Why civilians suffer more once a war is over | Margaret Bourdeaux

53,397 views ・ 2017-04-13

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00:12
So have you ever wondered what it would be like
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to live in a place with no rules?
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That sounds pretty cool.
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(Laughter)
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You wake up one morning, however,
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and you discover that the reason there are no rules
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is because there's no government, and there are no laws.
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In fact, all social institutions have disappeared.
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So there's no schools,
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there's no hospitals,
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there's no police,
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there's no banks,
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there's no athletic clubs,
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there's no utilities.
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Well, I know a little bit about what this is like,
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because when I was a medical student in 1999,
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I worked in a refugee camp in the Balkans during the Kosovo War.
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When the war was over,
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I got permission -- unbelievably -- from my medical school
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to take some time off
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and follow some of the families that I had befriended in the camp
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back to their village in Kosovo,
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and understand how they navigated life in this postwar setting.
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Postwar Kosovo was a very interesting place
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because NATO troops were there,
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mostly to make sure the war didn't break out again.
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But other than that, it was actually a lawless place,
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and almost every social institution, both public and private,
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had been destroyed.
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So I can tell you
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that when you go into one of these situations and settings,
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it is absolutely thrilling ...
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for about 30 minutes,
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because that's about how long it takes before you run into a situation
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where you realize how incredibly vulnerable you are.
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For me, that moment came when I had to cross the first checkpoint,
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and I realized as I drove up
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that I would be negotiating passage through this checkpoint
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with a heavily armed individual
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who, if he decided to shoot me right then and there,
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actually wouldn't be doing anything illegal.
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But the sense of vulnerability that I had was absolutely nothing
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in comparison to the vulnerability of the families that I got to know
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over that year.
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You see, life in a society where there are no social institutions
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is riddled with danger and uncertainty,
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and simple questions like, "What are we going to eat tonight?"
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are very complicated to answer.
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Questions about security, when you don't have any security systems,
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are terrifying.
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Is that altercation I had with the neighbor down the block
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going to turn into a violent episode that will end my life
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or my family's life?
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Health concerns when there is no health system
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are also terrifying.
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I listened as many families had to sort through questions like,
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"My infant has a fever. What am I going to do?"
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"My sister, who is pregnant, is bleeding. What should I do?
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Who should I turn to?"
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"Where are the doctors, where are the nurses?
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If I could find one, are they trustworthy?
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How will I pay them? In what currency will I pay them?"
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"If I need medications, where will I find them?
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If I take those medications, are they actually counterfeits?"
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And on and on.
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So for life in these settings,
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the dominant theme, the dominant feature of life,
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is the incredible vulnerability that people have to manage
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day in and day out,
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because of the lack of social systems.
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And it actually turns out
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that this feature of life is incredibly difficult to explain
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and be understood by people who are living outside of it.
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I discovered this when I left Kosovo.
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I came back to Boston, I became a physician,
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I became a global public health policy researcher.
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I joined the Harvard Medical School
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and Brigham and Women's Hospital Division of Global Health.
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And I, as a researcher,
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really wanted to get started on this problem right away.
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I was like, "How do we reduce the crushing vulnerability
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of people living in these types of fragile settings?
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Is there any way we can start to think about
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how to protect and quickly recover
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the institutions that are critical to survival,
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like the health system?"
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And I have to say, I had amazing colleagues.
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But one interesting thing about it was,
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this was sort of an unusual question for them.
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They were kind of like, "Oh, if you work in war,
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doesn't that mean you work on refugee camps,
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and you work on documenting mass atrocities?" --
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which is, by the way, very, very, very important.
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So it took me a while to explain why I was so passionate about this issue,
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until about six years ago.
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That's when this landmark study
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that looked at and described the public health consequences of war
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was published.
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They came to an incredible, provocative conclusion.
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These researchers concluded
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that the vast majority of death and disability from war
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happens after the cessation of conflict.
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So the most dangerous time to be a person living in a conflict-affected state
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is after the cessation of hostilities;
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it's after the peace deal has been signed.
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It's when that political solution has been achieved.
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That seems so puzzling, but of course it's not,
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because war kills people by robbing them of their clinics,
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of their hospitals,
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of their supply chains.
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Their doctors are targeted, are killed; they're on the run.
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And more invisible and yet more deadly is the destruction
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of the health governance institutions and their finances.
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So this is really not surprising at all to me.
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But what is surprising and somewhat dismaying,
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is how little impact this insight has had,
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in terms of how we think about human suffering and war.
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Let me give you a couple examples.
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Last year, you may remember,
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Ebola hit the West African country of Liberia.
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There was a lot of reporting about this group, Doctors Without Borders,
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sounding the alarm and calling for aid and assistance.
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But not a lot of that reporting answered the question:
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Why is Doctors Without Borders even in Liberia?
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Doctors Without Borders is an amazing organization,
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dedicated and designed to provide emergency care in war zones.
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Liberia's civil war had ended in 2003 --
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that was 11 years before Ebola even struck.
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When Ebola struck Liberia,
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there were less than 50 doctors in the entire country
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of 4.5 million people.
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Doctors Without Borders is in Liberia
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because Liberia still doesn't really have a functioning health system,
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11 years later.
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When the earthquake hit Haiti in 2010,
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the outpouring of international aid was phenomenal.
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But did you know that only two percent of that funding
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went to rebuild Haitian public institutions,
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including its health sector?
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From that perspective,
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Haitians continue to die from the earthquake even today.
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I recently met this gentleman.
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This is Dr. Nezar Ismet.
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He's the Minister of Health in the northern autonomous region of Iraq,
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in Kurdistan.
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Here he is announcing that in the last nine months,
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his country, his region, has increased from four million people
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to five million people.
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That's a 25 percent increase.
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Thousands of these new arrivals have experienced incredible trauma.
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His doctors are working 16-hour days without pay.
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His budget has not increased by 25 percent;
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it has decreased by 20 percent,
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as funding has flowed to security concerns and to short-term relief efforts.
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When his health sector fails --
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and if history is any guide, it will --
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how do you think that's going to influence
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the decision making of the five million people in his region
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as they think about whether they should flee
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that type of vulnerable living situation?
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So as you can see, this is a frustrating topic for me,
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and I really try to understand:
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Why the reluctance to protect and support
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indigenous health systems and security systems?
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I usually tier two concerns, two arguments.
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The first concern is about corruption,
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and the concern that people in these settings are corrupt
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and they are untrustworthy.
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And I will admit that I have met unsavory characters
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working in health sectors in these situations.
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But I will tell you that the opposite is absolutely true
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in every case I have worked on,
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from Afghanistan to Libya, to Kosovo, to Haiti, to Liberia --
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I have met inspiring people,
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who, when the chips were down for their country,
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they risked everything to save their health institutions.
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The trick for the outsider who wants to help
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is identifying who those individuals are,
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and building a pathway for them to lead.
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That is exactly what happened in Afghanistan.
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One of the unsung and untold success stories
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of our nation-building effort in Afghanistan
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involved the World Bank in 2002 investing heavily
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in identifying, training and promoting Afghani health sector leaders.
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These health sector leaders have pulled off an incredible feat
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in Afghanistan.
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They have aggressively increased access to health care
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for the majority of the population.
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They are rapidly improving the health status
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of the Afghan population,
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which used to be the worst in the world.
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In fact, the Afghan Ministry of Health does things
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that I wish we would do in America.
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They use things like data to make policy.
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It's incredible.
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(Laughter)
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The other concern I hear a lot about is:
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"We just can't afford it, we just don't have the money.
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It's just unsustainable."
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I would submit to you that the current situation
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and the current system we have
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is the most expensive, inefficient system we could possibly conceive of.
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The current situation is that when governments like the US --
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or, let's say, the collection of governments
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that make up the European Commission --
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every year, they spend 15 billion dollars
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on just humanitarian and emergency and disaster relief worldwide.
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That's nothing about foreign aid, that's just disaster relief.
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Ninety-five percent of it goes to international relief agencies,
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that then have to import resources into these areas,
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and knit together some type of temporary health system, let's say,
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which they then dismantle and send away when they run out of money.
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So our job, it turns out, is very clear.
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We, as the global health community policy experts,
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our first job is to become experts in how to monitor
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the strengths and vulnerabilities of health systems
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in threatened situations.
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And that's when we see doctors fleeing,
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when we see health resources drying up,
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when we see institutions crumbling --
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that's the emergency.
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That's when we need to sound the alarm and wave our arms.
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OK?
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Not now.
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Everyone can see that's an emergency, they don't need us to tell them that.
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Number two:
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places like where I work at Harvard need to take their cue
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from the World Bank experience in Afghanistan,
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and we need to -- and we will --
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build robust platforms to support health sector leaders like these.
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These people risk their lives.
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I think we can match their courage with some support.
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Number three:
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we need to reach out and make new partnerships.
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At our global health center,
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we have launched a new initiative with NATO and other security policy makers
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to explore with them what they can do to protect health system institutions
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during deployments.
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We want them to see
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that protecting health systems and other critical social institutions
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is an integral part of their mission.
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It's not just about avoiding collateral damage;
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it's about winning the peace.
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But the most important partner we need to engage is you,
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the American public, and indeed, the world public.
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Because unless you understand the value of social institutions,
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like health systems in these fragile settings,
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you won't support efforts to save them.
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You won't click on that article
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that talks about "Hey, all those doctors are on the run in country X.
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I wonder what that means.
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I wonder what that means
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for that health system's ability to, let's say, detect influenza."
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"Hmm, it's probably not good." That's what I'd tell you.
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Up on the screen,
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I've put up my three favorite American institution defenders and builders.
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Over here is George C. Marshall,
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he was the guy that proposed the Marshall Plan
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to save all of Europe's economic institutions after World War II.
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And this Eleanor Roosevelt.
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Her work on human rights really serves as the foundation
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for all of our international human rights organizations.
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Then my big favorite is Ben Franklin,
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who did many things in terms of creating institutions,
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but was the midwife of our constitution.
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And I would say to you
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that these are folks who, when our country was threatened,
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or our world was threatened,
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they didn't retreat.
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They didn't talk about building walls.
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They talked about building institutions to protect human security,
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for their generation and also for ours.
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And I think our generation should do the same.
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Thank you.
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(Applause)
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