
I got a job.

703
00:34:39,583 --> 00:34:43,083
And so I spent all those years
learning stuff, and I knew a lot of stuff.

704
00:34:43,708 --> 00:34:46,270
I knew all about the path of physiology
and all the drugs,

705
00:34:46,270 --> 00:34:48,082
everything there was to know about HIV.

706
00:34:48,082 --> 00:34:52,082
And then I got out of a situation where
I felt totally, woefully underequipped

707
00:34:52,520 --> 00:34:55,519
to even understand
what was going on or do anything useful.

708
00:34:55,957 --> 00:34:58,957
And so what it felt like it'd be useful
to do is just like, well,

709
00:34:58,957 --> 00:35:00,206
I'm going to just give medical care.

710
00:35:00,206 --> 00:35:01,331
Then I'm going to start getting patients

711
00:35:01,331 --> 00:35:03,644
and we got to get more drugs
here, etc., etc.

712
00:35:03,644 --> 00:35:07,018
but I was just focusing on that one
little piece of the puzzle.

713
00:35:07,018 --> 00:35:08,706
That's what
this cartoon is all about, right?

714
00:35:10,893 --> 00:35:12,143
So systems thinking is a

715
00:35:12,143 --> 00:35:16,455
way of like retraining your brain
to try to look for patterns and new ways.

716
00:35:16,768 --> 00:35:20,892
So commonly you think about moving
from linear thinking of cause and effect.

717
00:35:21,267 --> 00:35:24,392
A leads to B leads to C, end

718
00:35:25,079 --> 00:35:27,392
to circular thinking, A leads

719
00:35:27,392 --> 00:35:30,892
to B leads to C leads to a right.

720
00:35:31,079 --> 00:35:33,329
The head of the arrow catches its tail.

721
00:35:33,329 --> 00:35:34,954
We start to see our feedback loops.

722
00:35:34,954 --> 00:35:37,079
That could be,

723
00:35:37,079 --> 00:35:40,078
vicious cycles or virtuous circles.

724
00:35:40,453 --> 00:35:45,515
It could be stabilizing negative feedback
loops like the system in this room.

725
00:35:45,515 --> 00:35:47,078
I guess we have an open door right now,

726
00:35:47,078 --> 00:35:48,640
you know, heating and cooling
systems, right?

727
00:35:48,640 --> 00:35:49,078
Or negative

728
00:35:49,078 --> 00:35:52,765
feedback systems that are designed
to keep you at a comfortable temperature.

729
00:35:53,077 --> 00:35:55,265
And if it gets too hot,
the cooling kicks in.

730
00:35:55,265 --> 00:35:57,014
If it gets too cold, the heating kicks.

731
00:35:57,014 --> 00:36:00,452
So it's meant to keep you
at a stable equilibrium.

732
00:36:00,452 --> 00:36:03,451
So there's positive feedback
loops and negative feedback loops.

733
00:36:03,826 --> 00:36:06,014
Don't have to worry too much
about exactly what that means

734
00:36:06,014 --> 00:36:07,514
if your brains are tired right now.

735
00:36:07,514 --> 00:36:10,201
But the point is,
this is in the real world,

736
00:36:10,201 --> 00:36:13,138
the way most things
happen in technical systems,

737
00:36:14,576 --> 00:36:17,763
linear works in natural systems
and social systems.

738
00:36:17,763 --> 00:36:21,200
It tends to be circular,
thinking about patterns of cause

739
00:36:21,200 --> 00:36:24,200
and effect in in a circular fashion.

740
00:36:24,575 --> 00:36:27,325
Rather than thinking
about the component parts

741
00:36:27,325 --> 00:36:30,012
disconnection,
you think about interconnectedness, right?

742
00:36:30,012 --> 00:36:33,512
Scientifically, we do a lot of analysis
in systems thinking.

743
00:36:33,512 --> 00:36:34,511
We look at synthesis.

744
00:36:34,511 --> 00:36:37,886
We look at
how do all the pieces fit together.

745
00:36:38,699 --> 00:36:39,948
This one is really interesting.

746
00:36:39,948 --> 00:36:44,886
This concept of emergence of systems
thinking is like, how do all of the pieces

747
00:36:44,886 --> 00:36:46,885
create something together

748
00:36:46,885 --> 00:36:49,885
that is qualitatively different
than the sum of the parts?

749
00:36:50,573 --> 00:36:52,947
Buckminster Fuller, the

750
00:36:52,947 --> 00:36:56,385
whatever thinker, inventor,
geodesic dome guy once said, there's

751
00:36:56,385 --> 00:36:59,822
nothing in the caterpillar
that tells you it'll become a butterfly.

752
00:37:01,009 --> 00:37:02,884
That's the principle of emergence, right?

753
00:37:02,884 --> 00:37:06,259
You could dissect that little caterpillar,
and you never could figure out

754
00:37:06,259 --> 00:37:09,759
by how some day you're going to wake up
and that thing is going to be a butterfly,

755
00:37:10,446 --> 00:37:12,696
right? That's the magic of systems.

756
00:37:12,696 --> 00:37:15,633
Rather than thinking about stakeholders
in isolation,

757
00:37:15,633 --> 00:37:18,758
what's more interesting is what connects
those stakeholders to each other.

758
00:37:19,070 --> 00:37:22,070
What are their relation ships
where the flows of information,

759
00:37:22,508 --> 00:37:23,945
where the power dynamics,

760
00:37:25,007 --> 00:37:25,882
which actors are

761
00:37:25,882 --> 00:37:28,882
isolated from the system
and maybe don't have a voice.

762
00:37:29,070 --> 00:37:31,632
Right. Those are usually poor people

763
00:37:31,632 --> 00:37:34,444
or other groups that have been excluded
or marginalized from the system.

764
00:37:34,444 --> 00:37:37,506
So understanding where the relationships
are and are not is really important.

765
00:37:37,756 --> 00:37:40,631
So this is the way,
like you've been working on this week,

766
00:37:40,631 --> 00:37:42,568
to start thinking and then training.

767
00:37:42,568 --> 00:37:46,193
This part of your brain
is what allows you, along with some tools,

768
00:37:46,443 --> 00:37:48,256
to be able to see problems in a big way.

769
00:37:48,256 --> 00:37:49,943
It takes a lot of patience

770
00:37:49,943 --> 00:37:52,755
and it requires you
to sort of turn off the part of your brain

771
00:37:52,755 --> 00:37:56,255
that just wants to go fix it
and take time to learn and understand

772
00:37:56,817 --> 00:38:00,630
and try to see and hear
a lot of different perspectives.

773
00:38:01,317 --> 00:38:01,567
Right.

774
00:38:01,567 --> 00:38:04,254
You may be talking about an issue
that you know a lot about,

775
00:38:04,254 --> 00:38:07,441
and be pretty sure you know what's going
on, and it's going to be hard

776
00:38:07,441 --> 00:38:10,441
to hear someone else saying,
you know, based on my experience,

777
00:38:10,504 --> 00:38:11,754
this is what this means.

778
00:38:11,754 --> 00:38:13,066
And you have to be able to do that.

779
00:38:15,316 --> 00:38:15,941
So very

780
00:38:15,941 --> 00:38:20,690
briefly, normal innovation,
right, is innovation is about value

781
00:38:20,690 --> 00:38:24,690
adding processes of adding new things,
new technologies or whatever

782
00:38:25,815 --> 00:38:27,190
normal innovation, what they call here,

783
00:38:27,190 --> 00:38:30,627
parts of innovation is a new way
of solving a specific problem.

784
00:38:31,065 --> 00:38:34,689
And usually that involves bringing a new
product or a new service to the market.

785
00:38:35,814 --> 00:38:39,001
And you want to be able to steal that
because it affects more people.

786
00:38:39,814 --> 00:38:44,501
System
innovation starts with the idea stage is,

787
00:38:44,876 --> 00:38:47,876
can we look at the system in a new way?

788
00:38:48,751 --> 00:38:51,688
Everybody's looking at this
as a medical problem.

789
00:38:51,688 --> 00:38:55,688
Maybe if we look at it as a poverty
problem, that will give us some insights

790
00:38:55,688 --> 00:38:58,187
and some new ways
of actually attacking things.

791
00:38:58,187 --> 00:38:58,875
Okay.

792
00:38:58,875 --> 00:39:02,875
And so then ultimately when we do this
not I'll bring something to the market.

793
00:39:03,125 --> 00:39:06,812
It's a new way of coordinating
different parts of the system together.

794
00:39:07,062 --> 00:39:07,812
That makes sense.

795
00:39:09,124 --> 00:39:09,374
And now

796
00:39:09,374 --> 00:39:13,561
you can do you can shift systems
by doing this.

797
00:39:13,561 --> 00:39:14,936
It does happen, right.

798
00:39:14,936 --> 00:39:15,874
Bring things to scale.

799
00:39:15,874 --> 00:39:18,873
Think about,

800
00:39:19,311 --> 00:39:20,873
think about Netflix.

801
00:39:20,873 --> 00:39:24,435
Most of you are probably too young
to remember the days

802
00:39:24,435 --> 00:39:27,685
when if you wanted to watch a movie,
you had to go to a store

803
00:39:28,060 --> 00:39:30,810
and you had to walk around
and look at these shelves and whatever

804
00:39:30,810 --> 00:39:35,247
movies, TVs or tapes they had in stock,
that was the movie.

805
00:39:35,247 --> 00:39:39,497
You could watch that thing
and you pay some money knowing that

806
00:39:39,497 --> 00:39:42,996
eventually you're going to pay five times
more because you want to to about time.

807
00:39:43,434 --> 00:39:46,559
And as long as you had it, nobody else
in town could watch that movie.

808
00:39:46,621 --> 00:39:49,496
That was the way that we consumed
content, right?

809
00:39:49,496 --> 00:39:51,558
That seems insane right now.

810
00:39:51,558 --> 00:39:55,558
So Netflix came in with a better model,
which first was

811
00:39:55,558 --> 00:39:57,370
you can order anything you want
online will send it to you

812
00:39:57,370 --> 00:39:59,495
in the middle really fast,
keeping for as long as you want,

813
00:39:59,495 --> 00:40:01,432
as long as you're
paying your subscription fee.

814
00:40:01,432 --> 00:40:04,245
And then when the technology catches up,
we'll just get rid of the TVs

815
00:40:04,245 --> 00:40:05,495
and you can just choose anything.

816
00:40:06,494 --> 00:40:10,182
And that has transformed the way

817
00:40:10,182 --> 00:40:14,556
that our relationship with content,
it's changed the way content is produced.

818
00:40:14,556 --> 00:40:19,243
It's brought us to like an insane scale,
some good, some bad, obviously, etc.

819
00:40:19,431 --> 00:40:22,368
but that did change that
aspect of the call

820
00:40:22,368 --> 00:40:25,368
it the entertainment system
or the media system, right?

821
00:40:25,493 --> 00:40:30,305
So a traditional business venture
and a new technology in that way

822
00:40:30,680 --> 00:40:34,367
can shift a system at scale,
but it's not the only way to do it.

823
00:40:34,617 --> 00:40:38,429
And I would say that
the history of interventions

824
00:40:38,429 --> 00:40:41,867
in the so-called like social sector,
including health and everything else,

825
00:40:42,117 --> 00:40:43,866
is that this rarely works.

826
00:40:43,866 --> 00:40:46,991
You rarely have a new good idea or app

827
00:40:47,491 --> 00:40:50,178
or something else that can just be scaled

828
00:40:50,178 --> 00:40:53,616
such that it'll fix everything
and shift the system.

829
00:40:53,616 --> 00:40:56,990
So it's thinking about
how can we organize things in a new way,

830
00:40:57,678 --> 00:41:01,240
oftentimes doing something new
or doing something in a new way,

831
00:41:01,240 --> 00:41:05,052
or bringing that breakthrough product
like antiretroviral medicines

832
00:41:05,052 --> 00:41:08,052
into a place where it's needed
that wasn't accessing it before

833
00:41:08,302 --> 00:41:11,364
is really important,
but it's just one piece of the puzzle.

834
00:41:12,052 --> 00:41:14,552
Okay, so let's talk about Rwanda.

835
00:41:14,552 --> 00:41:18,426
Let me go through this story
a little quick,

836
00:41:18,739 --> 00:41:23,363
but what I want to do
is show how some, aspects of systems

837
00:41:23,363 --> 00:41:26,363
change system innovation
or system entrepreneurship,

838
00:41:26,801 --> 00:41:32,863
can really be illustrated by a country
that was once the poorest in the world

839
00:41:33,363 --> 00:41:37,112
with, all, almost all public

840
00:41:38,112 --> 00:41:39,737
infrastructure, physical

841
00:41:39,737 --> 00:41:44,112
infrastructure and human infrastructure
destroyed, where the life

842
00:41:44,112 --> 00:41:47,986
expectancy from birth was 28 years,

843
00:41:49,549 --> 00:41:50,361
it was older than 28.

844
00:41:50,361 --> 00:41:53,361
In this room, some of us right.

845
00:41:55,611 --> 00:41:58,860
To be, one of the fastest growing

846
00:41:58,860 --> 00:42:02,485
and most widely prosperous countries,
though still poor in the world.

847
00:42:02,485 --> 00:42:05,235
It's a remarkable story.

848
00:42:05,235 --> 00:42:07,672
Okay, so Rwanda, that tiny little country,

849
00:42:07,672 --> 00:42:12,109
it's in sort of straddle Central Africa
and East Africa, German colony.

850
00:42:12,109 --> 00:42:12,922
So no Germans

851
00:42:12,922 --> 00:42:16,797
actually went there for ten years after
they won it in the Berlin Conference.

852
00:42:16,797 --> 00:42:18,609
Then it was a Belgian colony,

853
00:42:18,609 --> 00:42:21,796
and its post-colonial history was a
really, was a really tragic one,

854
00:42:22,234 --> 00:42:26,171
living in the 1994
genocide, against the Tutsis

855
00:42:26,171 --> 00:42:29,296
that took a million lives
in a country of 7 million people

856
00:42:29,608 --> 00:42:32,608
in 100 days.

857
00:42:32,733 --> 00:42:33,670
And this was that.

858
00:42:33,670 --> 00:42:37,795
And this is a really hard image,
to look at, and I apologize for that.

859
00:42:37,795 --> 00:42:41,232
It is also the most 90s magazine cover
ever.

860
00:42:41,295 --> 00:42:44,044
There's a little okay, there as well.

861
00:42:44,044 --> 00:42:46,294
This was a thing that I'll move on.

862
00:42:46,294 --> 00:42:49,919
So you have to look at that,
that really, really tragic picture

863
00:42:50,544 --> 00:42:53,794
that happens so fast in an era

864
00:42:53,794 --> 00:42:56,793
where we couldn't see everything
that was happening every day all at once,

865
00:42:57,231 --> 00:43:01,355
that by the time, like, the media got into
Rwanda, it was almost over.

866
00:43:03,293 --> 00:43:06,230
And I remember, I think I was in college
at the time was crazy.

867
00:43:06,230 --> 00:43:11,917
So post genocide, Rwanda in 1995,
after a rebel army of Rwanda and diaspora

868
00:43:11,917 --> 00:43:15,542
in exile came in and ended the genocide
and started a new government.

869
00:43:16,854 --> 00:43:19,854
This was what you would call
a failed state, right?

870
00:43:21,416 --> 00:43:24,479
The, the the roots of that violence
were deeply rooted,

871
00:43:24,479 --> 00:43:27,978
some in colonial history
and political and social causes.

872
00:43:28,416 --> 00:43:31,416
2 million people had been internally
displaced in the country.

873
00:43:31,728 --> 00:43:34,540
2 million people
had been externally displaced.

874
00:43:34,540 --> 00:43:35,603
A million had been killed.

875
00:43:35,603 --> 00:43:38,103
That's five out of 7 million, right?

876
00:43:38,103 --> 00:43:40,977
Everybody ended up somehow,
somewhere else.

877
00:43:40,977 --> 00:43:43,227
If they if they survived at all.

878
00:43:43,227 --> 00:43:46,227
You had a situation where 100,000 people

879
00:43:46,539 --> 00:43:49,289
had allegedly taken another life.

880
00:43:49,289 --> 00:43:53,164
This was not a centralized Nazi
style tragedy.

881
00:43:53,164 --> 00:43:57,351
This was a neighbors being exported
to kill their neighbors tragedy.

882
00:43:57,538 --> 00:43:59,101
So how do you then deal with

883
00:44:00,351 --> 00:44:03,038
a the criminal justice aspects of things

884
00:44:03,038 --> 00:44:06,725
when you have no courts
and no judges and their lawyers?

885
00:44:07,163 --> 00:44:10,600
And how do you deal with like
the stitching back the fabric of society

886
00:44:10,600 --> 00:44:11,412
together?

887
00:44:11,412 --> 00:44:14,412
There's no playbook for this at all.

888
00:44:15,725 --> 00:44:19,724
I mean, incredible loss, obviously,
of human capital, infrastructure, etc.

889
00:44:19,912 --> 00:44:24,536
most of the doctors, for example,
were killed or fled even ten years later

890
00:44:25,474 --> 00:44:27,661
when I arrived and I,

891
00:44:27,661 --> 00:44:30,723
was, registering
and things to practice there.

892
00:44:31,786 --> 00:44:36,285
I got my, my membership card
for the Rwanda Pediatrician Society.

893
00:44:36,723 --> 00:44:41,285
And, you know, up in the corner
above my name, it said, number seven.

894
00:44:41,597 --> 00:44:44,285
And I was like,
hey, cool. I'm like James Bond.

895
00:44:44,285 --> 00:44:46,222
And then I, they asked the lady at the,

896
00:44:46,222 --> 00:44:49,722
at the, at the desk in their office
and like, asked me what I think it means.

897
00:44:50,159 --> 00:44:53,159
And she said, sir,
you are the seventh registered

898
00:44:53,159 --> 00:44:57,284
pediatrician in Rwanda, which at the time
was a country of about 11 million people.

899
00:44:58,409 --> 00:45:00,221
And she said

900
00:45:00,221 --> 00:45:03,471
and three of them were working in NGOs
and ones in the ministry.

901
00:45:05,096 --> 00:45:06,783
So you think about the number
of pediatricians

902
00:45:06,783 --> 00:45:11,220
for the 50% of the population
were under 15, right?

903
00:45:11,220 --> 00:45:13,282
For the 5 million kids.

904
00:45:13,282 --> 00:45:15,532
So that's like the situation, right?

905
00:45:15,532 --> 00:45:17,470
You saw spikes
and level of poverty and disease

906
00:45:17,470 --> 00:45:20,032
because diseases
thrive on social faultlines.

907
00:45:20,032 --> 00:45:21,094
Right?

908
00:45:21,094 --> 00:45:24,032
HIV have been weaponized
for sexual violence,

909
00:45:24,032 --> 00:45:27,469
tuberculosis runs rampant,
cholera, etc., etc.

910
00:45:27,719 --> 00:45:31,593
and perversely, Rwanda
became the lowest recipient of foreign aid

911
00:45:32,281 --> 00:45:36,656
in the Elamite sea world at that time
because people just ate

912
00:45:36,656 --> 00:45:41,218
all the cameras were going to the refugee
camps in DRC and Burundian elsewhere.

913
00:45:41,218 --> 00:45:42,280
So that's where the attention went.

914
00:45:42,280 --> 00:45:45,030
That's where the money went,
even though those who had perpetrated

915
00:45:45,030 --> 00:45:49,342
the genocide were in those camps,
and they just felt like there was no point

916
00:45:50,779 --> 00:45:51,154
like, this

917
00:45:51,154 --> 00:45:54,154
is there's
this is not a recoverable situation.

918
00:45:54,967 --> 00:45:57,966
So that was the
that was the story as it started.

919
00:45:59,591 --> 00:46:02,403
Where it went then was a,

920
00:46:02,403 --> 00:46:06,028
I think, a slow effort
first at stabilization,

921
00:46:06,903 --> 00:46:11,840
at rebuilding everything from the ground
up, not just physical infrastructure.

922
00:46:11,840 --> 00:46:15,215
I mean, the parliament building
was not habitable and safe.

923
00:46:15,215 --> 00:46:17,340
There's still they kept
when they renovated the one

924
00:46:17,340 --> 00:46:20,340
wall of the Parliament
building with all of the bullet holes,

925
00:46:20,465 --> 00:46:23,464
just as to when you drive by or walk by,
you can still see that,

926
00:46:23,714 --> 00:46:26,152
but when they constituted
a new parliament, they met,

927
00:46:26,152 --> 00:46:29,526
like outdoors in a tent,
because there wasn't a place to go.

928
00:46:29,526 --> 00:46:32,276
But like, hey,
you got to get on with business, right?

929
00:46:32,276 --> 00:46:36,651
What you see, though, is, is a leadership
and a very strong,

930
00:46:37,338 --> 00:46:39,651
political will, you know, a desire

931
00:46:39,651 --> 00:46:42,650
for action, for accountability, etc..

932
00:46:43,088 --> 00:46:44,650
This probably the most important thing.

933
00:46:44,650 --> 00:46:46,087
I'll talk about this in a moment.

934
00:46:46,087 --> 00:46:50,025
Equity
oriented national policies effectively

935
00:46:51,962 --> 00:46:52,462
what the

936
00:46:52,462 --> 00:46:55,712
leadership in Rwanda did,
if you wanted to sort of diagnose

937
00:46:56,399 --> 00:46:59,711
what happened in 1994
and all the years leading up to it,

938
00:46:59,711 --> 00:47:03,149
what were the conditions
that made violence at that scale possible?

939
00:47:04,274 --> 00:47:06,648
It was largely

940
00:47:06,648 --> 00:47:11,085
that in situations of desperate poverty,
you had entrenched,

941
00:47:11,085 --> 00:47:14,085
reified inequalities.

942
00:47:15,898 --> 00:47:18,897
And unless that was addressed,

943
00:47:19,085 --> 00:47:22,085
there would always be risk
of a further descent into violence.

944
00:47:22,335 --> 00:47:26,522
And the flip side of that is
if everyone's lives are getting better,

945
00:47:27,397 --> 00:47:30,834
or they have some hope for the future
and some kind of opportunity.

946
00:47:32,959 --> 00:47:35,896
They'll be a lot
less likely to be convinced

947
00:47:35,896 --> 00:47:38,958
or coerced to turn against their neighbors
again in the future, right?

948
00:47:38,958 --> 00:47:40,833
Or to hate the other or whatever.

949
00:47:40,833 --> 00:47:45,708
So then, like access to health care
becomes a national security imperative.

950
00:47:45,708 --> 00:47:48,707
Access to education becomes
a national security imperative, right?

951
00:47:48,707 --> 00:47:52,770
So because of that,
like the urgency of things was different,

952
00:47:52,895 --> 00:47:55,894
what they also did
was literally ID write a new constitution

953
00:47:55,894 --> 00:48:00,269
because its previous constitution was bad,
and they wrote it into the Constitution.

954
00:48:00,769 --> 00:48:03,769
So then
if you're working in the government

955
00:48:03,769 --> 00:48:07,206
and I did,
you are constitutionally obligated

956
00:48:07,893 --> 00:48:11,768
to effectively have an equity agenda
in the work that you do.

957
00:48:12,393 --> 00:48:15,330
You sign performance contracts in Rwanda
when you're in a

958
00:48:15,330 --> 00:48:17,643
any kind of elected office
or senior positions.

959
00:48:17,643 --> 00:48:21,142
When I was, I was appointed the chair
of the Rwanda Biomedical Center,

960
00:48:21,142 --> 00:48:25,455
which is like the implementation agency
for the health care system in Rwanda.

961
00:48:25,955 --> 00:48:28,079
And had signed a performance contract.

962
00:48:28,079 --> 00:48:30,392
So, like with the president's public,

963
00:48:30,392 --> 00:48:33,016
you have to say these are my performance
goals for the year.

964
00:48:33,016 --> 00:48:35,266
And there's an independent commission

965
00:48:35,266 --> 00:48:38,828
that goes around a couple times
a year and scores.

966
00:48:38,828 --> 00:48:41,703
You on how
well you've achieved your objectives.

967
00:48:41,703 --> 00:48:45,765
This is like every mayor, every governor,
all the people, ministers, etc.

968
00:48:46,203 --> 00:48:47,703
and it's published for everybody.

969
00:48:47,703 --> 00:48:49,203
It's like on the radio once a year.

970
00:48:49,203 --> 00:48:52,265
They're like, okay,
and now for the governor's list

971
00:48:52,390 --> 00:48:55,265
and the 30 governors in the country,
so-and-so

972
00:48:55,265 --> 00:48:58,327
in this district scored highest.

973
00:48:58,514 --> 00:49:01,014
Unfortunately, this guy scored lowest.

974
00:49:01,014 --> 00:49:02,014
And it's like a sport.

975
00:49:02,014 --> 00:49:04,826
And then people go crazy and like,
I doesn't get reelected.

976
00:49:04,826 --> 00:49:06,326
People get voted. Cetera.

977
00:49:06,326 --> 00:49:11,138
One thing you have to do
constitutionally is have an equity agenda.

978
00:49:11,138 --> 00:49:14,138
So if you're a governor
and you're in charge of the district,

979
00:49:14,701 --> 00:49:17,450
you have to identify

980
00:49:17,450 --> 00:49:21,638
the most vulnerable communities
in your district and say, this is our plan

981
00:49:21,825 --> 00:49:26,137
to materially improve the situation
for families in this particular area.

982
00:49:26,950 --> 00:49:28,512
You can't not do that.

983
00:49:28,512 --> 00:49:30,324
So it's baked in.

984
00:49:30,324 --> 00:49:32,012
And this was really, really important.

985
00:49:33,512 --> 00:49:35,636
And they turn things around and convince

986
00:49:35,636 --> 00:49:39,386
a lot of people to divert
a lot of aid into Rwanda.

987
00:49:39,386 --> 00:49:42,198
And they used it really effectively
and make out a lot more

988
00:49:42,198 --> 00:49:43,198
because they're actually doing

989
00:49:43,198 --> 00:49:46,261
what they said they were going to do
because of stuff like this.

990
00:49:47,136 --> 00:49:50,135
And so they went from being the lowest
recipient of national aid

991
00:49:50,198 --> 00:49:53,198
to capital, one of the highest
in about a ten year period.

992
00:49:54,385 --> 00:49:56,135
So we came in this is Paul Farmer.

993
00:49:56,135 --> 00:49:59,072
For those who know, partners in health
are mountains beyond mountains.

994
00:49:59,072 --> 00:50:02,134
The late Paul Farmer, a younger me,

995
00:50:02,822 --> 00:50:04,697
who's a friend and mentor
and founder of Partners Now,

996
00:50:04,697 --> 00:50:07,696
which is the group that I worked with
from my medical training,

997
00:50:07,884 --> 00:50:10,884
all the way through, the time I came here.

998
00:50:11,071 --> 00:50:16,008
So this is when we started in Rwanda
and we were invited by the government to,

999
00:50:17,133 --> 00:50:19,570
to help to use

1000
00:50:19,570 --> 00:50:23,070
all the new HIV money
that was suddenly there in 2003,

1001
00:50:23,820 --> 00:50:28,195
to not only introduce access
to HIV care for those who needed it,

1002
00:50:28,882 --> 00:50:32,507
but to use that as a way
to actually rebuild the health system.

1003
00:50:33,382 --> 00:50:35,944
Because Paul had been doing that in Haiti
for a number of years,

1004
00:50:35,944 --> 00:50:38,944
and the government said, we love that.

1005
00:50:39,444 --> 00:50:40,881
Could you do the same thing here?

1006
00:50:40,881 --> 00:50:43,881
But instead of doing it over 20 years,
could we do it in like five years?

1007
00:50:44,256 --> 00:50:48,193
And the principle is if you try to think
about what it takes to give good care

1008
00:50:48,193 --> 00:50:51,693
for a chronic disease
like HIV, it's not just the pills, right?

1009
00:50:52,755 --> 00:50:54,255
You need to have the infrastructure.

1010
00:50:54,255 --> 00:50:55,943
You need to have the health professionals.

1011
00:50:55,943 --> 00:50:58,067
You need to have the supply chains.

1012
00:50:58,067 --> 00:51:00,942
You need to have the electricity
and the diagnostic capabilities

1013
00:51:00,942 --> 00:51:03,942
and the medical records
and the information systems.

1014
00:51:04,067 --> 00:51:06,567
And you'd have financial access.

1015
00:51:06,567 --> 00:51:10,254
All of those things are the same things
you would need to treat diabetes

1016
00:51:11,254 --> 00:51:11,941
or high blood

1017
00:51:11,941 --> 00:51:15,253
pressure or heart disease
or any number of other things.

1018
00:51:15,253 --> 00:51:17,503
Right. Those are the makings
of a health care system.

1019
00:51:17,503 --> 00:51:20,191
So if you're smart about how you invest

1020
00:51:20,191 --> 00:51:23,440
those resources, you can use
that to do a whole lot of other stuff.

1021
00:51:23,815 --> 00:51:27,065
Because 3% of the population had HIV,
that was a lot of people,

1022
00:51:27,065 --> 00:51:30,065
but 97% had other stuff, right?

1023
00:51:30,127 --> 00:51:31,127
So it was about

1024
00:51:31,127 --> 00:51:34,752
leveraging the vertical investment
to actually try to build a system.

1025
00:51:35,002 --> 00:51:38,689
And we started in two of the districts
that were the where the worst off,

1026
00:51:38,939 --> 00:51:41,001
in the country,
including this place called Rivervale,

1027
00:51:41,001 --> 00:51:44,251
which was a town
that had been like a Belgian mining

1028
00:51:44,251 --> 00:51:47,313
town for coltan
and some other rare earth minerals.

1029
00:51:47,313 --> 00:51:52,188
There was a hospital that was built there
in the 50s, by Belgian colonists,

1030
00:51:52,188 --> 00:51:56,188
for the miners, by Belgians, for Belgians,
and then fell into disrepair.

1031
00:51:56,875 --> 00:51:59,125
In the in the years and decades since.

1032
00:51:59,125 --> 00:52:01,562
Once the Japanese came in
and they renovated it

1033
00:52:01,562 --> 00:52:06,437
and that kind of went away again
and we found, like genocide era graffiti

1034
00:52:06,437 --> 00:52:08,874
inside the operating theaters
and things from families

1035
00:52:08,874 --> 00:52:12,561
who were living in squatting there
and families living in conditions

1036
00:52:12,749 --> 00:52:15,874
something like, like this,
where you have this kind of

1037
00:52:15,874 --> 00:52:19,998
we call triple burden of extreme poverty,
high burden of disease.

1038
00:52:19,998 --> 00:52:23,748
Obviously, those things are connected
and lack of access to health care services

1039
00:52:23,748 --> 00:52:27,123
because of lack of financial means,
because the nearest health center

1040
00:52:27,123 --> 00:52:30,747
was sometimes,
you know, eight, ten, 12 hours walk away

1041
00:52:31,247 --> 00:52:33,997
or a boat trip away
or what have you, right.

1042
00:52:33,997 --> 00:52:38,809
Physical barriers, financial barriers,
social barriers for some groups, etc..

1043
00:52:40,122 --> 00:52:41,872
And, and so what

1044
00:52:41,872 --> 00:52:45,496
we started to do was working
only in the public sector.

1045
00:52:45,684 --> 00:52:49,558
So we, we came in with resources
that were from the Clinton Foundation,

1046
00:52:49,558 --> 00:52:52,058
from the Global Fund,
you know, kind of some of the

1047
00:52:52,058 --> 00:52:55,245
what became the usual suspects
in this space as well as a lot of private

1048
00:52:55,245 --> 00:52:59,370
donors, but funneling all that
into public sector infrastructure.

1049
00:52:59,370 --> 00:53:01,307
So there's no

1050
00:53:01,307 --> 00:53:03,370
partners in health hospital
anywhere in the world.

1051
00:53:03,370 --> 00:53:07,744
There are district hospitals
and referral hospitals and health centers.

1052
00:53:07,932 --> 00:53:10,494
But the idea is we work in partnership.

1053
00:53:10,494 --> 00:53:11,807
It gets built.

1054
00:53:11,807 --> 00:53:14,994
The day the ribbon is cut,
the keys are handed over to,

1055
00:53:15,744 --> 00:53:17,181
to the sort of local authorities.

1056
00:53:17,181 --> 00:53:20,368
And then we work sort of side by side
to do that, and did so in a way

1057
00:53:20,368 --> 00:53:23,681
that is not like rocket science in terms
of how a health system is organized.

1058
00:53:24,681 --> 00:53:27,618
But use
district hospitals as hubs in communities

1059
00:53:27,618 --> 00:53:30,868
with a network of health centers
that provide it, you know, primary

1060
00:53:30,868 --> 00:53:34,680
care, urgent care services,
and then like minor emergency services,

1061
00:53:34,992 --> 00:53:38,867
and then, importantly,
an army of community health workers

1062
00:53:39,304 --> 00:53:43,804
to in every neighborhood
or village in the entire country.

1063
00:53:43,804 --> 00:53:45,804
So we're talking about 50,000

1064
00:53:45,804 --> 00:53:49,304
elected by their peers in the community
and then trained and paid.

1065
00:53:49,804 --> 00:53:53,491
What that meant was that in every
community, even in really remote places,

1066
00:53:53,678 --> 00:53:57,865
you have eyes and ears who are there,
who can identify kids who aren't thriving,

1067
00:53:58,053 --> 00:54:01,053
women who are maybe recently pregnant,

1068
00:54:01,678 --> 00:54:04,490
others who need help, who can monitor HIV

1069
00:54:04,490 --> 00:54:07,677
patients or cancer patients
with their ongoing treatment, etc..

1070
00:54:08,240 --> 00:54:12,239
And can be like living links to these
health facilities was especially important

1071
00:54:12,239 --> 00:54:15,239
when the infrastructure was poor
and they were really far away, but

1072
00:54:15,239 --> 00:54:18,801
a huge value add to the health care
system.

1073
00:54:19,364 --> 00:54:23,676
Not as in so many places, community
health workers are like a cheap

1074
00:54:23,676 --> 00:54:26,801
and bad replacement
for a failing health care system.

1075
00:54:27,113 --> 00:54:31,925
Here, I think really critical to
professionalized adjuncts, to the system.

1076
00:54:32,113 --> 00:54:37,175
And so we started this,
in the two districts and ultimately built

1077
00:54:37,487 --> 00:54:40,487
what became kind of
we thought of these as,

1078
00:54:41,299 --> 00:54:44,862
as sort of model districts
or innovation hubs

1079
00:54:45,112 --> 00:54:47,611
that would
then be kind of like learning laboratories

1080
00:54:47,611 --> 00:54:49,924
for the rest of the health system
in the country.

1081
00:54:49,924 --> 00:54:53,049
So, for example,
after a few years, the the then

1082
00:54:53,049 --> 00:54:56,236
Minister of Health called
me into his office and said,

1083
00:54:58,111 --> 00:54:59,048
we're going eight years you.

1084
00:54:59,048 --> 00:55:00,423
Which means Doctor Jesus.

1085
00:55:00,423 --> 00:55:01,923
That was my nickname in Rwanda.

1086
00:55:01,923 --> 00:55:04,923
Is that longer hair, doctor? Jesus.

1087
00:55:05,048 --> 00:55:06,547
Thank you for your support.

1088
00:55:06,547 --> 00:55:10,547
As you know, our HIV program
now is the best in the world, right?

1089
00:55:10,735 --> 00:55:12,484
And this is true literally outcomes.

1090
00:55:12,484 --> 00:55:16,672
Much better than my patients
at my HIV clinic in Boston at the time.

1091
00:55:18,047 --> 00:55:20,296
You know, we have these results.

1092
00:55:20,296 --> 00:55:21,734
The funders are happy.

1093
00:55:21,734 --> 00:55:23,109
The patients are doing well.

1094
00:55:23,109 --> 00:55:25,608
We think we've got it.

1095
00:55:25,608 --> 00:55:29,046
But if you know, our population
is suffering from diabetes,

1096
00:55:29,233 --> 00:55:32,045
from heart disease, from cancer,
we still have premature

1097
00:55:32,045 --> 00:55:35,045
babies that are dying, etc., etc.

1098
00:55:35,233 --> 00:55:37,857
there is no global funds
for maternal health.

1099
00:55:37,857 --> 00:55:40,795
There's no global fund
for non-communicable diseases.

1100
00:55:40,795 --> 00:55:42,482
And we work together to figure out

1101
00:55:42,482 --> 00:55:45,482
how to do some of the same things
with a lot less resources.

1102
00:55:45,669 --> 00:55:48,857
And so we would shift the kind of work
that we were focusing on,

1103
00:55:49,482 --> 00:55:52,419
bringing the access
to, you know, Harvard Medical School,

1104
00:55:52,419 --> 00:55:54,356
the School of Public Health,
and the research

1105
00:55:54,356 --> 00:55:58,168
and the training and everything else to
then say, okay, let's start an initiative

1106
00:55:58,481 --> 00:55:59,856
to try to eliminate,

1107
00:56:01,231 --> 00:56:02,668
infant mortality

1108
00:56:02,668 --> 00:56:05,793
through sort of quality improvement
initiatives and doing what works well.

1109
00:56:05,855 --> 00:56:08,230
So it was constantly about giving
and taking,

1110
00:56:08,230 --> 00:56:11,230
evolving and shifting with what
the kind of disease burdens were,

1111
00:56:11,230 --> 00:56:14,355
and then building a health system, brick
by brick, that could do all the things

1112
00:56:14,355 --> 00:56:17,354
that you want the health system to do.

1113
00:56:18,917 --> 00:56:19,854
And I'm going

1114
00:56:19,854 --> 00:56:22,854
through a complex and long story
really quickly,

1115
00:56:23,041 --> 00:56:27,353
but I want to just reflect on
or kind of give to you some.

1116
00:56:27,791 --> 00:56:29,728
I call them here systemic interventions.

1117
00:56:29,728 --> 00:56:33,041
I think there were principles
and approaches of the work that we did

1118
00:56:33,041 --> 00:56:37,790
and shared work all the way through that
I think were important in what was,

1119
00:56:39,415 --> 00:56:41,727
I mean, it was rebuilding a system
which is a little bit different

1120
00:56:41,727 --> 00:56:43,540
than shifting a system,
you know what I mean? Like,

1121
00:56:43,540 --> 00:56:46,852
there's some advantages and disadvantages
to almost nothing to start with.

1122
00:56:47,164 --> 00:56:50,164
The first one,
and this is really simple, was investing

1123
00:56:50,164 --> 00:56:54,101
in the actual system capabilities
and the infrastructure of the system.

1124
00:56:54,664 --> 00:56:55,789
This doesn't happen very much.

1125
00:56:55,789 --> 00:56:57,789
Whether that's research, collaborations

1126
00:56:57,789 --> 00:57:01,226
where you have to find
like a local professor to be your co-pi,

1127
00:57:01,476 --> 00:57:04,663
but they don't have the administrative
support, all the other stuff that you do,

1128
00:57:05,350 --> 00:57:06,663
it's not going to sort of change anything.

1129
00:57:06,663 --> 00:57:10,288
So here we talk about staff
stuff, space and systems.

1130
00:57:11,100 --> 00:57:14,287
That could be information
systems, supply chains, etc.

1131
00:57:14,475 --> 00:57:17,974
actually investing in what we call
health system readiness.

1132
00:57:17,974 --> 00:57:22,037
So we would sort of develop standards
and say the starting point

1133
00:57:22,224 --> 00:57:25,911
is that every facility is going to meet
this level of standards.

1134
00:57:25,911 --> 00:57:29,599
They're going to have all the basics
in terms of personnel and training

1135
00:57:29,786 --> 00:57:32,223
and infrastructure and stuff.

1136
00:57:32,223 --> 00:57:37,223
And then we're going to focus on quality
and process improvements and ongoing stuff

1137
00:57:37,410 --> 00:57:38,598
so that we can actually improve

1138
00:57:38,598 --> 00:57:41,473
the quality of what's happening
and build from there.

1139
00:57:41,473 --> 00:57:44,910
The second thing was complimenting

1140
00:57:45,535 --> 00:57:48,784
doing the work,
which is doing health care,

1141
00:57:48,847 --> 00:57:51,847
patient care with, investments

1142
00:57:51,847 --> 00:57:55,784
in training and education
and capacity building.

1143
00:57:55,784 --> 00:57:58,784
And that led to a massive initiative
where we once

1144
00:57:58,784 --> 00:58:02,033
went to Pep far, in the US and said,

1145
00:58:03,158 --> 00:58:05,471
and this was I said,
we've this is the Minister of Health time.

1146
00:58:05,471 --> 00:58:09,095
Look, we've met all our targets
and you have committed X

1147
00:58:09,095 --> 00:58:12,595
amount to us over the next several years,
which is great.

1148
00:58:13,033 --> 00:58:17,720
We think the best way to build for
the long term would be to take 100 million

1149
00:58:17,720 --> 00:58:21,782
of that money that you've committed,
and instead of buying Aids drugs

1150
00:58:21,782 --> 00:58:24,032
and doing the usual stuff
we've been doing,

1151
00:58:24,032 --> 00:58:26,969
we want to invest it
in creating training programs for

1152
00:58:26,969 --> 00:58:30,844
one of the specialist doctors and nurses,
because we have five pediatricians

1153
00:58:30,844 --> 00:58:34,406
and one psychiatrist
and no orthopedic surgeons, etc.,

1154
00:58:34,718 --> 00:58:38,593
and that then built up a program
where we partnered with a bunch of U.S.

1155
00:58:38,593 --> 00:58:40,155
universities and built training programs.

1156
00:58:40,155 --> 00:58:44,155
So there now are plastic surgeons
and oncologists, etc., in Rwanda

1157
00:58:44,468 --> 00:58:45,592
building for the long term.

1158
00:58:45,592 --> 00:58:48,592
Those are now training
the next generation, etc..

1159
00:58:49,092 --> 00:58:53,342
So the idea that when you mix service
delivery with training and research,

1160
00:58:53,342 --> 00:58:56,967
you create these virtuous cycles of kind
of positive learning and improvement,

1161
00:58:59,279 --> 00:59:02,279
a bunch of programs to address
the social determinants of health.

1162
00:59:02,529 --> 00:59:06,528
These could be programs that would help,
kids have access to school.

1163
00:59:07,653 --> 00:59:11,028
Food security programs
that might do agriculture training,

1164
00:59:11,528 --> 00:59:12,340
and things like that.

1165
00:59:12,340 --> 00:59:14,028
Economic development programs.

1166
00:59:14,028 --> 00:59:16,152
Every time we built a new facility,

1167
00:59:16,152 --> 00:59:19,902
it was built by and for
and with the local communities.

1168
00:59:19,902 --> 00:59:23,214
So we have our own engineer
and the social worker do all the hiring.

1169
00:59:24,214 --> 00:59:28,464
So, adults age orphans, single moms, etc.

1170
00:59:28,464 --> 00:59:29,089
would be hired

1171
00:59:29,089 --> 00:59:33,026
and then trained to be masons and tailors
and welders and things like that.

1172
00:59:33,526 --> 00:59:36,526
So actually creating jobs and skills
in the, in the community,

1173
00:59:38,401 --> 00:59:42,213
I talked about this already and I talked
about the public sector partnership.

1174
00:59:42,275 --> 00:59:44,213
And I think the reasons
that are really important. Right.

1175
00:59:44,213 --> 00:59:48,587
Number one, you're funneling private
capital into public infrastructure.

1176
00:59:50,400 --> 00:59:51,400
Second, there was

1177
00:59:51,400 --> 00:59:55,149
investment in working alongside
and I guess

1178
00:59:55,149 --> 00:59:59,274
building the capacity, though
I hate that term of public sector leaders.

1179
00:59:59,274 --> 01:00:00,836
So whoever was in charge

1180
01:00:00,836 --> 01:00:04,586
of noncommunicable diseases with partners
in health would effectively be seconded

1181
01:00:04,586 --> 01:00:07,586
to the head of non-communicable diseases
and the Ministry of Health,

1182
01:00:07,648 --> 01:00:10,086
and they'd be working together
and they'd get to come to Harvard and do

1183
01:00:10,086 --> 01:00:13,085
courses
and learn from researchers, etc., etc..

1184
01:00:13,210 --> 01:00:16,773
And so over time, that helps to build
the capability of the system itself.

1185
01:00:17,273 --> 01:00:21,272
And then finally, and most importantly,
is using the public sector to scale.

1186
01:00:21,585 --> 01:00:22,647
And this is a really important

1187
01:00:22,647 --> 01:00:26,459
strategic decision that we made
after going from 2 to 3 districts.

1188
01:00:26,459 --> 01:00:28,772
So it's like, okay, now do we go to four?

1189
01:00:28,772 --> 01:00:30,397
But there's 30.

1190
01:00:30,397 --> 01:00:34,896
And so instead the idea was
can we create these innovation hubs,

1191
01:00:34,896 --> 01:00:40,333
these models that can test out
new service delivery innovations like a

1192
01:00:41,583 --> 01:00:43,833
infant mortality reduction program?

1193
01:00:43,833 --> 01:00:47,395
And then if and when it works,
roll it out to the rest of the country

1194
01:00:47,395 --> 01:00:49,708
through the public sector,
and they can engage other donors

1195
01:00:49,708 --> 01:00:52,707
and other partners
to help implement where necessary.

1196
01:00:52,832 --> 01:00:56,644
But what we started here and learned
can then be done everywhere else.

1197
01:00:56,644 --> 01:00:59,832
We've got a training hub to do it
in that ultimately

1198
01:01:00,832 --> 01:01:04,894
is what led to, which I alluded to before.

1199
01:01:04,894 --> 01:01:08,706
This is a really old graph,
but in the Washington Post in 2013,

1200
01:01:08,706 --> 01:01:10,456
it was the graph of the year.

1201
01:01:10,456 --> 01:01:11,518
So I still show it.

1202
01:01:11,518 --> 01:01:14,206
This is, child mortality, right?

1203
01:01:14,206 --> 01:01:15,768
Under-five mortality.

1204
01:01:15,768 --> 01:01:20,393
Actually, so, this is, you may know,
is considered one of the best

1205
01:01:20,393 --> 01:01:24,205
single indicators of the overall
performance of a health system.

1206
01:01:24,267 --> 01:01:24,517
Right?

1207
01:01:24,517 --> 01:01:27,517
So it's how many the fraction of kids
out of a thousand would die

1208
01:01:27,517 --> 01:01:28,829
before their fifth birthday.

1209
01:01:30,954 --> 01:01:31,392
And you can see

1210
01:01:31,392 --> 01:01:34,516
after the genocide in Rwanda
that spiked to 275.

1211
01:01:34,516 --> 01:01:38,891
So like over 1 in 4, practically
1 in 3 kids, we're not making it to H5.

1212
01:01:39,454 --> 01:01:42,203
This is the sub-Saharan trend
and this is the rest of the world

1213
01:01:42,203 --> 01:01:45,453
average by 2012.

1214
01:01:45,453 --> 01:01:46,953
At the time we did the study,

1215
01:01:46,953 --> 01:01:51,453
it had basically dropped
far below the sub-Saharan African, average

1216
01:01:51,453 --> 01:01:55,015
and down to the,
the mean for the rest of the world.

1217
01:01:55,265 --> 01:01:58,077
And, it was continuing
to sort of drop from there.

1218
01:01:58,077 --> 01:02:01,889
This is the steepest,
this and many others were the,

1219
01:02:02,452 --> 01:02:05,889
steepest declines and premature mortality
ever recorded

1220
01:02:06,389 --> 01:02:10,951
anywhere in the world
at any time, in at least recorded history,

1221
01:02:11,138 --> 01:02:14,138
more than the Asian Tigers
in the 90s, in China

1222
01:02:14,138 --> 01:02:17,263
in the 80s and so many other
sort of economic miracles, etc.

1223
01:02:17,575 --> 01:02:22,200
life expectancy doubled over a
just over the 15 year period.

1224
01:02:23,637 --> 01:02:25,137
It's still a very poor country.

1225
01:02:25,137 --> 01:02:29,325
But what's important
is that the GDP tripled during this time.

1226
01:02:29,824 --> 01:02:34,262
And this is really weird, but this is
what's called a growth incidence curve.

1227
01:02:34,262 --> 01:02:37,136
So the 99% is that is the top 1%.

1228
01:02:37,136 --> 01:02:40,324
These are the so-called 1%,
if you will, of,

1229
01:02:40,761 --> 01:02:43,511
you know, of wealth, the richest 1%.

1230
01:02:43,511 --> 01:02:45,136
This is the poorest 1%.

1231
01:02:45,136 --> 01:02:47,136
This is the share of economic growth.

1232
01:02:47,136 --> 01:02:48,261
So I want you to understand

1233
01:02:48,261 --> 01:02:51,698
here is as the economy was like,
growing really fast, what usually happens

1234
01:02:52,010 --> 01:02:56,322
there's there's a bubble here
where the well-off get better off.

1235
01:02:56,635 --> 01:02:56,947
Right.

1236
01:02:56,947 --> 01:02:58,260
The rich get richer,

1237
01:02:58,260 --> 01:03:02,134
and then you hope some of that trickles
down because of this equity agenda,

1238
01:03:02,134 --> 01:03:06,822
because the policies were pro-poor
and there was accountability for that.

1239
01:03:07,134 --> 01:03:10,571
The vast majority of economic growth
benefited the poorest 20%

1240
01:03:10,571 --> 01:03:12,759
of the population. And a million people,

1241
01:03:14,133 --> 01:03:14,946
brought themselves out

1242
01:03:14,946 --> 01:03:17,946
of extreme poverty
during this time period.

1243
01:03:18,008 --> 01:03:22,133
So Paul Collier, who's, you know, here,
in Oxford, a very famous development

1244
01:03:22,133 --> 01:03:25,508
economist, he came we published
some of these reports as like 2014.

1245
01:03:26,382 --> 01:03:29,695
He called this the development happen
and said this combination of rapid

1246
01:03:29,695 --> 01:03:33,382
and sustained economic growth,
dramatic improvements in health outcomes

1247
01:03:33,757 --> 01:03:37,382
and poverty reduction,
with decreases in income inequality

1248
01:03:38,819 --> 01:03:41,819
was something that had not been done
anywhere

1249
01:03:41,819 --> 01:03:44,818
ever before in his in his knowledge.

1250
01:03:45,193 --> 01:03:46,193
So briefly.

1251
01:03:46,193 --> 01:03:48,881
And then we're down here.

1252
01:03:48,881 --> 01:03:51,255
We then was to get all these people
from all over

1253
01:03:51,255 --> 01:03:54,818
Africa and elsewhere coming to be like,
okay, what's in the secret sauce?

1254
01:03:54,818 --> 01:03:55,630
How can we do this?

1255
01:03:55,630 --> 01:03:59,255
I'm like sending delegations from other
ministries of health for study tours.

1256
01:04:00,192 --> 01:04:01,130
And we're thinking to ourselves,

1257
01:04:01,130 --> 01:04:04,692
will a study tour like following
around your counterparts for a week

1258
01:04:05,067 --> 01:04:08,692
in Rwanda is not really going to help,
make that happen.

1259
01:04:08,692 --> 01:04:10,566
And we sort of thought a lot about what

1260
01:04:11,566 --> 01:04:13,504
what it would
take to sort of take some of these lessons

1261
01:04:13,504 --> 01:04:16,503
and grow from here, because one that's
a little country in a really big world,

1262
01:04:16,941 --> 01:04:18,441
that has a long ways to go.

1263
01:04:18,441 --> 01:04:21,441
And so we, as I hinted at earlier,

1264
01:04:21,941 --> 01:04:26,253
built a university at the site of actually
one of those hospitals that was pictured

1265
01:04:26,253 --> 01:04:29,252
earlier called University of Global
Health Equity.

1266
01:04:29,252 --> 01:04:31,377
We launched it in

1267
01:04:31,377 --> 01:04:34,440
we cooked up the idea in 2013 involves

1268
01:04:34,440 --> 01:04:39,939
a great deal of wine
and a, failed, failed relationship with,

1269
01:04:40,314 --> 01:04:45,314
with the University of Rwanda
and Harvard and, and launched in 2015.

1270
01:04:45,814 --> 01:04:49,501
And it is a health sciences
and public health university

1271
01:04:49,501 --> 01:04:53,313
that is focused on equity and focused
on using the kinds of principles

1272
01:04:53,313 --> 01:04:56,250
I was just talking about in trying
to make those fundamental bedrocks,

1273
01:04:57,438 --> 01:05:00,437
trying to sort of disrupt global health.

1274
01:05:01,312 --> 01:05:04,000
Fundamentally and

1275
01:05:04,000 --> 01:05:07,499
also physically, right, by
trying to create like an intellectual hub

1276
01:05:07,499 --> 01:05:11,312
in global health that's in a poor rural
community in sub-Saharan Africa.

1277
01:05:11,437 --> 01:05:13,374
And think about what happens.

1278
01:05:13,374 --> 01:05:15,499
We talked about who's at the table.

1279
01:05:15,499 --> 01:05:19,186
Think about what happens when
the conversations around poverty reduction

1280
01:05:19,436 --> 01:05:22,373
in global health are not in Davos

1281
01:05:22,373 --> 01:05:25,248
or Geneva or Oxford or New York,

1282
01:05:25,248 --> 01:05:29,185
but are in utero Rwanda, a little hilltop
in a little village

1283
01:05:29,435 --> 01:05:32,622
in a place where community
health workers are on faculty

1284
01:05:33,247 --> 01:05:37,559
alongside PhDs because they possess
a different kind of expertise.

1285
01:05:37,747 --> 01:05:39,372
So that was the thing that we we created.

1286
01:05:39,372 --> 01:05:40,747
It's still very small.

1287
01:05:40,747 --> 01:05:44,371
It was in December by Times
Higher Education ranked the number four

1288
01:05:44,371 --> 01:05:49,121
university on the continent of Africa,
which is both really cool

1289
01:05:49,121 --> 01:05:54,058
and a really tough verdict on the state
of higher education on the continent.

1290
01:05:54,996 --> 01:05:56,995
Okay, so

1291
01:05:56,995 --> 01:06:01,433
to close, to come to your question
about equity and systems,

1292
01:06:02,245 --> 01:06:05,245
because I think
this is the most important lesson for me.

1293
01:06:05,557 --> 01:06:08,682
What I gained from my time
doing this work in Rwanda

1294
01:06:08,682 --> 01:06:12,619
and working with Paul and others,
is that equity

1295
01:06:12,869 --> 01:06:16,869
or an equity agenda or an equity
lens can be a driver of innovation.

1296
01:06:16,869 --> 01:06:19,869
So if we go back to this notion of system
innovation,

1297
01:06:19,869 --> 01:06:22,743
and I think this happens in three ways,
right.

1298
01:06:22,743 --> 01:06:26,556
First,
equity expands our moral imagination.

1299
01:06:26,931 --> 01:06:30,243
Instead of just saying,
no, it's not possible.

1300
01:06:30,618 --> 01:06:33,368
Too hard, too expensive,
we could go through

1301
01:06:33,368 --> 01:06:36,680
the litany of excuses that were used
to deny poor people access to care.

1302
01:06:37,117 --> 01:06:39,804
In the late 90s, in the early 2000, head

1303
01:06:39,804 --> 01:06:42,929
of USA Andrew Natsios in 2001

1304
01:06:43,367 --> 01:06:47,366
testified to Congress and said
Africans have a different concept of time.

1305
01:06:48,241 --> 01:06:51,116
They don't have watches and they won't be
able to take their medicines on time.

1306
01:06:51,116 --> 01:06:52,553
Therefore, we shouldn't waste money

1307
01:06:53,553 --> 01:06:56,553
given the major drugs right?

1308
01:06:56,991 --> 01:06:58,803
So that's the usual response.

1309
01:06:58,803 --> 01:07:01,803
Or you do a cost effectiveness analysis
that says is 22 times

1310
01:07:01,803 --> 01:07:05,052
more cost effective to do the easy thing
rather than the right thing.

1311
01:07:05,802 --> 01:07:09,365
And once you start
from a premise of equity

1312
01:07:10,552 --> 01:07:13,739
that everyone deserves access to health
and ideally the same kind of health care

1313
01:07:13,739 --> 01:07:16,739
you'd want for your sister
or your mom or your kids or whatever,

1314
01:07:17,239 --> 01:07:18,989
then you can't say no.

1315
01:07:18,989 --> 01:07:21,051
You have to ask, how?

1316
01:07:21,051 --> 01:07:22,926
How do we do it? Yeah,
the situations are the same.

1317
01:07:22,926 --> 01:07:24,613
Yeah, the resources aren't there.

1318
01:07:24,613 --> 01:07:26,926
But let's figure it out.

1319
01:07:26,926 --> 01:07:27,176
Right.

1320
01:07:27,176 --> 01:07:30,175
And that drives new ways of thinking,
a new innovation.

1321
01:07:30,550 --> 01:07:34,175
Second, it brings additional expertise

1322
01:07:34,613 --> 01:07:37,550
and ideas into the system.

1323
01:07:37,550 --> 01:07:41,112
The number of times that we've been stuck
with a program that wasn't

1324
01:07:41,112 --> 01:07:45,174
performing the way that we wanted it to,
and we doctors would get together

1325
01:07:45,174 --> 01:07:49,111
and assess all the data
and try to figure out what was going on.

1326
01:07:49,299 --> 01:07:52,549
And then a community
health worker raised their hand and said,

1327
01:07:52,861 --> 01:07:55,861
actually,
let me tell you what's really going on.

1328
01:07:55,923 --> 01:07:58,798
It's not that the patients
are not understanding their instructions

1329
01:07:58,798 --> 01:08:01,735
or their ignorance, it's
that they have someone at home

1330
01:08:01,735 --> 01:08:04,423
who's too sick to come in
and they split their pills and

1331
01:08:04,423 --> 01:08:07,610
or it's that they don't have enough food
to eat or whatever.

1332
01:08:07,922 --> 01:08:08,235
Right.

1333
01:08:08,235 --> 01:08:11,547
So the the different kind of
professional experience of the community

1334
01:08:11,547 --> 01:08:14,984
health worker brings
made us smarter and better at our jobs.

1335
01:08:14,984 --> 01:08:16,609
And that's one example

1336
01:08:16,609 --> 01:08:19,796
of how that happens, because you're
bringing new people to the table.

1337
01:08:19,984 --> 01:08:24,421
And then third, and maybe most importantly
is this builds

1338
01:08:24,421 --> 01:08:27,733
trust and creates the conditions
that actually implement change.

1339
01:08:28,171 --> 01:08:31,171
One of the great things
that Rwanda did was,

1340
01:08:31,671 --> 01:08:35,233
to make everybody in the country

1341
01:08:35,920 --> 01:08:39,170
an active participant in the country's
development.

1342
01:08:39,357 --> 01:08:39,982
Right.

1343
01:08:39,982 --> 01:08:43,295
It started with we can't rely on outsiders
to come and save us

1344
01:08:43,295 --> 01:08:46,294
and let us down in our moment of
of greatest need.

1345
01:08:46,857 --> 01:08:49,982
And they're coming now,
but we can't wait for the cavalry to come.

1346
01:08:50,169 --> 01:08:51,794
It's on us to build it.

1347
01:08:51,794 --> 01:08:54,981
And there's like a community service day
once a month on Saturdays,

1348
01:08:54,981 --> 01:08:58,856
and you like, build
to roofs, to fix a, you know,

1349
01:09:00,106 --> 01:09:03,168
a person's
house or work on the roads or whatever.

1350
01:09:03,168 --> 01:09:04,918
But everybody is involved in some way.

1351
01:09:04,918 --> 01:09:08,293
And actually Africans place there's
something called a national dialog,

1352
01:09:09,355 --> 01:09:12,480
in Michigan,
where once a year, the president

1353
01:09:12,480 --> 01:09:15,917
and the cabinet and all the leaders
get together in a giant hall in Kigali,

1354
01:09:16,604 --> 01:09:20,104
and anybody can come and it's live
streamed and it's on the radio.

1355
01:09:20,292 --> 01:09:23,854
And anybody in the country
can ask any question of any leader

1356
01:09:24,541 --> 01:09:27,541
that goes on for two days,
and they're not screened.

1357
01:09:28,166 --> 01:09:30,728
And you can say anything.

1358
01:09:30,728 --> 01:09:34,291
And you know, once somebody said,

1359
01:09:34,915 --> 01:09:38,353
yeah, I've been coughing for three months
and I think I might have tuberculosis,

1360
01:09:38,353 --> 01:09:39,665
but I went to the health center
three times

1361
01:09:39,665 --> 01:09:42,665
and they didn't have any of those
little cups to collect my sputum.

1362
01:09:42,727 --> 01:09:45,727
And, I'm worried about
what's going to happen.

1363
01:09:45,977 --> 01:09:48,914
And then you rush off and
you give an answer and like, do that. So.

1364
01:09:48,914 --> 01:09:51,914
So people actually have access
to to their leaders.

1365
01:09:51,914 --> 01:09:52,789
And that's remarkable.

1366
01:09:52,789 --> 01:09:57,414
But again, this notion of bringing
new people into the conversation creates

1367
01:09:57,414 --> 01:10:01,288
the sort of social capital and the trust
that you need to actually drive change.

1368
01:10:02,226 --> 01:10:04,288
I think I'm going to leave it there.
And there might be one more slide.

1369
01:10:04,288 --> 01:10:05,726
See, I go on next year.

1370
01:10:05,726 --> 01:10:08,163
I'll give me two hours
and I'll still go on too long.

1371
01:10:11,413 --> 01:10:13,600
That's what I want to leave you with.

1372
01:10:13,600 --> 01:10:15,037
Great book by this title.

1373
01:10:15,037 --> 01:10:17,350
By the way, this is Jonas Salk.

1374
01:10:17,350 --> 01:10:20,224
Who was, you know, was a, you know,
inventor of one of the polio vaccines.

1375
01:10:20,224 --> 01:10:22,287
He wrote a great memoir,

1376
01:10:22,287 --> 01:10:24,849
in the, in the 70s.

1377
01:10:24,849 --> 01:10:26,536
And, that's where this phrase comes.

1378
01:10:26,536 --> 01:10:29,036
Our greatest responsibility
is to pick your ancestors.

1379
01:10:29,036 --> 01:10:33,786
When one thing about systems thinking
that is really useful is moving

1380
01:10:33,786 --> 01:10:36,098
beyond the, like three months,
six months, one year

1381
01:10:36,098 --> 01:10:39,098
time frame and trying to think about like,
where do we want to be

1382
01:10:39,160 --> 01:10:42,723
15, 20 years
from now, generations from now?

1383
01:10:42,973 --> 01:10:45,222
We would ask when we were starting
University of Global Equity.

1384
01:10:45,222 --> 01:10:48,660
Once Paul and I took a walk,
we were at, on the campus of Harvard,

1385
01:10:48,660 --> 01:10:55,159
and there's the statue of John Harvard,
from like the 1636 or something like that.

1386
01:10:55,784 --> 01:10:58,784
And we said, okay, so 400 years,

1387
01:10:59,034 --> 01:11:00,346
you think you ever would have thought that

1388
01:11:00,346 --> 01:11:02,658
that thing you started
then would become like this?

1389
01:11:02,658 --> 01:11:04,158
And then we asked ourselves,
where do we think

1390
01:11:04,158 --> 01:11:06,533
the world's going to be in 400 years?

1391
01:11:06,533 --> 01:11:07,221
And what do we want?

1392
01:11:07,221 --> 01:11:10,408
University of Global Health equities
place in that world to be.

1393
01:11:10,783 --> 01:11:13,533
And the power of that radically long
term thinking and the kind of

1394
01:11:13,533 --> 01:11:17,345
like thing you want to build
and the legacy that you want to leave to

1395
01:11:17,595 --> 01:11:20,407
not just your kids,
but your grandchildren's grandchildren

1396
01:11:21,469 --> 01:11:24,032
is it's like an insane thought exercise,

1397
01:11:24,032 --> 01:11:27,032
but it's also a very, a very powerful,

1398
01:11:28,656 --> 01:11:30,969
way of approaching problems.

1399
01:11:30,969 --> 01:11:31,719
Anyways.

1400
01:11:31,719 --> 01:11:34,343
Okay, sorry I talk so much.

1401
01:11:34,343 --> 01:11:37,343
Thank you for staying away.

1402
01:11:41,593 --> 01:11:44,593
For few minutes of their questions.

1403
01:11:48,280 --> 01:11:50,405
And if I warn you, I won't.

1404
01:11:50,405 --> 01:11:51,155
Then we'll feel bad.

1405
01:11:51,155 --> 01:11:52,779
You just want to go up there?

1406
01:11:52,779 --> 01:11:53,592
Yeah.

1407
01:11:53,592 --> 01:11:54,029
Okay.

1408
01:11:54,029 --> 01:11:57,029
Got a lot of things
that have come up earlier in the day.

1409
01:11:57,967 --> 01:12:00,966
And the Rwanda story
is absolutely amazing because.

1410
01:12:01,716 --> 01:12:03,904
Incredible.

1411
01:12:03,904 --> 01:12:04,778
I did have a question.

1412
01:12:04,778 --> 01:12:05,903
I can't remember what it was.

1413
01:12:05,903 --> 01:12:08,278
And someone else come up with more mind.

1414
01:12:08,278 --> 01:12:09,778
Why? No. Yeah. What about that? Chris?

1415
01:12:09,778 --> 01:12:11,090
You know, tell us about the Crucible.

1416
01:12:11,090 --> 01:12:14,090
Yeah. So. Okay. Crucible.

1417
01:12:14,465 --> 01:12:15,403
It's a startup.

1418
01:12:15,403 --> 01:12:18,465
So it's a new, probably nonprofit.

1419
01:12:18,465 --> 01:12:19,840
We don't actually have a business
model yet.

1420
01:12:19,840 --> 01:12:21,277
I'm staying true to my word. Right.

1421
01:12:21,277 --> 01:12:22,902
We're trying to, like, address an issue.

1422
01:12:23,964 --> 01:12:26,339
So the idea behind Crucible

1423
01:12:26,339 --> 01:12:29,214
is that you've got a couple of problems,
right?

1424
01:12:29,214 --> 01:12:32,714
You have to say you have a problem
and you've got an asset that's unused.

1425
01:12:32,964 --> 01:12:35,526
The problem is,

1426
01:12:35,526 --> 01:12:38,213
certainly when you look across
a lot of sub-Saharan Africa,

1427
01:12:38,213 --> 01:12:41,213
but I argue globally as well.

1428
01:12:41,338 --> 01:12:43,400
Leadership is failing us. Right.

1429
01:12:43,400 --> 01:12:44,775
And if you look at countries

1430
01:12:44,775 --> 01:12:48,525
that have been able to move themselves
out of poverty and develop

1431
01:12:48,525 --> 01:12:52,837
economically, socially and otherwise,
there is a role for effective leaders.

1432
01:12:53,087 --> 01:12:56,399
And those effective leaders
have almost always had access

1433
01:12:56,399 --> 01:13:00,212
to really good quality education
at some point in their lives.

1434
01:13:02,336 --> 01:13:03,274
That's number one.

1435
01:13:03,274 --> 01:13:04,899
Number two,

1436
01:13:04,899 --> 01:13:06,899
sub-Saharan Africa,

1437
01:13:06,899 --> 01:13:09,023
fastest growing continent in the world.

1438
01:13:09,023 --> 01:13:12,773
By 2035, 50% of people
entering the workforce

1439
01:13:13,086 --> 01:13:16,585
every year will come from Africa,
in the entire world.

1440
01:13:17,273 --> 01:13:20,085
So you have a ton of young

1441
01:13:20,085 --> 01:13:23,710
talent like amazing, brilliant kids.

1442
01:13:23,710 --> 01:13:28,022
And I've met so many, you know,
at different places, you know, that

1443
01:13:28,022 --> 01:13:31,584
my work has taken me and my kids were born
there and all that kind of stuff.

1444
01:13:31,834 --> 01:13:35,084
And we know the education
systems are generally very weak,

1445
01:13:35,084 --> 01:13:36,646
like in many countries.

1446
01:13:36,646 --> 01:13:39,646
I don't know the exact statistics
for Malawi, for example,

1447
01:13:39,833 --> 01:13:44,583
maybe 20% of kids
make it into secondary school,

1448
01:13:45,083 --> 01:13:48,020
less than half finished secondary school,
and it's usually less than 10%

1449
01:13:48,020 --> 01:13:51,020
who access
a tertiary education of any kind.

1450
01:13:51,145 --> 01:13:54,082
So even the basics aren't there.

1451
01:13:54,082 --> 01:13:57,332
And then where are the pathways
for the really, really

1452
01:13:57,707 --> 01:14:01,332
kind of off the charts
for special kids with real

1453
01:14:01,332 --> 01:14:04,894
like sort of intellectual potential,
leadership potential, etc.?

1454
01:14:05,081 --> 01:14:08,081
So we're taking an approach
that's a little bit different.

1455
01:14:08,456 --> 01:14:12,643
To kind of education,
the sort of equity socialist type in me

1456
01:14:12,643 --> 01:14:14,893
would be like,
we just need to do this everywhere

1457
01:14:14,893 --> 01:14:16,643
in the same way
we did this with Partizan Health.

1458
01:14:16,643 --> 01:14:21,268
The idea my Crucible is to set up
a network of secondary school leadership

1459
01:14:21,268 --> 01:14:24,705
academies, secondary school,
because that's like the highest leverage

1460
01:14:24,955 --> 01:14:27,955
point
to help someone change their trajectory

1461
01:14:28,267 --> 01:14:31,267
and the most neglected part of education.

1462
01:14:31,267 --> 01:14:33,704
In Lmics, it's create

1463
01:14:33,704 --> 01:14:36,954
a network of world class
secondary school leadership academies.

1464
01:14:37,516 --> 01:14:40,266
If anyone's ever heard of Africa
Leadership Academy, amazing place.

1465
01:14:40,266 --> 01:14:42,141
It's like that on steroids.

1466
01:14:42,141 --> 01:14:47,141
Actively seek out
and go like to every corner of the country

1467
01:14:47,141 --> 01:14:51,328
this school is in hunting
for the most gifted young people

1468
01:14:51,328 --> 01:14:53,577
and then give them a shot
at world class education.

1469
01:14:54,577 --> 01:14:56,452
And, you know, it's sort of

1470
01:14:56,452 --> 01:15:00,202
Cambridge A-levels combined
with a really cool liberal arts curriculum

1471
01:15:00,202 --> 01:15:03,264
and sort of experiential
leadership training, and hopefully

1472
01:15:03,264 --> 01:15:08,514
that will be a catapult for them to
then be able to go on further studies

1473
01:15:08,764 --> 01:15:12,513
and at scale, because we're talking about
doing this up to 100 schools,

1474
01:15:13,326 --> 01:15:16,326
so tens of thousands of students per year.

1475
01:15:16,326 --> 01:15:19,450
The idea is that 25 years from now,
you got a whole generation

1476
01:15:19,888 --> 01:15:23,825
of super talented young leaders
who will be building

1477
01:15:23,825 --> 01:15:27,075
businesses, making change,
leading in governments, etc.

1478
01:15:27,325 --> 01:15:30,575
and help a lot of places
that have been held back for a long time

1479
01:15:30,575 --> 01:15:34,574
by, leadership and structural forces
and lots of other things,

1480
01:15:35,574 --> 01:15:38,136
you know, ones
that have been talking about brain drain,

1481
01:15:38,136 --> 01:15:42,074
you know, from Africa to elsewhere,
the content will become a brain magnet.

1482
01:15:42,074 --> 01:15:43,074
That's the that's the goal.

1483
01:15:43,074 --> 01:15:46,511
So we got one university, and my job is
to figure out how to get that in a more.

1484
01:15:47,636 --> 01:15:50,635
So I pleased,

1485
01:15:52,323 --> 01:15:54,573
with Aileen for example,

1486
01:15:54,573 --> 01:15:57,635
that they had the high school
and then they have the university as well.

1487
01:15:58,947 --> 01:16:01,947
But I for one,
I've seen what tends to happen

1488
01:16:01,947 --> 01:16:05,134
is that these kids are excellently trained

1489
01:16:05,759 --> 01:16:08,509
and then go to McKinsey.

1490
01:16:08,509 --> 01:16:11,321
And it's just it's just this straight

1491
01:16:11,321 --> 01:16:15,633
funneling them to McKinsey
or the more radical ones who try and,

1492
01:16:16,258 --> 01:16:19,258
you know, try to go back,
but they're not absorbed very well.

1493
01:16:21,008 --> 01:16:24,633
So I don't know what your thought
processes are about that.

1494
01:16:24,633 --> 01:16:27,695
But I mean everybody
that I know would tell you.

1495
01:16:28,695 --> 01:16:29,945
Yeah. Yeah.

1496
01:16:29,945 --> 01:16:33,257
Because they all went to the elite
universities where one third of graduates

1497
01:16:33,257 --> 01:16:35,257
go into consulting or finance. Yeah.

1498
01:16:35,257 --> 01:16:37,069
And some of these kids
theoretically will as well.

1499
01:16:37,069 --> 01:16:37,882
I mean not that clever.

1500
01:16:37,882 --> 01:16:40,506
And if they do well they'll probably have
those kinds of opportunities.

1501
01:16:40,506 --> 01:16:45,006
What I would say is this is like
a wicked systemic problem, right?

1502
01:16:45,006 --> 01:16:46,506
From I was just talking about education.

1503
01:16:46,506 --> 01:16:49,756
We're talking about, for example,
lack of economic opportunity.

1504
01:16:49,756 --> 01:16:50,256
Right.

1505
01:16:50,256 --> 01:16:55,005
It's hard to tell a kid who's grown up
in a little village with no opportunity.

1506
01:16:55,005 --> 01:16:56,943
I mean, there's
some kids who join our school play soccer

1507
01:16:56,943 --> 01:16:59,755
who had never been to soccer before,
and they're like,

1508
01:16:59,755 --> 01:17:01,505
they stopped in there
gazing at a traffic light.

1509
01:17:01,505 --> 01:17:03,317
They're like, I've never actually seen
one of those before.

1510
01:17:03,317 --> 01:17:04,817
And, it sounds silly, but like,

1511
01:17:04,817 --> 01:17:07,754
just think about the lived experience
and how different that is,

1512
01:17:07,754 --> 01:17:10,754
even to come in with other kids
at a high school at that time.

1513
01:17:10,879 --> 01:17:15,066
So ten years from now, who am I to say
you need to come back into here?

1514
01:17:15,066 --> 01:17:17,503
Because, you know,
because we gave you that chance

1515
01:17:17,503 --> 01:17:20,503
like nobody ever asked me
to do that, right?

1516
01:17:20,503 --> 01:17:23,503
And the reality is,

1517
01:17:23,628 --> 01:17:27,190
there are a lot of structural forces
that are causing this to happen, right?

1518
01:17:27,940 --> 01:17:31,190
If you want to build a business
or you want to start an organization,

1519
01:17:31,190 --> 01:17:34,190
a social business or whatever,
it doesn't matter,

1520
01:17:34,377 --> 01:17:36,064
where are you likely to find capital?

1521
01:17:36,064 --> 01:17:38,939
Where are you likely
to find the talent that you need to do it?

1522
01:17:38,939 --> 01:17:41,939
Is it in Malawi or is it in London?

1523
01:17:42,189 --> 01:17:44,939
Unfortunately, we all know the answer
to that question, right?

1524
01:17:44,939 --> 01:17:47,689
So a lot of things need to happen

1525
01:17:47,689 --> 01:17:51,063
to create the conditions
where there is a pull rather than a push.

1526
01:17:51,563 --> 01:17:55,563
And so our our thesis is not proven.

1527
01:17:55,938 --> 01:18:00,250
And I may be wrong,
is that doing this at scale,

1528
01:18:00,250 --> 01:18:04,500
like at massive scale
will do a couple of things.

1529
01:18:04,500 --> 01:18:08,874
First, because like Ella's
amazing and Lou, but it was 250 kids

1530
01:18:09,374 --> 01:18:10,687
a year roughly.

1531
01:18:10,687 --> 01:18:13,062
We're talking about 20,000 kids a year.

1532
01:18:13,062 --> 01:18:15,186
If we ever reach any kind of scale.

1533
01:18:15,186 --> 01:18:18,186
First of all, not all those kids
will ever get absorbed into the Harvard

1534
01:18:18,249 --> 01:18:19,873
and Oxford's of the world.

1535
01:18:19,873 --> 01:18:23,311
And they'll go to other kinds of places,
including studying in Asia,

1536
01:18:23,998 --> 01:18:26,998
and elsewhere, where there are lots
of rising universities be.

1537
01:18:27,123 --> 01:18:31,560
This will put a lot of pressure on
what is a really weak and underperforming,

1538
01:18:31,560 --> 01:18:35,497
hopefully tertiary system in Africa,
and hopefully we'll start to see more

1539
01:18:35,810 --> 01:18:41,622
Aleuts and UGS and accesses, etc.,
so that there actually are opportunities

1540
01:18:41,622 --> 01:18:44,622
for continued education
and career progression on the continent.

1541
01:18:45,434 --> 01:18:48,684
We want to be sort of a demand
driven stimulus or catalyst

1542
01:18:48,934 --> 01:18:50,933
for that part of the system.

1543
01:18:50,933 --> 01:18:51,808
As well.

1544
01:18:51,808 --> 01:18:55,433
And and then, of course, you hope
that there's a sense of purpose and shared

1545
01:18:55,433 --> 01:18:59,183
responsibility and Pan-Africanism
and things everybody wants to come back,

1546
01:18:59,683 --> 01:19:01,870
for the most part, has been my experience.

1547
01:19:01,870 --> 01:19:05,557
But it's not practical for a lot of people
because the opportunities out there,

1548
01:19:06,182 --> 01:19:08,557
and sometimes you fall in love
with somebody from some other country

1549
01:19:08,557 --> 01:19:10,619
and you want to go
there, too. I mean, like, you know,

1550
01:19:11,619 --> 01:19:13,994
so happened to us, me and my wife.

1551
01:19:13,994 --> 01:19:16,244
So anyways, that's the thesis.

1552
01:19:16,244 --> 01:19:18,181
The thesis is to do this at scale.

1553
01:19:18,181 --> 01:19:22,243
So we want to make this
like a massive 25 year moonshot

1554
01:19:22,243 --> 01:19:26,431
in developing human capital
on the continent. And,

1555
01:19:28,118 --> 01:19:29,368
so we going to.

1556
01:19:29,368 --> 01:19:31,180
Start to just

1557
01:19:31,180 --> 01:19:31,805
just hold on.

1558
01:19:31,805 --> 01:19:36,617
Are you going to attach yourself
to existing ESRI government schools?

1559
01:19:36,617 --> 01:19:39,930
Because I feel like that's
probably where it needs to happen,

1560
01:19:40,617 --> 01:19:42,679
because, I mean, I went to private school.

1561
01:19:42,679 --> 01:19:47,054
No one likes to go to like me
back home in a government office.

1562
01:19:47,054 --> 01:19:49,929
And like, it's there's a different ethos.

1563
01:19:49,929 --> 01:19:50,491
Yeah.

1564
01:19:50,491 --> 01:19:53,616
I feel that the two different things
carry.

1565
01:19:53,616 --> 01:19:55,553
Yeah. So I don't know.

1566
01:19:55,553 --> 01:19:59,053
Are you attaching them to the more at home
politics policy,

1567
01:19:59,366 --> 01:20:02,803
the hurdle are you attaching CBS
this is or.

1568
01:20:03,365 --> 01:20:06,365
I think we should pick it up transfer
over time after.

1569
01:20:06,552 --> 01:20:07,865
Do you want to ask
one more quick question.

1570
01:20:07,865 --> 01:20:09,615
And then we're doing like kind of similar.

1571
01:20:09,615 --> 01:20:11,427
I was wondering about like whether,

1572
01:20:13,677 --> 01:20:15,114
these are like funded places

1573
01:20:15,114 --> 01:20:19,114
at the schools
and how that link like government funding.

1574
01:20:19,426 --> 01:20:19,739
Yeah.

1575
01:20:19,739 --> 01:20:23,801
So the briefly the idea is that

1576
01:20:24,301 --> 01:20:26,926
every kid who

1577
01:20:26,926 --> 01:20:30,426
sort of meets the meets
the bar gets an opportunity to come.

1578
01:20:30,426 --> 01:20:33,425
So initially at this first school,
they're all fully funded.

1579
01:20:33,800 --> 01:20:35,613
That probably will change a little bit.

1580
01:20:35,613 --> 01:20:37,737
It could be
everybody has to pay a little bit.

1581
01:20:37,737 --> 01:20:39,987
Because that sort of changes
the nature of things a little bit.

1582
01:20:39,987 --> 01:20:43,674
Or it could be a mixed model of,
you know, some discounted fee paying

1583
01:20:43,674 --> 01:20:44,674
and then some kind of.

1584
01:20:44,674 --> 01:20:46,799
But the idea is that,

1585
01:20:46,799 --> 01:20:48,174
because there are a lot of good
private schools

1586
01:20:48,174 --> 01:20:51,236
that are out there for families
who have some needs, and that's great.

1587
01:20:51,236 --> 01:20:53,049
There needs to be more of them.

1588
01:20:53,049 --> 01:20:55,736
But this is the place where it's it's
sort of all

1589
01:20:55,736 --> 01:20:58,736
about potential, not where you come from.

1590
01:20:59,236 --> 01:21:01,111
So that's the whole
how we're going to finance that.

1591
01:21:01,111 --> 01:21:05,048
I mean, we're talking about
like a multi-billion dollar

1592
01:21:05,048 --> 01:21:08,797
initiative, over time is, is,

1593
01:21:09,985 --> 01:21:10,547
vicious.

1594
01:21:10,547 --> 01:21:13,547
I will
say that we're going to figure it out

1595
01:21:13,735 --> 01:21:16,734
with.

1596
01:21:16,859 --> 01:21:19,859
Even that is just amazing.

1597
01:21:20,422 --> 01:21:20,859
Yeah.

1598
01:21:20,859 --> 01:21:23,859
Thank you so much for coming
and inspiring us.

1599
01:21:23,859 --> 01:21:27,233
To, I think we've got a recording
because I know some of the students are

1600
01:21:27,233 --> 01:21:31,858
double booked and they'll be watching it,
so thank you very much for being.