Bill Clinton: TED Prize wish: Let's build a health care system in Rwanda

109,057 views ・ 2007-04-05

TED


Please double-click on the English subtitles below to play the video.

00:24
I thought in getting up to my TED wish
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I would try to begin by putting in perspective what I try to do
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and how it fits with what they try to do.
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We live in a world that everyone knows is interdependent,
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but insufficient in three major ways.
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It is, first of all, profoundly unequal:
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half the world's people still living on less than two dollars a day;
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a billion people with no access to clean water;
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two and a half billion no access to sanitation;
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a billion going to bed hungry every night;
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one in four deaths every year from AIDS, TB, malaria
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and the variety of infections associated with dirty water --
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80 percent of them under five years of age.
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Even in wealthy countries it is common now to see inequality growing.
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In the United States, since 2001 we've had five years of economic growth,
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five years of productivity growth in the workplace,
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but median wages are stagnant and the percentage of working families
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dropping below the poverty line is up by four percent.
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The percentage of working families without health care up by four percent.
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So this interdependent world which has been pretty good to most of us --
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which is why we're all here in Northern California doing what we do
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for a living, enjoying this evening -- is profoundly unequal.
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It is also unstable.
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Unstable because of the threats of terror,
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weapons of mass destruction, the spread of global disease
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and a sense that we are vulnerable to it in a way that we weren't not so many years ago.
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And perhaps most important of all, it is unsustainable
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because of climate change, resource depletion and species destruction.
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When I think about the world I would like to leave to my daughter
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and the grandchildren I hope to have,
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it is a world that moves away from unequal, unstable, unsustainable
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interdependence to integrated communities -- locally, nationally and globally --
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that share the characteristics of all successful communities:
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a broadly shared, accessible set of opportunities,
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a shared sense of responsibility for the success of the common enterprise
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and a genuine sense of belonging.
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All easier said than done.
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When the terrorist incidents occurred in the United Kingdom a couple of years ago,
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I think even though they didn't claim as many lives as we lost in the United States on 9/11,
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I think the thing that troubled the British most
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was that the perpetrators were not invaders, but homegrown citizens
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whose religious and political identities were more important to them
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than the people they grew up with, went to school with,
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worked with, shared weekends with, shared meals with.
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In other words, they thought their differences
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were more important than their common humanity.
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It is the central psychological plague of humankind in the 21st century.
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Into this mix, people like us, who are not in public office,
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have more power to do good than at any time in history,
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because more than half the world's people
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live under governments they voted in and can vote out.
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And even non-democratic governments are more sensitive to public opinion.
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Because primarily of the power of the Internet,
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people of modest means can band together and amass vast sums of money
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that can change the world for some public good if they all agree.
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When the tsunami hit South Asia, the United States contributed 1.2 billion dollars.
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30 percent of our households gave.
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Half of them gave over the Internet.
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The median contribution was somewhere around 57 dollars.
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And thirdly, because of the rise of non-governmental organizations.
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They, businesses, other citizens' groups, have enormous power
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to affect the lives of our fellow human beings.
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When I became president in 1993,
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there were none of these organizations in Russia.
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There are now a couple of hundred thousand.
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None in India. There are now at least a half a million active.
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None in China. There are now 250,000 registered with the government,
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probably twice again that many who are not registered for political reasons.
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When I organized my foundation, and I thought about the world as it is
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and the world that I hope to leave to the next generation,
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and I tried to be realistic about what I had cared about all my life
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that I could still have an impact on.
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I wanted to focus on activities
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that would help to alleviate poverty, fight disease, combat climate change,
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bridge the religious, racial and other divides that torment the world,
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but to do it in a way that would either use
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whatever particular skills we could put together in our group
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to change the way some public good function was performed
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so that it would sweep across the world more.
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You saw one reference to that in what we were able to do with AIDS drugs.
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And I want to say that the head of our AIDS effort,
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and the person who also is primarily active in the wish I'll make tonight,
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Ira Magaziner, is here with me and I want to thank him for everything he's done.
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He's over there.
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(Applause)
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When I got out of office and was asked to work, first in the Caribbean,
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to try to help deal with the AIDS crisis,
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generic drugs were available for about 500 dollars a person a year.
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If you bought them in vast bulks,
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you could get them at a little under 400 dollars.
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The first country we went to work in, the Bahamas,
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was paying 3,500 dollars for these drugs.
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The market was so terribly disorganized
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that they were buying this medicine through two agents
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who were gigging them sevenfold.
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So the very first week we were working,
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we got the price down to 500 dollars.
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And all of a sudden, they could save seven times as many lives
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for the same amount of money.
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Then we went to work with the manufacturers of AIDS medicines,
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one of whom was cited in the film,
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and negotiated a whole different change in business strategy,
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because even at 500 dollars, these drugs
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were being sold on a high-margin, low-volume, uncertain-payment basis.
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So we worked on improving the productivity of the operations
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and the supply chain, and went to a low-margin, high-volume,
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absolutely certain-payment business.
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I joked that the main contribution we made
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to the battle against AIDS was to get the manufacturers
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to change from a jewelry store to a grocery store strategy.
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But the price went to 140 dollars from 500.
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And pretty soon, the average price was 192 dollars.
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Now we can get it for about 100 dollars.
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Children's medicine was 600 dollars,
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because nobody could afford to buy any of it.
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We negotiated it down to 190.
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Then, the French imposed their brilliantly conceived airline tax
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to create a something called UNITAID,
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got a bunch of other countries to help.
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That children's medicine is now 60 dollars a person a year.
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The only thing that is keeping us from basically saving the lives
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of everybody who needs the medicine to stay alive
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are the absence of systems necessary to diagnose, treat and care
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for people and deliver this medicine.
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We started a childhood obesity initiative with the Heart Association in America.
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We tried to do the same thing by negotiating industry-right deals
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with the soft drink and the snack food industry to cut the caloric
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and other dangerous content of food going to our children in the schools.
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We just reorganized the markets.
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And it occurred to me that in this whole non-governmental world,
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somebody needs to be thinking about organizing public goods markets.
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And that is now what we're trying to do,
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and working with this large cities group to fight climate change,
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to negotiate huge, big, volume deals that will enable cities
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which generate 75 percent of the world's greenhouse gases,
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to drastically and quickly reduce greenhouse gas emissions
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in a way that is good economics.
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And this whole discussion as if it's some sort of economic burden,
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is a mystery to me.
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I think it's a bird's nest on the ground.
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When Al Gore won his well-deserved Oscar
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for the "Inconvenient Truth" movie, I was thrilled,
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but I had urged him to make a second movie quickly.
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For those of you who saw "An Inconvenient Truth,"
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the most important slide in the Gore lecture is the last one,
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which shows here's where greenhouse gases are going
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if we don't do anything, here's where they could go.
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And then there are six different categories
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of things we can do to change the trajectory.
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We need a movie on those six categories.
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And all of you need to have it embedded in your brains
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and to organize yourselves around it.
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So we're trying to do that.
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So organizing these markets is one thing we try to do.
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Now we have taken on a second thing, and this gets to my wish.
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It has been my experience in working in developing countries
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that while the headlines may all be -- the pessimistic headlines may say,
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well, we can't do this, that or the other thing because of corruption --
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I think incapacity is a far bigger problem in poor countries than corruption,
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and feeds corruption.
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We now have the money, given these low prices, to distribute
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AIDS drugs all over the world to people we cannot presently reach.
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Today these low prices are available in the 25 countries where we work,
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and in a total of 62 countries,
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and about 550,000 people are getting the benefits of them.
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But the money is there to reach others.
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The systems are not there to reach the people.
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So what we have been trying to do,
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working first in Rwanda and then in Malawi and other places --
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but I want to talk about Rwanda tonight --
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is to develop a model for rural health care in a very poor area
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that can be used to deal with AIDS, TB, malaria, other infectious diseases,
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maternal and child health, and a whole range of health issues
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poor people are grappling with in the developing world,
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that can first be scaled for the whole nation of Rwanda,
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and then will be a model that could literally
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be implemented in any other poor country in the world.
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And the test is: one, will it do the job?
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Will it provide high quality care?
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And two, will it do it at a price
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that will enable the country to sustain a health care system
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without foreign donors after five to 10 years?
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Because the longer I deal with these problems,
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the more convinced I am that we have to --
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whether it's economics, health, education, whatever --
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we have to build systems.
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And the absence of systems that function
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break the connection which got you all in this seat tonight.
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You think about whatever your life has been,
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however many obstacles you have faced in your life,
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at critical junctures you always knew
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there was a predictable connection between the effort you exerted
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and the result you achieved.
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In a world with no systems, with chaos,
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everything becomes a guerilla struggle,
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and this predictability is not there.
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And it becomes almost impossible to save lives,
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educate kids, develop economies, whatever.
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The person, in my view,
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who has done the best job of this in the health care area,
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of building a system in a very poor area, is Dr. Paul Farmer,
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who, many of you know, has worked for now 20 years with his group,
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Partners in Health, primarily in Haiti where he started,
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but they've also worked in Russia, in Peru
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and other places around the world.
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As poor as Haiti is, in the area where Farmer's clinic is active --
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and they serve a catchment area far greater
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than the medical professionals they have would indicate they could serve --
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since 1988, they have not lost one person to tuberculosis, not one.
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And they've achieved a lot of other amazing health results.
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So when we decided to work in Rwanda
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on trying to dramatically increase the income of the country and fight the AIDS problem,
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we wanted to build a healthcare network,
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because it had been totally destroyed during the genocide in 1994,
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and the per capita income was still under a dollar a day.
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So I rang up, asked Paul Farmer if he would help.
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Because it seemed to me if we could prove there was a model in Haiti
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and a model in Rwanda that we could then take all over the country,
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number one, it would be a wonderful thing for a country
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that has suffered as much as any on Earth in the last 15 years,
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and number two, we would have something that could then be adapted
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to any other poor country anywhere in the world.
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And so we have set about doing that.
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Now, we started working together 18 months ago.
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And we're working in an area called Southern Kayonza,
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which is one of the poorest areas in Rwanda,
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with a group that originally includes about 400,000 people.
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We're essentially implementing what Paul Farmer did in Haiti:
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he develops and trains paid community health workers
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who are able to identify health problems,
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ensure that people who have AIDS or TB are properly diagnosed
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and take their medicine regularly,
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who work on bringing about health education, clean water and sanitation,
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providing nutritional supplements and moving people up the chain of health care
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if they have problems of the severity that require it.
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The procedures that make this work have been perfected,
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as I said, by Paul Farmer and his team
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in their work in rural Haiti over the last 20 years.
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Recently we did an evaluation of the first 18 months of our efforts in Rwanda.
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And the results were so good that the Rwandan government
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has now agreed to adopt the model for the entire country,
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and has strongly supported and put the full resources of the government behind it.
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I'll tell you a little bit about our team because it's indicative of what we do.
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We have about 500 people around the world
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working in our AIDS program, some of them for nothing --
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just for transportation, room and board.
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And then we have others working in these other related programs.
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Our business plan in Rwanda
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was put together under the leadership of Diana Noble,
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who is an unusually gifted woman,
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but not unusual in the type of people who have been willing to do this kind of work.
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She was the youngest partner at Schroder Ventures in London in her 20s.
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She was CEO of a successful e-venture --
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she started and built Reed Elsevier Ventures --
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and at 45 she decided she wanted to do something different with her life.
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So she now works full-time on this for very little pay.
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She and her team of former business people have created a business plan
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that will enable us to scale this health system up for the whole country.
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And it would be worthy of the kind of private equity work
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she used to do when she was making a lot more money for it.
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When we came to this rural area, 45 percent of the children under the age of five
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had stunted growth due to malnutrition.
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23 percent of them died before they reached the age of five.
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Mortality at birth was over two-and-a-half percent.
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Over 15 percent of the deaths among adults and children occurred
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because of intestinal parasites and diarrhea from dirty water and inadequate sanitation --
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all entirely preventable and treatable.
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Over 13 percent of the deaths were from respiratory illnesses --
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again, all preventable and treatable.
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And not a single soul in this area was being treated for AIDS or tuberculosis.
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Within the first 18 months, the following things happened:
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we went from zero to about 2,000 people being treated for AIDS.
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That's 80 percent of the people who need treatment in this area.
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Listen to this: less than four-tenths of one percent of those being treated
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stopped taking their medicine or otherwise defaulted on treatment.
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That's lower than the figure in the United States.
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Less than three-tenths of one percent
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had to transfer to the more expensive second-line drugs.
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400,000 pregnant women were brought into counseling
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and will give birth for the first time within an organized healthcare system.
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That's about 43 percent of all the pregnancies.
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About 40 percent of all the people -- I said 400,000. I meant 40,000.
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About 40 percent of all the people who need TB treatment are now getting it --
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in just 18 months, up from zero when we started.
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43 percent of the children in need of an infant feeding program
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to prevent malnutrition and early death
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are now getting the food supplements they need to stay alive and to grow.
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We've started the first malaria treatment programs they've ever had there.
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Patients admitted to a hospital that was destroyed during the genocide
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that we have renovated along with four other clinics,
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complete with solar power generators, good lab technology.
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We now are treating 325 people a month,
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despite the fact that almost 100 percent of the AIDS patients are now treated at home.
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And the most important thing is
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because we've implemented Paul Farmer's model, using community health workers,
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we estimate that this system could be put into place for all of Rwanda
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for between five and six percent of GDP,
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and that the government could sustain that
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without depending on foreign aid after five or six years.
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And for those of you who understand healthcare economics
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you know that all wealthy countries spend between nine and 11 percent of GDP
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on health care, except for the United States, we spend 16 --
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but that's a story for another day.
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(Laughter)
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We're now working with Partners in Health and the Ministry of Health in Rwanda
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and our Foundation folks to scale this system up.
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We're also beginning to do this in Malawi and Lesotho.
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And we have similar projects in Tanzania, Mozambique,
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Kenya and Ethiopia with other partners trying to achieve the same thing:
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to save as many lives as quickly as we can,
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but to do it in a systematic way that can be implemented nationwide
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and then with a model that can be implemented in any country in the world.
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We need initial upfront investment to train doctors, nurses,
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health administration and community health workers throughout the country,
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to set up the information technology, the solar energy,
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the water and sanitation, the transportation infrastructure.
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But over a five- to 10-year period,
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we will take down the need for outside assistance
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and eventually it will be phased out.
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My wish is that TED assist us in our work and help us to build
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a high-quality rural health system in a poor country, Rwanda,
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that can be a model for Africa,
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and indeed, for any poor country anywhere in the world.
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My belief is that this will help us to build a more integrated world
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with more partners and fewer terrorists,
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with more productive citizens and fewer haters,
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a place we'd all want our kids and our grandchildren to grow up in.
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It has been an honor for me, particularly, to work in Rwanda
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where we also have a major economic development project
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in partnership with Sir Tom Hunter, the Scottish philanthropist,
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where last year we, using the same thing with AIDS drugs,
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cut the cost of fertilizer and the interest rates on microcredit loans by 30 percent
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and achieved three- to four-hundred percent increases
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in crop yields with the farmers.
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These people have been through a lot and none of us, most of all me,
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helped them when they were on the verge of destroying each other.
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We're undoing that now, and they are so over it and so into their future.
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We're doing this in an environmentally responsible way.
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I'm doing my best to convince them not to run the electric grid
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to the 35 percent of the people that have no access,
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but to do it with clean energy. To have responsible reforestation projects,
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the Rwandans, interestingly enough, have been quite good, Mr. Wilson,
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in preserving their topsoil.
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There's a couple of guys from southern farming families --
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the first thing I did when I went out to this place
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was to get down on my hands and knees and dig in the dirt
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and see what they'd done with it.
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We have a chance here to prove that a country
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that almost slaughtered itself out of existence
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can practice reconciliation, reorganize itself, focus on tomorrow
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and provide comprehensive, quality health care with minimal outside help.
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I am grateful for this prize, and I will use it to that end.
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We could use some more help to do this,
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but think of what it would mean if we could have a world-class health system
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in Rwanda -- in a country with a less-than-one-dollar-a-day-per-capita income,
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one that could save hundreds of millions of lives
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over the next decade if applied to every similarly situated country on Earth.
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It's worth a try and I believe it would succeed.
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Thank you and God bless you.
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(Applause)
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