They would you speak who was at the business school?
But now you set up a new gig.
You're going to have to tell him about it, because I never left.
But Peter does really cool stuff
in social entrepreneurship in low income countries.
He also
illustrates how to give an amazingly cool lecture.
And I just love watching life and learning stuff from you.
I'm going to let you introduce because I'm going to get
get it wrong, cause I never memorized that paragraph.
That was just my heart.
Thanks for,
Hey, everyone, great to be with you.
Hello to those of you who are online.
My name is Peter.
Feel free.
Let me just say, first off, we have a good chunk of time.
We won't necessarily use it all.
I want to respect the fact that you've been in class all day.
But we can be a little bit relaxed, and so please feel free to interrupt.
Ask questions.
You know, slam me with, critiques, whatever it is,
including you folks online as well.
So I am a, a doctor by training,
pediatrician, internal medicine and practices and public health.
And I've spent most of my career doing global health work,
and we're going to talk about a lot of that today, really doing systems,
building health equity work in places like Rwanda,
Malawi, Ceuta, rural Haiti,
Lima, Peru, Siberian prisons, inner cities in the US, etc..
And we're talk about one specific example of that.
And the social entrepreneur thing sort of happened by accident.
It was just trying to, you know, be useful, and help address problems.
But, but I did go on with some colleagues in Rwanda to, to found a university,
there called University of Global Health Equity,
which you should all know about and I will talk about as well.
And after several years of doing that,
and kind of getting it off the ground and handing it over to a much more competent,
vice chancellor, I moved here and I ran the school center
for social Entrepreneurship, which is what took me to the business school in 2017.
Ran that for a little over six years,
had a little sabbatical, and then started this new gig that I just mentioned.
And we can talk more about Crucible later if you're if you're interested.
I think there's some interesting parallels between the health systems work
and now the kinds of the needs and strengthening education systems,
and that's
why it's been attracted to me to sort of get out of my comfort zone again.
Just like being a global health social justice doctor and
turning up in an elite business school, like I had no business being there.
It was was weird.
My first lecture, at Sade in 2017, I was talking about equity,
which you'll hear about today, and the first couple minutes.
Everyone's face is screwed up and it looks so confused and I was like,
you guys okay?
And I thought I was talking about the financial person
securities and things like that.
I'm like, oh, I'm totally in the wrong place.
This is amazing.
And it was great, actually, to be in a different discipline and in a milieu
we're not.
I sort of thought the same way and saw the world the same way,
and got to spend a lot of time with amazing MBAs, many of whom are impact
driven and actually quite a number from health care, etc.
and are using MBA as a masters in getting stuff done.
That's what the school center does, is try to bring together
folks from across disciplines, across sectors who are trying to solve big,
hard problems, sustainable development challenges and things like that.
So, it's been a it's been a weird ride.
For me for sure.
And then every once in a while, like every no, ten years or so,
I seem to sort of get restless and decide to do something completely different.
That's what I'm doing. Yeah. And as of this is just as of January. Right.
So it's all brand new.
We don't even have a website yet, but we can talk about that later today.
We're going to talk about system entrepreneurship,
and I understand that you've been talking about and thinking about
and working on complex systems problems, already today in this week.
So hopefully you'll be really, really primed for this.
And I'm going to come at it from the angle of,
how we frame social entrepreneurship at the school center.
And I'm going to talk through sort of my experiences,
over about ten years in, in Rwanda, which is one of the most remarkable,
country level transformations, not only in health care, but sort of
social and economic, that, you know, that I've ever seen
and in fact, you know, the statistics kind of bear this out as well.
I'll acknowledge that at the moment, Rwanda is is engulfed
in, a really messy and tragic situation, involving DRC.
That's really a conflict that's gone back 20 years.
It's a complex place and it's a complex neighborhood.
Happy to talk about that.
But there's a lot to learn from what is probably
the most entrepreneurial countries and one of the most interesting
places, to be doing this work in the world right now.
So 2025
has gotten off to kind of a crap start, right?
It's like not been the best year.
I'm also American, as you could probably tell on my accent.
I'm not Canadian.
Not from the 51st state. So.
I didn't mean that, of course.
But, you know, it's been it's been rough.
And, I'm
speaking to a group of small business leaders in the UK at the business school
next week,
and we kind of talk about each year I come and talk about the kind of big
global trends.
And, and I think the watchword for 2025 is uncertainty, right?
We just don't know what's happening right now.
We don't know where we're going.
How sort of one guy has been able to throw
so many things into, into question and in a rapid fashion
has been pretty remarkable for those of us working in global health.
You know, like USA is an important institution,
but they don't do everything everywhere.
But what turns out happens, as I'm sure many of you know
and have seen, was that the kind of,
sudden shutting down
created so much uncertainty that it just rippled
throughout the entire global health system.
So W.H.O.
stopped working.
Basically, they stopped hiring.
They put a whole bunch of projects on hold.
Ministries of health have stopped
because they're not sure if money's ever coming through
and if they're going to have to repurpose funding for this nutty other thing.
So of course, projects are being shut down, jobs are being lost,
lives are being lost.
But it goes way beyond that.
One single institution is affecting the entire system
in a pretty catastrophic way.
And of course, those things are being replicated, unfortunately,
in lots of other places.
And I don't want to depress you by talking about all the things that seem to be.
That he's going to do that tomorrow.
Oh, good, good, good going wrong in the world.
But where's all this coming from?
It's coming from the fact that the challenges that we're facing are
this we sometimes called wicked problems have based in Boston for a long time.
So it's wicked in the Boston sense, which means messy,
really hard, really terrible problems.
We're living in a world that is interconnected and entangled in
so many ways. Our systems are entangled,
etc., etc.
and, what we mean by wicked problem is, is a problem
that is not just complicated, but complex,
where not only do you not know
a cure, a whole group
of smart people thinking about this probably don't even agree on the cause.
They may not even agree on whether there's a problem at all.
And these are the big kinds of challenges that we face today.
We saw a lot of this during Covid.
We see a lot of this kind of conversation with the climate crisis, etc..
And so the way I think about social entrepreneurs are that social
entrepreneurs are the ones who try to entrepreneur wicked problems.
And so that's what we're going to talk about, today.
So you've talked a lot about systems.
I don't know if you've confronted the work of, Janella meadows,
who is, you know, a sort of, you know, a major intellectual figure
in, the rise of systems thinking for social change, right?
You probably know that, systems theory has come
from many disparate disciplines.
In many ways, a lot of that has come together in
almost what seems like a new ish way in trying to understand how systems
thinking can help us address complexity in terms of social systems, basically.
And, and so what she said or wrote is the world is a complex.
I'm going to read this for the benefit of the recording.
The world is a complex, interconnected, finite
ecological, social, psychological, economic system.
It's one big system. It's all connected, right?
We treat it as if it were not as if it were two visible,
separable, simple and infinite.
Our persistent intractable global problems, wicked problems
arise directly from this mismatch. Right?
We've made a lot of progress in the world
through kind of, you know, reductive
thinking and breaking things down into their component pieces
and teaching systems thinking for the last eight years or so.
One of the interesting things I've learned is that there is an inverse
relationship between someone sort of age and career status,
and their ability to, like, psychically handle systems thinking.
What I mean is that when I'm talking to kids or secondary school
students, they intuitively grasp what we mean when we talk about systems.
The idea that things don't move in linear cause and effect, A
to B to C, but that they move in kind of cycles.
For example.
And when I was teaching systems thinking to executive in
Vas to the Masters in Global Health Leadership,
over at the
business school as well, we're talking like mid career
C-suite, super accomplished, successful, high powered people.
They hated it. Right.
And one guy at the end of the module, the exec MBA one, stood up and he said,
I'm speaking on behalf of, of the entire cohort here.
This was to to myself and my colleagues on the one week program on Monday.
We hated you and we didn't know why we were here.
And on Friday, you change the way we see the world at least a little bit.
And that's great.
But we, you know, we get through life like.
Right?
You've been successful people, your problem solvers, right?
You take a problem, you want to tackle it.
You want to find a solution.
You want to say, okay, what's going on?
I'm going to break it down into pieces, into steps and, and do this.
And then we're going to do this and then we're going to do this.
I think about the way you work in development with things like log
frames, you know, inputs, outputs, outcomes, that kind of stuff.
It's totally linear and that works really well for a lot of hard problems.
For complicated, hard problems, it doesn't work well for systemic problems
because the interactions are too messy, they're too interconnected.
And so doing something over here can cause a second
or third order thing over here and a totally different part of the system.
And oftentimes that's what we call the speculative law of unintended
consequences.
I called Thomas Merton from 1936 the unintended consequences
of proposed social action.
It means you can go into a situation and do something
with the best of intentions and with a lot of rigor,
and still mess everything up and make it worse,
because you're only looking at this one narrow thing.
You're looking at addressing one disease in one community
or one little part of the system, and actually not understanding that,
you know, that the benefits that you're distributing
without much education, cause you're trying to do it faster at scale,
are not being used properly, and they're being resold as fishing nets
and choking off fish and clogging up waterways and things like that.
Or starting a frozen fish factory at Lake Turkana in Kenya.
In, you know, the north of Kenya as an economic development project
for the locals, but not actually investing in stable electricity
like a power infrastructure.
And then all of those fish don't get frozen
because the power goes off all the time, etc..
You know, like the history of the late 20th century
is littered with well-intended projects that have gone amok.
Right.
And a big part of it is because you're actually not looking
at the, at the entire system.
So my view and what I submit to you is that systems thinking,
the kind of stuff you've been working on this week, is, is a kind of a super power,
is a kind of an edge because it allows you to see things
and new ways to step into other shoes,
see problems in new ways, see them as different kinds of problems.
And from that you can see opportunities to make change that maybe others don't see.
And that's kind of the essence of entrepreneurship, as
you'll see when I talk about the work in Rwanda, what
what's sure looked and felt a lot like a medical problem
when I started as a young doctor, in rural Rwanda at the time,
and it was 2004 on what was essentially an HIV project,
you know, funded by the Global Fund and all of the new, vehicles
that were bringing resources to the global Aids, fight.
What I realized was that it wasn't an HIV problem, wasn't even a medical problem.
It was a poverty problem. Right?
There were structural problems.
There were other things that were driving this, actually,
the forces that determine who gets sick and who doesn't,
who gets access to care and who doesn't or not biological right.
Their political and their social and economic other other things.
And so once I was able to understand it, this wasn't like, I figured it out.
This was having the good fortune of amazing mentors,
that actually were dealing with different kinds of problems.
I understood that as,
one of our patients in Haiti once said,
taking your antiretroviral medicines or HIV medicines
without food is like washing your hands and drying them in the dirt.
So yeah, the pills are cheap.
You can get the pills, to people.
But unless you understand the entire situation, not actually going
to be creating the kind of value you want and having the impact that you want to.
So this is the kind of system stuff I'm getting ahead of myself already.
But great.
Another aspect to addressing complex problems that's important.
You guys have heard of tragedy of the Commons, right?
The idea that, you know, we're all in the same boat together,
but we tend to each stay in our own lane
and do what is in our self-interest.
That could be myself and my family or our community.
That could be our organization.
We do a great simulation called Fish Banks that was developed at MIT.
Which basically puts a bunch
of people in a room like you and you're all,
fisher people, you're running fishing businesses,
and you're all fishing out of the same scene,
and your job is to build your business and get as profitable as possible
and make money and buy more ships and do more fishing, etc., etc..
And what happens?
You are fishing from the same sea, which is in
some ways a closed resource, right?
So if each of you or each of your teams are acting in your own
individual self-interest, what happens.
Is he gets overfished.
The sea gets overfished, and then there are no fish left.
And then you go under and you all go under.
And the amazing thing about this simulation is,
like at the time that we explain it to you, you figure this out.
So you come into the situation, knowing what we have to do
is figure this out together.
Otherwise we're all going to, you know, fish all the fish out of the sea
and go bankrupt and lose our livelihoods.
But every single time it happens anyways.
Because
of this fact, the tragedy of the comments, like, I still have a goal
and I'm trying to make a balance sheet and I'm trying to get my employees paid.
I'm trying to feed my family.
And by the way, if I'm the first one to blink
and even one other person doesn't go along with it
and I'm going to lose and they're going to win
and I'm sacrificing for nothing, right?
And so in the end, best of intentions,
we still mess it up most of the time.
It's kind of what happened during Covid, right?
If you think about this right, think about the right.
We have an example of,
you know,
one of the one of the greatest examples of sort of rapid scientific cooperation,
probably in our lifetimes, right,
in the development of Covid vaccines here and around the world
and getting them through regulatory approvals
and finding ways to finance them, etc., etc.
we didn't do as great a job at getting them
into the arms of the people who need it the most.
I know spends a lot of time doing Covid related stuff,
and but mostly talking about it.
But I know that in 2021, you know, which was the year that the vaccine
rollout really happened in earnest by the end of 2021, Canada
had purchased six times more Covid vaccines
than they could ever possibly need for their own population
because they were trying to leverage against the different types and have
whichever ones would be most effective.
And Malawi had still not been able to vaccinate its frontline doctors, nurses.
Right.
You designed a system, you would never do it that way.
And, you know, we thought at the beginning that like,
this is like the alien invasion.
Finally, the global threat that can bring us all together
like a Will Smith movie, right?
And like, we can work together and we can conquer it.
And this is going to be great.
This is the way we can figure out how we're going to start to cooperate
as a society for world scale problems, and climate change is next, right?
This is my naive optimism in 2020.
And it didn't go that way.
And again, because of sort of narrow, narrow self-interest.
So the way Antonio Guterres put it,
a couple of years ago, the secretary general
of the UN, we faced the greatest cascade of crises in our lifetimes.
And yet solidarity is missing when we need it most.
And you'll see, as we talk about system leadership and system entrepreneurship,
how important it is for you as leaders to be doing
the work of building relationships and bringing people together.
That's it really important in the global Aids movement that I came in
sort of at the tail end of when you think about what had to happen
to go from,
let's say, 1997, I was a like a young university
graduate who went to work as a volunteer for a Tanzanian NGO called Kuleana
that was doing children's rights work and particularly working
with homeless kids and shelters and things like that.
And so I happened there, to try to be useful as a 21 year old
who didn't know very much about anything, at the height of the Aids crisis.
Right.
And 2000 kids in one shelter, all of them had lost their parents
and their families to to the Aids pandemic and ended up from small villages
in a city in terrible circumstances and situations and suffering immeasurably.
And I once got sick with malaria and went to the hospital, to Kondo Hospital.
And it was like the worst place I've ever seen, you know, for people to a bed.
Nothing was working.
There were just people lying in hallways.
There was suffering everywhere. The system was totally overwhelmed.
I knew that if things didn't go well, I could get out.
Why do I deserve to get out of nothing else?
Right? This was the conversion moment for me.
But then from there to 2003, 2005, somewhere in there,
we suddenly saw the creation of the President's Program for Aids relief
in the US, for the Global Fund to Fight Aids, TB and malaria, billions of dollars
of investment, and a whole bunch of things that brought drug costs down.
And suddenly everyone was like, yeah, Africa with Aids
deserves a shot of treatment and we're going to do stuff.
So how did that happen?
It didn't happen that quickly.
Of course, this was activism and advocacy and social movements
and other kinds of things that happened over 20 years.
But ultimately, there was a
time in which Aids activists who had been throwing blood on politicians
and pharmaceutical CEOs for years
had to sit down at the table together with them and said, let's try to figure
this out together, along with doctors and other kinds of folks,
so people who don't see the world the same way, who don't trust each other,
who don't like each other,
have to find a way to see that there's something
that they share in common in terms of their interests.
Right.
And the people who were able to broker those kinds of relationships and those
kinds of conversations are the ones that can change the trajectory of things.
Right?
That's what we call system leadership.
Okay.
So I want to talk about social entrepreneurship briefly,
because that's sort of the the angle at which, I come from
and at the school center, I'll say we even though I'm not there anymore,
it's a very expansive definition of social entrepreneurship.
So many people think of social enterprise when you hear social entrepreneurship.
And that is true.
Social enterprises are businesses that try to create positive impacts, right?
And they often do that by generating some revenue
for sustainability and getting some grants.
And breaking even, etc.
that's all good and that's all fine, but it's just one little piece of the puzzle.
So let's start with entrepreneurship.
What do you think of
when you think of entrepreneurship, or when you think of entrepreneurial?
What kinds of words come to mind?
You can you can share a definition if you've got one in mind.
But what what comes to mind, child?
Things that.
Like get rich quick, people.
Get rich quick, people. Okay.
Should I take a personally millionaire?
Oh that's right.
Think like, willing to take risks, but ultimately chasing profit.
Yeah. Okay. Big risks.
In search of big opportunity. But in this case, big profit.
And of course, we as a society kind of lionize, right?
Or fetishize.
The heroic entrepreneur is usually like a middle aged
white guy in a black turtleneck or wielding a chainsaw or whatever.
Right. But but those are the success stories that we think of.
It's like the heroic entrepreneur.
Great. What else?
Yeah.
So like a structured problem solving process.
Step one would be see a problem set to solve it.
And then step three scale your solution. Okay. Awesome.
Yeah.
I also spent around 40 years on Kendall Square.
So I think of like biotech startup. Yeah yeah.
Yeah. Amazing.
So but that's really about, you know, leveraging new technology to,
to drive value, right.
To, to speak broadly.
And that could be solving problems and saving lives and making money.
Hopefully both of them. Right. Yeah.
Pioneering. Pioneering. Fantastic. Right.
So doing stuff that maybe nobody's ever done before
or doing things in a way that no one's ever done them before
or doing them in a place where it hasn't been done before.
Sometimes it's about bringing things like the fruits of modern medical science
to market sort of communities that have been excluded from the system.
What else?
Come on new, you got more ideas?
Work with me here. Try to keep you all the way.
Oh, it's kind of in line with labor.
I mean I think creativity. Yeah. Great.
So creativity, pioneering, taking risk, solving problems.
Absolutely.
All of these things, all of these things are true.
Going big right.
Yeah. It could be. You know, I want to be a billionaire.
We could just be like,
I want to build something massive on and do something massive.
So the classic definition, a classic definition of entrepreneurship.
This is a guy called Howard Stephenson, I think back in the 80s,
at Harvard, the pursuit of opportunity
beyond the resources
currently under your control.
And I share this because entrepreneurship
is not about starting a venture necessarily.
It's about the pursuit of opportunity
beyond what seems possible right now, beyond the resources that we have.
And that could mean leveraging or introducing new products or technologies.
It could be leveraging networks or relationships and new ways of coming
together or new markets, like I say, trying to bring technologies
or the fruits of medical science or whatever it is to new markets, right?
The people who figured out how to address the market failures of Aids, drugs
that were $10,000 per person per year
and said we could rejig this whole thing
and they could be produced for less than $100 per person per year.
And the volume would explode.
So we can go to pharmaceutical companies and say, hey,
you can make just as much money as you're making right now,
maybe more by dropping your prices 95%.
And we'll give you a guaranteed market to hundreds of millions
of more people for life.
Your margins will be small, your shareholders will still be happy,
and activists won't be throwing blood on you anymore.
That sounds good, right?
So that's an entrepreneurial kind
of solution to bringing a technology into a new market.
So we think of entrepreneurial entrepreneurship
as entrepreneurial ism, right?
So it's people in groups that are acting the way that you guys are talking about
being creative, seeing new possibilities, thinking big, thinking differently,
trying to pioneer stuff, trying to solve problems,
trying to create opportunity where there is right
entrepreneurs see opportunity, where others see challenges and problems.
And we talk about social.
Oh, sorry, it was already there.
The sort of the technical term is primacy of social environmental value creation.
So it defines,
the entrepreneur that you were talking about from a social entrepreneur
is the social entrepreneur says, we may be in a for profit venture,
we may be a not for profit,
we may be in government, whatever our primary purpose, our primary
and the reason we exist and are doing this work is to make the world
better in some way, shape or form.
So that's addressing a
social problem or an environmental problem or what have you.
And you know, in many cases, being profitable
or making money might be a way to scale your impact, right?
Because nobody wants to rely on donations forever.
There's usually a ceiling to that,
or a duration, you know, after which it's going to be difficult to do.
That's fine.
That's the business model. The business model is separate.
It's about being entrepreneurial and focusing on problems.
The second thing that I want to emphasize about this,
if you buy my argument that this is about entrepreneurial ism,
you don't have to be someone who's starting or helping to start
a new venture.
So classically, right, an entrepreneur is someone who builds something
new, starts an organization, starts a venture, etc.
an entrepreneur is someone who is being entrepreneurial, but working inside
of an existing
organization that says system here, but I would say organization.
So that could be someone who is working in a big company
and actually saying we could do things differently
and leverage the incredible market share and power
and influence and all these other things that this company has.
It could be someone like
the Minister of Health during the period, or one that I'm talking about,
one of the most social entrepreneurial people I've ever worked with.
She was a sitting minister of health, but she acted like an entrepreneur
because she was never accepting the status quo.
She was always looking for new opportunities.
She was always pushing to do better and more and faster and bigger,
and was the one who really drove this kind of transformation.
And she did it from within a government bureaucracy.
So it can happen anywhere.
Maybe not in the University of Oxford, that
maybe the only bureaucracy impervious.
I'm just kidding.
And then the third kind, which is sometimes called extra preneur,
are the ones who entrepreneur at the systems level
that sort of go beyond single organization,
whether it's a startup or an incumbent existing organization, and say, actually,
you know, the kinds of problem that we're wanting to address here
is the sort of thing that no single organization can solve on its own.
We have to get a whole bunch of different actors
orchestrated in a way that's going to help address this problem.
We have to find people in different parts of the system
that have the right leverage in the right place to get stuff done.
We need the activists and the pharmaceutical companies
and the, you know, really cutting edge, implementation doctors like Paul Farmer
and the political leaders, which included George W Bush.
Right.
All pointing in the same direction.
And that system, entrepreneurship is another term for this.
So this is what
the actual purpose of this talk is.
Now we're 30 minutes in and I'm just getting to the point.
But here we are.
So I want to talk about systems entrepreneurship.
I take all the things that I've said now and give you an example.
I'm not going to spend a ton of time talking about
systems thinking and systems change and the really technical stuff.
I'm hoping it sounds like you've already had some of that.
So. But feel free to ask questions if anything isn't clear.
What I'd rather do is kind of show you by example
and try to bring this to life, because what I've learned is that systems
change is really easy to talk about, and it's really hard to do.
And a lot of our research work at the school center was really focused on like,
what are practical approaches to trying to shift systems for the better?
How do you do it?
If you're starting out at the beginning of a journey, where do you start?
And it's just not that easy, right?
It's like it's like intangible, almost.
And so we and lots of others
have been engaged and trying to figure out sort of how that works.
So when I talk about system entrepreneurship,
here's just some bits of definition.
There will not be a quiz. You'll have these slides.
I know your brains are tired person or organization
that facilitates change to an entire ecosystem.
By addressing and incorporating all the components and actors that are required.
Not all of them,
but all that are required to move the needle on a particular issue.
So we could do this in the context of a health system or an education system,
or an environmental or an energy system, etc..
System entrepreneurs move beyond delivering solutions
and think
about and influence the architecture of the system itself.
One tool that we use a lot in systems thinking is something called the iceberg
model.
Some of you are probably familiar with that.
You know, like if you think about the iceberg,
right, you've heard tip of the iceberg, this little bit that's above the water
is represents only a very small piece of the mass of the entire thing.
That's why the Titanic sunk. Right.
And so beneath the surface, that's where a lot of the action is.
And so an iceberg model of a level that's above the surface is called events.
These are the things that are happening that we can see and observe.
And then you have three levels below the surface is kind of a root
cause analysis.
So first you look at the patterns ways you can measure trends
and things like that to see what's happening over time.
Below that you have the structures what are the laws and the policies
and the economic factors
and the power dynamics that make things are the way they are.
What are the rules of the game?
And then even deeper than that, you have the mental models are kind of shared
ways of seeing the world
and what we think of as normal.
And obviously not everybody shares the same mental models about everything.
But that is the sort of deepest level of the system.
And so what I would say is that what social entrepreneurs want to do
is not to,
address the problem superficially,
just treating a patient in a clinic.
Very good and very important.
Tom. Shoes.
For those who are American, you buy a pair of, like, cool canvas shoes
and they give away a pair of shoes to somebody in need.
Somewhere in the world.
I was working in Rwanda.
They call us up every year or two and be like, hey,
can we send you a 40ft container of shoes?
Would you help distribute them?
We'll be like, yeah, no, that'd be great.
There's a lot of people who need shoes here.
But I'd always
have this gnawing sense that, like,
is this really fixing anything?
Because, like, the shoes are going to wear out
and the kid who couldn't go to school because they didn't have shoes today
might not be able to next year unless like, Tom shoes comes along again.
Why can't we understand and think about why we're living in a world
where kids can't go to school because they don't have shoes
in the first place, and address those underlying root causes?
Right?
That's what we're talking about when we talk about systems thinking that's
what kind of the iceberg does.
So it's really going deep
and trying to understand what is the architecture of the status quo.
Why are things the way they are right now, and why is it so hard to change?
Because of status quo? Is is rigid. You know what I mean?
People don't want it to change because often times they're benefiting from it.
So systems entrepreneurs think about that kind of stuff
and act as a as a catalytic force.
What that means is it's not always about doing the thing,
like providing the service or the intervention or the product
or whatever it is about it, and creating
the conditions that enable change.
Sometimes that is bringing the right group of people together.
Sometimes that is a policy change that, maybe incentivizes action
or increases the cost of inaction or something else.
You're doing something that shifts
the dynamics of the whole system, that allows things to happen.
Okay.
So we're wired to think about solutions, right?
We see a problem.
We want to fix it in the systems thinking course
that I taught to all of the MBAs and MBAs for six years.
They you work in teams on
like a sort of big sustainable development channel at different stages of a year.
What I would tell them is that only 20% of your final
mark is based on the solution that you come up with.
80% of your mark is based on your understanding of the system
and what's going on there, and your ability to articulate that.
Because if you just jump to the solution
in ways we all want to do, you'll usually get it wrong.
Or you only get one piece of the puzzle.
And so let's cash, we would say like strike
the word solution from your vocabulary for the next two months.
And every time you have an idea, oh, we could do this.
Write it down on a piece of paper over here.
That's your parking lot.
And now let's go back to
trying to understand what's actually going on in the system.
Right. So it's it's a different way of thinking.
That's why those exact MBAs were going
berserk and really struggling with this at the beginning, because they're,
you know, they're action oriented people.
So it's different.
It's different. Right.
Then we talk about systems thinking,
we've seen this.
It sounds like, right.
We see the parts of the system that were most proximate to.
So if I'm a doctor, I think about a problem,
a health care problem from the level of patient care in a clinic or a hospital.
For example, somebody else
might be a pharmacist, somebody else might be a policy person.
For patients, it's going to be completely different
for community health workers going to market,
for somebody halfway around the world, it's
going to be totally different because their context is different.
We tend to see what's right in front of us,
or we tend to focus on the part of the problem where we have expertise.
You know, I started this.
Some of you must be medical, right?
You know, medical training is like years.
I did three specialties in a public health degree.
I was like in my mid 30s before I got a job.
And so I spent all those years learning stuff, and I knew a lot of stuff.
I knew all about the path of physiology and all the drugs,
everything there was to know about HIV.
And then I got out of a situation where I felt totally, woefully underequipped
to even understand what was going on or do anything useful.
And so what it felt like it'd be useful to do is just like, well,
I'm going to just give medical care.
Then I'm going to start getting patients
and we got to get more drugs here, etc., etc.
but I was just focusing on that one little piece of the puzzle.
That's what this cartoon is all about, right?
So systems thinking is a
way of like retraining your brain to try to look for patterns and new ways.
So commonly you think about moving from linear thinking of cause and effect.
A leads to B leads to C, end
to circular thinking, A leads
to B leads to C leads to a right.
The head of the arrow catches its tail.
We start to see our feedback loops.
That could be,
vicious cycles or virtuous circles.
It could be stabilizing negative feedback loops like the system in this room.
I guess we have an open door right now,
you know, heating and cooling systems, right?
Or negative
feedback systems that are designed to keep you at a comfortable temperature.
And if it gets too hot, the cooling kicks in.
If it gets too cold, the heating kicks.
So it's meant to keep you at a stable equilibrium.
So there's positive feedback loops and negative feedback loops.
Don't have to worry too much about exactly what that means
if your brains are tired right now.
But the point is, this is in the real world,
the way most things happen in technical systems,
linear works in natural systems and social systems.
It tends to be circular, thinking about patterns of cause
and effect in in a circular fashion.
Rather than thinking about the component parts
disconnection, you think about interconnectedness, right?
Scientifically, we do a lot of analysis in systems thinking.
We look at synthesis.
We look at how do all the pieces fit together.
This one is really interesting.
This concept of emergence of systems thinking is like, how do all of the pieces
create something together
that is qualitatively different than the sum of the parts?
Buckminster Fuller, the
whatever thinker, inventor, geodesic dome guy once said, there's
nothing in the caterpillar that tells you it'll become a butterfly.
That's the principle of emergence, right?
You could dissect that little caterpillar, and you never could figure out
by how some day you're going to wake up and that thing is going to be a butterfly,
right? That's the magic of systems.
Rather than thinking about stakeholders in isolation,
what's more interesting is what connects those stakeholders to each other.
What are their relation ships where the flows of information,
where the power dynamics,
which actors are
isolated from the system and maybe don't have a voice.
Right. Those are usually poor people
or other groups that have been excluded or marginalized from the system.
So understanding where the relationships are and are not is really important.
So this is the way, like you've been working on this week,
to start thinking and then training.
This part of your brain is what allows you, along with some tools,
to be able to see problems in a big way.
It takes a lot of patience
and it requires you to sort of turn off the part of your brain
that just wants to go fix it and take time to learn and understand
and try to see and hear a lot of different perspectives.
Right.
You may be talking about an issue that you know a lot about,
and be pretty sure you know what's going on, and it's going to be hard
to hear someone else saying, you know, based on my experience,
this is what this means.
And you have to be able to do that.
So very
briefly, normal innovation, right, is innovation is about value
adding processes of adding new things, new technologies or whatever
normal innovation, what they call here,
parts of innovation is a new way of solving a specific problem.
And usually that involves bringing a new product or a new service to the market.
And you want to be able to steal that because it affects more people.
System innovation starts with the idea stage is,
can we look at the system in a new way?
Everybody's looking at this as a medical problem.
Maybe if we look at it as a poverty problem, that will give us some insights
and some new ways of actually attacking things.
Okay.
And so then ultimately when we do this not I'll bring something to the market.
It's a new way of coordinating different parts of the system together.
That makes sense.
And now
you can do you can shift systems by doing this.
It does happen, right.
Bring things to scale.
Think about,
think about Netflix.
Most of you are probably too young to remember the days
when if you wanted to watch a movie, you had to go to a store
and you had to walk around and look at these shelves and whatever
movies, TVs or tapes they had in stock, that was the movie.
You could watch that thing and you pay some money knowing that
eventually you're going to pay five times more because you want to to about time.
And as long as you had it, nobody else in town could watch that movie.
That was the way that we consumed content, right?
That seems insane right now.
So Netflix came in with a better model, which first was
you can order anything you want online will send it to you
in the middle really fast, keeping for as long as you want,
as long as you're paying your subscription fee.
And then when the technology catches up, we'll just get rid of the TVs
and you can just choose anything.
And that has transformed the way
that our relationship with content, it's changed the way content is produced.
It's brought us to like an insane scale, some good, some bad, obviously, etc.
but that did change that aspect of the call
it the entertainment system or the media system, right?
So a traditional business venture and a new technology in that way
can shift a system at scale, but it's not the only way to do it.
And I would say that the history of interventions
in the so-called like social sector, including health and everything else,
is that this rarely works.
You rarely have a new good idea or app
or something else that can just be scaled
such that it'll fix everything and shift the system.
So it's thinking about how can we organize things in a new way,
oftentimes doing something new or doing something in a new way,
or bringing that breakthrough product like antiretroviral medicines
into a place where it's needed that wasn't accessing it before
is really important, but it's just one piece of the puzzle.
Okay, so let's talk about Rwanda.
Let me go through this story a little quick,
but what I want to do is show how some, aspects of systems
change system innovation or system entrepreneurship,
can really be illustrated by a country that was once the poorest in the world
with, all, almost all public
infrastructure, physical
infrastructure and human infrastructure destroyed, where the life
expectancy from birth was 28 years,
it was older than 28.
In this room, some of us right.
To be, one of the fastest growing
and most widely prosperous countries, though still poor in the world.
It's a remarkable story.
Okay, so Rwanda, that tiny little country,
it's in sort of straddle Central Africa and East Africa, German colony.
So no Germans
actually went there for ten years after they won it in the Berlin Conference.
Then it was a Belgian colony,
and its post-colonial history was a really, was a really tragic one,
living in the 1994 genocide, against the Tutsis
that took a million lives in a country of 7 million people
in 100 days.
And this was that.
And this is a really hard image, to look at, and I apologize for that.
It is also the most 90s magazine cover ever.
There's a little okay, there as well.
This was a thing that I'll move on.
So you have to look at that, that really, really tragic picture
that happens so fast in an era
where we couldn't see everything that was happening every day all at once,
that by the time, like, the media got into Rwanda, it was almost over.
And I remember, I think I was in college at the time was crazy.
So post genocide, Rwanda in 1995, after a rebel army of Rwanda and diaspora
in exile came in and ended the genocide and started a new government.
This was what you would call a failed state, right?
The, the the roots of that violence were deeply rooted,
some in colonial history and political and social causes.
2 million people had been internally displaced in the country.
2 million people had been externally displaced.
A million had been killed.
That's five out of 7 million, right?
Everybody ended up somehow, somewhere else.
If they if they survived at all.
You had a situation where 100,000 people
had allegedly taken another life.
This was not a centralized Nazi style tragedy.
This was a neighbors being exported to kill their neighbors tragedy.
So how do you then deal with
a the criminal justice aspects of things
when you have no courts and no judges and their lawyers?
And how do you deal with like the stitching back the fabric of society
together?
There's no playbook for this at all.
I mean, incredible loss, obviously, of human capital, infrastructure, etc.
most of the doctors, for example, were killed or fled even ten years later
when I arrived and I,
was, registering and things to practice there.
I got my, my membership card for the Rwanda Pediatrician Society.
And, you know, up in the corner above my name, it said, number seven.
And I was like, hey, cool. I'm like James Bond.
And then I, they asked the lady at the,
at the, at the desk in their office and like, asked me what I think it means.
And she said, sir, you are the seventh registered
pediatrician in Rwanda, which at the time was a country of about 11 million people.
And she said
and three of them were working in NGOs and ones in the ministry.
So you think about the number of pediatricians
for the 50% of the population were under 15, right?
For the 5 million kids.
So that's like the situation, right?
You saw spikes and level of poverty and disease
because diseases thrive on social faultlines.
Right?
HIV have been weaponized for sexual violence,
tuberculosis runs rampant, cholera, etc., etc.
and perversely, Rwanda became the lowest recipient of foreign aid
in the Elamite sea world at that time because people just ate
all the cameras were going to the refugee camps in DRC and Burundian elsewhere.
So that's where the attention went.
That's where the money went, even though those who had perpetrated
the genocide were in those camps, and they just felt like there was no point
like, this
is there's this is not a recoverable situation.
So that was the that was the story as it started.
Where it went then was a,
I think, a slow effort first at stabilization,
at rebuilding everything from the ground up, not just physical infrastructure.
I mean, the parliament building was not habitable and safe.
There's still they kept when they renovated the one
wall of the Parliament building with all of the bullet holes,
just as to when you drive by or walk by, you can still see that,
but when they constituted a new parliament, they met,
like outdoors in a tent, because there wasn't a place to go.
But like, hey, you got to get on with business, right?
What you see, though, is, is a leadership and a very strong,
political will, you know, a desire
for action, for accountability, etc..
This probably the most important thing.
I'll talk about this in a moment.
Equity oriented national policies effectively
what the
leadership in Rwanda did, if you wanted to sort of diagnose
what happened in 1994 and all the years leading up to it,
what were the conditions that made violence at that scale possible?
It was largely
that in situations of desperate poverty, you had entrenched,
reified inequalities.
And unless that was addressed,
there would always be risk of a further descent into violence.
And the flip side of that is if everyone's lives are getting better,
or they have some hope for the future and some kind of opportunity.
They'll be a lot less likely to be convinced
or coerced to turn against their neighbors again in the future, right?
Or to hate the other or whatever.
So then, like access to health care becomes a national security imperative.
Access to education becomes a national security imperative, right?
So because of that, like the urgency of things was different,
what they also did was literally ID write a new constitution
because its previous constitution was bad, and they wrote it into the Constitution.
So then if you're working in the government
and I did, you are constitutionally obligated
to effectively have an equity agenda in the work that you do.
You sign performance contracts in Rwanda when you're in a
any kind of elected office or senior positions.
When I was, I was appointed the chair of the Rwanda Biomedical Center,
which is like the implementation agency for the health care system in Rwanda.
And had signed a performance contract.
So, like with the president's public,
you have to say these are my performance goals for the year.
And there's an independent commission
that goes around a couple times a year and scores.
You on how well you've achieved your objectives.
This is like every mayor, every governor, all the people, ministers, etc.
and it's published for everybody.
It's like on the radio once a year.
They're like, okay, and now for the governor's list
and the 30 governors in the country, so-and-so
in this district scored highest.
Unfortunately, this guy scored lowest.
And it's like a sport.
And then people go crazy and like, I doesn't get reelected.
People get voted. Cetera.
One thing you have to do constitutionally is have an equity agenda.
So if you're a governor and you're in charge of the district,
you have to identify
the most vulnerable communities in your district and say, this is our plan
to materially improve the situation for families in this particular area.
You can't not do that.
So it's baked in.
And this was really, really important.
And they turn things around and convince
a lot of people to divert a lot of aid into Rwanda.
And they used it really effectively and make out a lot more
because they're actually doing
what they said they were going to do because of stuff like this.
And so they went from being the lowest recipient of national aid
to capital, one of the highest in about a ten year period.
So we came in this is Paul Farmer.
For those who know, partners in health are mountains beyond mountains.
The late Paul Farmer, a younger me,
who's a friend and mentor and founder of Partners Now,
which is the group that I worked with from my medical training,
all the way through, the time I came here.
So this is when we started in Rwanda and we were invited by the government to,
to help to use
all the new HIV money that was suddenly there in 2003,
to not only introduce access to HIV care for those who needed it,
but to use that as a way to actually rebuild the health system.
Because Paul had been doing that in Haiti for a number of years,
and the government said, we love that.
Could you do the same thing here?
But instead of doing it over 20 years, could we do it in like five years?
And the principle is if you try to think about what it takes to give good care
for a chronic disease like HIV, it's not just the pills, right?
You need to have the infrastructure.
You need to have the health professionals.
You need to have the supply chains.
You need to have the electricity and the diagnostic capabilities
and the medical records and the information systems.
And you'd have financial access.
All of those things are the same things you would need to treat diabetes
or high blood
pressure or heart disease or any number of other things.
Right. Those are the makings of a health care system.
So if you're smart about how you invest
those resources, you can use that to do a whole lot of other stuff.
Because 3% of the population had HIV, that was a lot of people,
but 97% had other stuff, right?
So it was about
leveraging the vertical investment to actually try to build a system.
And we started in two of the districts that were the where the worst off,
in the country, including this place called Rivervale,
which was a town that had been like a Belgian mining
town for coltan and some other rare earth minerals.
There was a hospital that was built there in the 50s, by Belgian colonists,
for the miners, by Belgians, for Belgians, and then fell into disrepair.
In the in the years and decades since.
Once the Japanese came in and they renovated it
and that kind of went away again and we found, like genocide era graffiti
inside the operating theaters and things from families
who were living in squatting there and families living in conditions
something like, like this, where you have this kind of
we call triple burden of extreme poverty, high burden of disease.
Obviously, those things are connected and lack of access to health care services
because of lack of financial means, because the nearest health center
was sometimes, you know, eight, ten, 12 hours walk away
or a boat trip away or what have you, right.
Physical barriers, financial barriers, social barriers for some groups, etc..
And, and so what
we started to do was working only in the public sector.
So we, we came in with resources that were from the Clinton Foundation,
from the Global Fund, you know, kind of some of the
what became the usual suspects in this space as well as a lot of private
donors, but funneling all that into public sector infrastructure.
So there's no
partners in health hospital anywhere in the world.
There are district hospitals and referral hospitals and health centers.
But the idea is we work in partnership.
It gets built.
The day the ribbon is cut, the keys are handed over to,
to the sort of local authorities.
And then we work sort of side by side to do that, and did so in a way
that is not like rocket science in terms of how a health system is organized.
But use district hospitals as hubs in communities
with a network of health centers that provide it, you know, primary
care, urgent care services, and then like minor emergency services,
and then, importantly, an army of community health workers
to in every neighborhood or village in the entire country.
So we're talking about 50,000
elected by their peers in the community and then trained and paid.
What that meant was that in every community, even in really remote places,
you have eyes and ears who are there, who can identify kids who aren't thriving,
women who are maybe recently pregnant,
others who need help, who can monitor HIV
patients or cancer patients with their ongoing treatment, etc..
And can be like living links to these health facilities was especially important
when the infrastructure was poor and they were really far away, but
a huge value add to the health care system.
Not as in so many places, community health workers are like a cheap
and bad replacement for a failing health care system.
Here, I think really critical to professionalized adjuncts, to the system.
And so we started this, in the two districts and ultimately built
what became kind of we thought of these as,
as sort of model districts or innovation hubs
that would then be kind of like learning laboratories
for the rest of the health system in the country.
So, for example, after a few years, the the then
Minister of Health called me into his office and said,
we're going eight years you.
Which means Doctor Jesus.
That was my nickname in Rwanda.
Is that longer hair, doctor? Jesus.
Thank you for your support.
As you know, our HIV program now is the best in the world, right?
And this is true literally outcomes.
Much better than my patients at my HIV clinic in Boston at the time.
You know, we have these results.
The funders are happy.
The patients are doing well.
We think we've got it.
But if you know, our population is suffering from diabetes,
from heart disease, from cancer, we still have premature
babies that are dying, etc., etc.
there is no global funds for maternal health.
There's no global fund for non-communicable diseases.
And we work together to figure out
how to do some of the same things with a lot less resources.
And so we would shift the kind of work that we were focusing on,
bringing the access to, you know, Harvard Medical School,
the School of Public Health, and the research
and the training and everything else to then say, okay, let's start an initiative
to try to eliminate,
infant mortality
through sort of quality improvement initiatives and doing what works well.
So it was constantly about giving and taking,
evolving and shifting with what the kind of disease burdens were,
and then building a health system, brick by brick, that could do all the things
that you want the health system to do.
And I'm going
through a complex and long story really quickly,
but I want to just reflect on or kind of give to you some.
I call them here systemic interventions.
I think there were principles and approaches of the work that we did
and shared work all the way through that I think were important in what was,
I mean, it was rebuilding a system which is a little bit different
than shifting a system, you know what I mean? Like,
there's some advantages and disadvantages to almost nothing to start with.
The first one, and this is really simple, was investing
in the actual system capabilities and the infrastructure of the system.
This doesn't happen very much.
Whether that's research, collaborations
where you have to find like a local professor to be your co-pi,
but they don't have the administrative support, all the other stuff that you do,
it's not going to sort of change anything.
So here we talk about staff stuff, space and systems.
That could be information systems, supply chains, etc.
actually investing in what we call health system readiness.
So we would sort of develop standards and say the starting point
is that every facility is going to meet this level of standards.
They're going to have all the basics in terms of personnel and training
and infrastructure and stuff.
And then we're going to focus on quality and process improvements and ongoing stuff
so that we can actually improve
the quality of what's happening and build from there.
The second thing was complimenting
doing the work, which is doing health care,
patient care with, investments
in training and education and capacity building.
And that led to a massive initiative where we once
went to Pep far, in the US and said,
and this was I said, we've this is the Minister of Health time.
Look, we've met all our targets and you have committed X
amount to us over the next several years, which is great.
We think the best way to build for the long term would be to take 100 million
of that money that you've committed, and instead of buying Aids drugs
and doing the usual stuff we've been doing,
we want to invest it in creating training programs for
one of the specialist doctors and nurses, because we have five pediatricians
and one psychiatrist and no orthopedic surgeons, etc.,
and that then built up a program where we partnered with a bunch of U.S.
universities and built training programs.
So there now are plastic surgeons and oncologists, etc., in Rwanda
building for the long term.
Those are now training the next generation, etc..
So the idea that when you mix service delivery with training and research,
you create these virtuous cycles of kind of positive learning and improvement,
a bunch of programs to address the social determinants of health.
These could be programs that would help, kids have access to school.
Food security programs that might do agriculture training,
and things like that.
Economic development programs.
Every time we built a new facility,
it was built by and for and with the local communities.
So we have our own engineer and the social worker do all the hiring.
So, adults age orphans, single moms, etc.
would be hired
and then trained to be masons and tailors and welders and things like that.
So actually creating jobs and skills in the, in the community,
I talked about this already and I talked about the public sector partnership.
And I think the reasons that are really important. Right.
Number one, you're funneling private capital into public infrastructure.
Second, there was
investment in working alongside and I guess
building the capacity, though I hate that term of public sector leaders.
So whoever was in charge
of noncommunicable diseases with partners in health would effectively be seconded
to the head of non-communicable diseases and the Ministry of Health,
and they'd be working together and they'd get to come to Harvard and do
courses and learn from researchers, etc., etc..
And so over time, that helps to build the capability of the system itself.
And then finally, and most importantly, is using the public sector to scale.
And this is a really important
strategic decision that we made after going from 2 to 3 districts.
So it's like, okay, now do we go to four?
But there's 30.
And so instead the idea was can we create these innovation hubs,
these models that can test out new service delivery innovations like a
infant mortality reduction program?
And then if and when it works, roll it out to the rest of the country
through the public sector, and they can engage other donors
and other partners to help implement where necessary.
But what we started here and learned can then be done everywhere else.
We've got a training hub to do it in that ultimately
is what led to, which I alluded to before.
This is a really old graph, but in the Washington Post in 2013,
it was the graph of the year.
So I still show it.
This is, child mortality, right?
Under-five mortality.
Actually, so, this is, you may know, is considered one of the best
single indicators of the overall performance of a health system.
Right?
So it's how many the fraction of kids out of a thousand would die
before their fifth birthday.
And you can see
after the genocide in Rwanda that spiked to 275.
So like over 1 in 4, practically 1 in 3 kids, we're not making it to H5.
This is the sub-Saharan trend and this is the rest of the world
average by 2012.
At the time we did the study,
it had basically dropped far below the sub-Saharan African, average
and down to the, the mean for the rest of the world.
And, it was continuing to sort of drop from there.
This is the steepest, this and many others were the,
steepest declines and premature mortality ever recorded
anywhere in the world at any time, in at least recorded history,
more than the Asian Tigers in the 90s, in China
in the 80s and so many other sort of economic miracles, etc.
life expectancy doubled over a just over the 15 year period.
It's still a very poor country.
But what's important is that the GDP tripled during this time.
And this is really weird, but this is what's called a growth incidence curve.
So the 99% is that is the top 1%.
These are the so-called 1%, if you will, of,
you know, of wealth, the richest 1%.
This is the poorest 1%.
This is the share of economic growth.
So I want you to understand
here is as the economy was like, growing really fast, what usually happens
there's there's a bubble here where the well-off get better off.
Right.
The rich get richer,
and then you hope some of that trickles down because of this equity agenda,
because the policies were pro-poor and there was accountability for that.
The vast majority of economic growth benefited the poorest 20%
of the population. And a million people,
brought themselves out
of extreme poverty during this time period.
So Paul Collier, who's, you know, here, in Oxford, a very famous development
economist, he came we published some of these reports as like 2014.
He called this the development happen and said this combination of rapid
and sustained economic growth, dramatic improvements in health outcomes
and poverty reduction, with decreases in income inequality
was something that had not been done anywhere
ever before in his in his knowledge.
So briefly.
And then we're down here.
We then was to get all these people from all over
Africa and elsewhere coming to be like, okay, what's in the secret sauce?
How can we do this?
I'm like sending delegations from other ministries of health for study tours.
And we're thinking to ourselves,
will a study tour like following around your counterparts for a week
in Rwanda is not really going to help, make that happen.
And we sort of thought a lot about what
what it would take to sort of take some of these lessons
and grow from here, because one that's a little country in a really big world,
that has a long ways to go.
And so we, as I hinted at earlier,
built a university at the site of actually one of those hospitals that was pictured
earlier called University of Global Health Equity.
We launched it in
we cooked up the idea in 2013 involves
a great deal of wine and a, failed, failed relationship with,
with the University of Rwanda and Harvard and, and launched in 2015.
And it is a health sciences and public health university
that is focused on equity and focused on using the kinds of principles
I was just talking about in trying to make those fundamental bedrocks,
trying to sort of disrupt global health.
Fundamentally and
also physically, right, by trying to create like an intellectual hub
in global health that's in a poor rural community in sub-Saharan Africa.
And think about what happens.
We talked about who's at the table.
Think about what happens when the conversations around poverty reduction
in global health are not in Davos
or Geneva or Oxford or New York,
but are in utero Rwanda, a little hilltop in a little village
in a place where community health workers are on faculty
alongside PhDs because they possess a different kind of expertise.
So that was the thing that we we created.
It's still very small.
It was in December by Times Higher Education ranked the number four
university on the continent of Africa, which is both really cool
and a really tough verdict on the state of higher education on the continent.
Okay, so
to close, to come to your question about equity and systems,
because I think this is the most important lesson for me.
What I gained from my time doing this work in Rwanda
and working with Paul and others, is that equity
or an equity agenda or an equity lens can be a driver of innovation.
So if we go back to this notion of system innovation,
and I think this happens in three ways, right.
First, equity expands our moral imagination.
Instead of just saying, no, it's not possible.
Too hard, too expensive, we could go through
the litany of excuses that were used to deny poor people access to care.
In the late 90s, in the early 2000, head
of USA Andrew Natsios in 2001
testified to Congress and said Africans have a different concept of time.
They don't have watches and they won't be able to take their medicines on time.
Therefore, we shouldn't waste money
given the major drugs right?
So that's the usual response.
Or you do a cost effectiveness analysis that says is 22 times
more cost effective to do the easy thing rather than the right thing.
And once you start from a premise of equity
that everyone deserves access to health and ideally the same kind of health care
you'd want for your sister or your mom or your kids or whatever,
then you can't say no.
You have to ask, how?
How do we do it? Yeah, the situations are the same.
Yeah, the resources aren't there.
But let's figure it out.
Right.
And that drives new ways of thinking, a new innovation.
Second, it brings additional expertise
and ideas into the system.
The number of times that we've been stuck with a program that wasn't
performing the way that we wanted it to, and we doctors would get together
and assess all the data and try to figure out what was going on.
And then a community health worker raised their hand and said,
actually, let me tell you what's really going on.
It's not that the patients are not understanding their instructions
or their ignorance, it's that they have someone at home
who's too sick to come in and they split their pills and
or it's that they don't have enough food to eat or whatever.
Right.
So the the different kind of professional experience of the community
health worker brings made us smarter and better at our jobs.
And that's one example
of how that happens, because you're bringing new people to the table.
And then third, and maybe most importantly is this builds
trust and creates the conditions that actually implement change.
One of the great things that Rwanda did was,
to make everybody in the country
an active participant in the country's development.
Right.
It started with we can't rely on outsiders to come and save us
and let us down in our moment of of greatest need.
And they're coming now, but we can't wait for the cavalry to come.
It's on us to build it.
And there's like a community service day once a month on Saturdays,
and you like, build to roofs, to fix a, you know,
a person's house or work on the roads or whatever.
But everybody is involved in some way.
And actually Africans place there's something called a national dialog,
in Michigan, where once a year, the president
and the cabinet and all the leaders get together in a giant hall in Kigali,
and anybody can come and it's live streamed and it's on the radio.
And anybody in the country can ask any question of any leader
that goes on for two days, and they're not screened.
And you can say anything.
And you know, once somebody said,
yeah, I've been coughing for three months and I think I might have tuberculosis,
but I went to the health center three times
and they didn't have any of those little cups to collect my sputum.
And, I'm worried about what's going to happen.
And then you rush off and you give an answer and like, do that. So.
So people actually have access to to their leaders.
And that's remarkable.
But again, this notion of bringing new people into the conversation creates
the sort of social capital and the trust that you need to actually drive change.
I think I'm going to leave it there. And there might be one more slide.
See, I go on next year.
I'll give me two hours and I'll still go on too long.
That's what I want to leave you with.
Great book by this title.
By the way, this is Jonas Salk.
Who was, you know, was a, you know, inventor of one of the polio vaccines.
He wrote a great memoir,
in the, in the 70s.
And, that's where this phrase comes.
Our greatest responsibility is to pick your ancestors.
When one thing about systems thinking that is really useful is moving
beyond the, like three months, six months, one year
time frame and trying to think about like, where do we want to be
15, 20 years from now, generations from now?
We would ask when we were starting University of Global Equity.
Once Paul and I took a walk, we were at, on the campus of Harvard,
and there's the statue of John Harvard, from like the 1636 or something like that.
And we said, okay, so 400 years,
you think you ever would have thought that
that thing you started then would become like this?
And then we asked ourselves, where do we think
the world's going to be in 400 years?
And what do we want?
University of Global Health equities place in that world to be.
And the power of that radically long term thinking and the kind of
like thing you want to build and the legacy that you want to leave to
not just your kids, but your grandchildren's grandchildren
is it's like an insane thought exercise,
but it's also a very, a very powerful,
way of approaching problems.
Anyways.
Okay, sorry I talk so much.
Thank you for staying away.
For few minutes of their questions.
And if I warn you, I won't.
Then we'll feel bad.
You just want to go up there?
Yeah.
Okay.
Got a lot of things that have come up earlier in the day.
And the Rwanda story is absolutely amazing because.
Incredible.
I did have a question.
I can't remember what it was.
And someone else come up with more mind.
Why? No. Yeah. What about that? Chris?
You know, tell us about the Crucible.
Yeah. So. Okay. Crucible.
It's a startup.
So it's a new, probably nonprofit.
We don't actually have a business model yet.
I'm staying true to my word. Right.
We're trying to, like, address an issue.
So the idea behind Crucible
is that you've got a couple of problems, right?
You have to say you have a problem and you've got an asset that's unused.
The problem is,
certainly when you look across a lot of sub-Saharan Africa,
but I argue globally as well.
Leadership is failing us. Right.
And if you look at countries
that have been able to move themselves out of poverty and develop
economically, socially and otherwise, there is a role for effective leaders.
And those effective leaders have almost always had access
to really good quality education at some point in their lives.
That's number one.
Number two,
sub-Saharan Africa,
fastest growing continent in the world.
By 2035, 50% of people entering the workforce
every year will come from Africa, in the entire world.
So you have a ton of young
talent like amazing, brilliant kids.
And I've met so many, you know, at different places, you know, that
my work has taken me and my kids were born there and all that kind of stuff.
And we know the education systems are generally very weak,
like in many countries.
I don't know the exact statistics for Malawi, for example,
maybe 20% of kids make it into secondary school,
less than half finished secondary school, and it's usually less than 10%
who access a tertiary education of any kind.
So even the basics aren't there.
And then where are the pathways for the really, really
kind of off the charts for special kids with real
like sort of intellectual potential, leadership potential, etc.?
So we're taking an approach that's a little bit different.
To kind of education, the sort of equity socialist type in me
would be like, we just need to do this everywhere
in the same way we did this with Partizan Health.
The idea my Crucible is to set up a network of secondary school leadership
academies, secondary school, because that's like the highest leverage
point to help someone change their trajectory
and the most neglected part of education.
In Lmics, it's create
a network of world class secondary school leadership academies.
If anyone's ever heard of Africa Leadership Academy, amazing place.
It's like that on steroids.
Actively seek out and go like to every corner of the country
this school is in hunting for the most gifted young people
and then give them a shot at world class education.
And, you know, it's sort of
Cambridge A-levels combined with a really cool liberal arts curriculum
and sort of experiential leadership training, and hopefully
that will be a catapult for them to then be able to go on further studies
and at scale, because we're talking about doing this up to 100 schools,
so tens of thousands of students per year.
The idea is that 25 years from now, you got a whole generation
of super talented young leaders who will be building
businesses, making change, leading in governments, etc.
and help a lot of places that have been held back for a long time
by, leadership and structural forces and lots of other things,
you know, ones that have been talking about brain drain,
you know, from Africa to elsewhere, the content will become a brain magnet.
That's the that's the goal.
So we got one university, and my job is to figure out how to get that in a more.
So I pleased,
with Aileen for example,
that they had the high school and then they have the university as well.
But I for one, I've seen what tends to happen
is that these kids are excellently trained
and then go to McKinsey.
And it's just it's just this straight
funneling them to McKinsey or the more radical ones who try and,
you know, try to go back, but they're not absorbed very well.
So I don't know what your thought processes are about that.
But I mean everybody that I know would tell you.
Yeah. Yeah.
Because they all went to the elite universities where one third of graduates
go into consulting or finance. Yeah.
And some of these kids theoretically will as well.
I mean not that clever.
And if they do well they'll probably have those kinds of opportunities.
What I would say is this is like a wicked systemic problem, right?
From I was just talking about education.
We're talking about, for example, lack of economic opportunity.
Right.
It's hard to tell a kid who's grown up in a little village with no opportunity.
I mean, there's some kids who join our school play soccer
who had never been to soccer before, and they're like,
they stopped in there gazing at a traffic light.
They're like, I've never actually seen one of those before.
And, it sounds silly, but like,
just think about the lived experience and how different that is,
even to come in with other kids at a high school at that time.
So ten years from now, who am I to say you need to come back into here?
Because, you know, because we gave you that chance
like nobody ever asked me to do that, right?
And the reality is,
there are a lot of structural forces that are causing this to happen, right?
If you want to build a business or you want to start an organization,
a social business or whatever, it doesn't matter,
where are you likely to find capital?
Where are you likely to find the talent that you need to do it?
Is it in Malawi or is it in London?
Unfortunately, we all know the answer to that question, right?
So a lot of things need to happen
to create the conditions where there is a pull rather than a push.
And so our our thesis is not proven.
And I may be wrong, is that doing this at scale,
like at massive scale will do a couple of things.
First, because like Ella's amazing and Lou, but it was 250 kids
a year roughly.
We're talking about 20,000 kids a year.
If we ever reach any kind of scale.
First of all, not all those kids will ever get absorbed into the Harvard
and Oxford's of the world.
And they'll go to other kinds of places, including studying in Asia,
and elsewhere, where there are lots of rising universities be.
This will put a lot of pressure on what is a really weak and underperforming,
hopefully tertiary system in Africa, and hopefully we'll start to see more
Aleuts and UGS and accesses, etc., so that there actually are opportunities
for continued education and career progression on the continent.
We want to be sort of a demand driven stimulus or catalyst
for that part of the system.
As well.
And and then, of course, you hope that there's a sense of purpose and shared
responsibility and Pan-Africanism and things everybody wants to come back,
for the most part, has been my experience.
But it's not practical for a lot of people because the opportunities out there,
and sometimes you fall in love with somebody from some other country
and you want to go there, too. I mean, like, you know,
so happened to us, me and my wife.
So anyways, that's the thesis.
The thesis is to do this at scale.
So we want to make this like a massive 25 year moonshot
in developing human capital on the continent. And,
so we going to.
Start to just
just hold on.
Are you going to attach yourself to existing ESRI government schools?
Because I feel like that's probably where it needs to happen,
because, I mean, I went to private school.
No one likes to go to like me back home in a government office.
And like, it's there's a different ethos.
Yeah.
I feel that the two different things carry.
Yeah. So I don't know.
Are you attaching them to the more at home politics policy,
the hurdle are you attaching CBS this is or.
I think we should pick it up transfer over time after.
Do you want to ask one more quick question.
And then we're doing like kind of similar.
I was wondering about like whether,
these are like funded places
at the schools and how that link like government funding.
Yeah.
So the briefly the idea is that
every kid who
sort of meets the meets the bar gets an opportunity to come.
So initially at this first school, they're all fully funded.
That probably will change a little bit.
It could be everybody has to pay a little bit.
Because that sort of changes the nature of things a little bit.
Or it could be a mixed model of, you know, some discounted fee paying
and then some kind of.
But the idea is that,
because there are a lot of good private schools
that are out there for families who have some needs, and that's great.
There needs to be more of them.
But this is the place where it's it's sort of all
about potential, not where you come from.
So that's the whole how we're going to finance that.
I mean, we're talking about like a multi-billion dollar
initiative, over time is, is,
vicious.
I will say that we're going to figure it out
with.
Even that is just amazing.
Yeah.
Thank you so much for coming and inspiring us.
To, I think we've got a recording because I know some of the students are
double booked and they'll be watching it, so thank you very much for being.