it's >> next, look at health care innovation in a quality

expanding that they're on how zip codes are an indicator of life expectancy. from the computer museum in mountain view, california, this is an hour and a half. designed to change policy and encourage civic engagement in 14 california communities are affected by healthcare inequality. prior to that self-destruct in county health officer, and if you look at his resume use a string of academic degrees that's very impressive to say the least.

he is going to be interviewed tonight by vanessa mason. the cofounder of p to help benches, public health tech venture fund pictures also ceo and founder of riveted partners, digital health consultancy if she knows what she's talking about. this should be fascinating. please join me in welcoming both tony and vanessa to the stage. [applause] [applause] >> all right. well, this promises to be a lovely evening. just if we get started with interviewing doctor eitan, he has a wonderful to show just by building healthy community initiatives got started and wrote the impact they have already. we're going to watch that first.

>> what determines how long we will live? is it what we do? is it who we are? actually when he comes to predicting how long you will live, your zip code is more important than your genetic code. here's how this works. they both have jobs, around the same age, both married and they both have two kids. she lives in a count by maria lives less than one mile away. they are similar in so many ways but here's the thing. on average residence of the hill will die more than 15 years sooner than the residence of a

town. why? because where you live is about more than just your address. it's about your opportunities here for example, their access to healthy options is really different. in a town her profeminist ready healthy food options, including farmers markets, grocery shops and grocery stores. the air is cleaner and fresher and there are lots of safe, clean parks when she can exercise and her children can play. a town is good public schools and easy access to emergency and preventive health care. on the other hand, b'vlle, the air is filled with truck exhaust and for food options are only choice are transforming a liquor stores, convenience stores. the schools and b'vlle overcrowded and under supported.

even with maria can get her kids into better schools far away, she needs to figure out how to get them there without access to a car. so for me having to juggle so much can be a source of chronic stress which is a serious health risk factor. and all the residents of b'ville, stressed drives health problems like diabetes, asthma and heart disease. how did they get so different? in many cases in cities and towns across california, the root cause was racial and economic discrimination. over the generations, poor white people and people of color were pushed to less desirable parts of town where banks refused to lend money, businesses left, jobs, too. schools declined and neighborhoods crumbled. everyone who could move away did. and what's more, when

communities like a town and b'ville so unequal, b'ville isn't the only one that suffers. because it turns out not only is your zip code a predictor of how long you live, so is what country you live in. countries with the greatest income inequality have the lowest life expectancy. so even americans like dad were white, insured, college-educated and upper income, die younger than their peers in other countries. in fact, our life expectancy is 43rd in the world, and that number is slipping. in the end, our biggest health risk may actually be inequality and extreme inequality hurts us all. so what do we do? well, if we're all going to be healthier, we don't just need to help the folks in b'ville beat the odds, we need to change the

odds for everyone. and that's what we're doing. there's a movement happening where californians, we don't follow. we lead. we're building the power to make health happen in communities across the state. we are coming together to build one california, a smarter, more inclusive and equitable state that creates health and opportunity for all of us. join us. to learn more visit building healthy communities.org. [applause] >> so thank you so much for bringing this video to us. it's a really wonderful willing way of posting what the foundational public of concept. people have a hard time understanding i know we're both in this innovation picture pursuing policy. myself through more of that technology and finance it but i

to hear from you tell how did you get started with this research and kind of chart starts on the story because as we move along you guys will be able to see how technology is playing a role both in the discovery and moving this forward as well. >> yes. so it's actual interesting because it's kind of a technological story. i was, i'm going to tell you the quick version of it but but i t to medical school at johns hopkins and for the the you who may not know, johns hopkins medical schools located in east baltimore, which is one of probably the worst slums in america, if not north america and it was a real shock to me because i'd grown up in canada and kind of candidate had sort of a deep level of investment in its people, universal healthcare, universal childcare, paid sick leave, vacations, heavy investments of public art and infrastructure. i grew up in montréal and what i

got to east baltimore at us all the conditions, i was really quite shocked. it triggered this thinking in my head that in the u.s., where you live ultimately cheaper health more than any of your genetic factors? i got interested when i graduate medical school and then i went through studies in policy, i get interested in how do you illustrate these differences between neighborhoods and the impacts, the ultimate cumulative impacts on people self? using technology. at the time this was in the early 1990s, geographic information systems were just sort of coming online and i cut it got hooked on gis. if we can bring up the slide, i just want to show just a couple slides of the sort how we approached this work. i do that?

debacle. so most of you probably don't recognize this but you all have one of these at some point in your life. this is a death certificate, and when you are the county health officer, you are the registrar of all births and deaths. there are about 10,000 deaths a year in this county. i get really excited with the technological possibility of using these death certificates to start painting a picture of the distribution of death across alameda county. each death certificate needs my signature on it before the body can be buried or cremated or whatever is going to happen to it. it's a real opportunity to get very good data because you can refuse to sign a death certificate to the certificate is completely filled out and you all the data you need. on the death certificate the date of its most critical for doing this is the age at which somebody dies, their race ethnicity, what they died of an way they live.

all of that information is on the death certificate so you can take a death certificate and you can plot a map. visit alameda county which is shaped like a boot. each of those boundaries are census tracts in alameda county, about 150 of them. you can calculate in any given senses attract the average age to which somebody can expect to live. when you do that the green areas are neighborhoods that would alameda county where people can expect to live greater than 80 is picked the right areas are areas with people cannot expect to live about 74 years, and then the yellow is in between 74 and 80. you noticed very quickly that are clusters of red areas. there are neighborhoods in alameda county what people die earlier than others. this is a phenomenon that you contract is over decades. this is not a fluctuating phenomenon. these neighborhoods have been essentially concentrated neighborhoods of premature deaths for decades.

this was very interesting. this ended up on the front page of the "san francisco chronicle," and people would say to me after this happened, it caused a bit of a stir, they would say what's the story with alameda county? why is it so inequitable? my answer was, it's not just alameda county. so we had to start looking around the country for other places where we could replicate this gis analysis. it was something that wasn't really done at the time, to look a relatively small geographic areas in calculating life expectancy for a neighborhood. and then comparing those neighborhoods to other neighborhoods in the same city or the same county. we took our map of alameda county and i had to go back to baltimore because that's where i had come out of school and this it triggered my whole interest in this issue. baltimore there are neighborhoods where people on average live into their late

50s, and so they were dramatic disparities across the city of baltimore. we went to cuyahoga county, cleveland, which showed neighborhoods with 25 years of life expectancy difference between neighborhoods that were within a mile and half of each other. new york city hermetic disparity, seattle, los angeles, minneapolis, boston, philadelphia, san antonio. everywhere we looked. we haven't found a city in the united states yet that doesn't have a significant life expectancy difference from neighborhood to neighborhood. this is the american pattern. before you really had the technological ability to bore down into neighborhoods and use larger data sets that sort of discernment these patterns, we didn't understand this. we now understand that you can have two contiguous neighborhoods with a life expectancy difference of 15

years. that's a fixed difference. it's not something fluctuates from year-to-year. and try to understand that is what i have spent my career basically doing. so that's how i got into this. >> yes, and that is certainly the problem at hand and i see that in my work as well. we are a fund that is infested in prevention and health care disparities trying to find technology that addresses of those. so the question is unfortunately universal and persistent and we're going to get into may be how we address that today. some of the more into the policy perspective, like queen of the zip codes in house relationship is here the aca is on everyone's minds. visit our is it going to be gone at any point in time? from your perspective, like how has the aca help to decouple the relationship between the zip codes and health, and how could repeal a fact that relationship? >> yeah, , so this is a little

complex. it's not really that complex but you might think it's complex the way i explain it. [laughing] health care is important for you because obviously when you get sick you need access to healthcare. healthcare helps you avoid adverse consequences from being sick. but that's not the most important reason that the aca improves health. one of the things we try to explore in these neighborhoods where you have chronically low life expectancies trying to understand what are the drivers of that? was happening to people in these communities? the things that you come away with most obviously is that people in those communities, mostly low income communities, are facing inexorable stress. basically every system that they're trying to engage is failing them, transportation, housing, employment, criminal justice. even water in some instances. so people are navigating in an

environment we are constantly facing stress, and stress is basically a balance between resources and risk. and in those communities of their facing enormous risks and the have limited resources. they are constantly other ballots. what that does is it creates a fancy word the way of explaining it is called out the static load but actually chronic stress. that changed your physiology and the changes your genetic expression and over time it actually mimics premature aging in these populations. so the issue of the aca is that the reason the aca is particularly beneficial for your help, and all of the western democracies around the world that have universal healthcare systems so to recognize this, is that it reduces stress. it allows you not to have to worry about what will happen if you get sick or your children get sick, or you get hit by a bus or what have you.

so that aspect of it by reducing the load actually has profound beneficial health impacts. and that's the fundamental approach that we've taken in our work. >> wonderful. and it's something that we've been keeping close track of, i know tom price just announced their trying to scale back bundled payments. paying for outcomes is stored td introduce questions about whether or not that is still going to be around. so getting more into the work, so how are your local partners really using technology to improve the health of the communities that you work with? >> yeah, so i love technology. i mean, it's just fun to work with. it's great. we have data sets that we never had before. we have the ability to manipulate this massive tomes of

information and get a relatively small questions. but the thing that we recognize i think that is most important about technology where the real potential lies because of this recognition of health, not just time a low income people, not just the people of color. we're talking that all americans, all of us in this room are experiencing allostatic load for it varies in terms of its manifestations. again, this risk versus resources balance. a lot of the risks are societally created risk, unnecessary, man-made. the way other societies attend to them is through policy. universal healthcare is one obvious example of that but also subsidize education and housing policies that reduces the risk that people have to face. so this notion that people are experiencing this heavy risk, this burden of risk in their lives is a fundamental issue with trying to address in tackling these problems.

how does technology work for that? we recognize when people can participate specifically in their environments, fundamental would talk about people who feel they lack of control over what's happening for for the lack of control is very bad for your health. i can go into the physiology of that, but bottom line is feeling that you lack control or agency is bad for your health. so if you want to help people develop agency or sense of control, one of the ways that you do that is to organize them, to bring them together with similarly situated people to have them start tackling things that are presenting essentially risks in their lives. one of those things is government, unfortunately, or the lack of policies where people are looking for policies to benefit them or their families. so technology that allows people to participate civically, tuple,

express their opinions locally, whether it be city council, school board, with the services that they're getting, to rate those services, and so there's accountability to some of the service providers, that's health protected. so part of our strategy is to essentially facilitate voice in communities so people have more control over the resources that are ostensibly designed to serve their needs. they also have the ability to hold systems accountable for more equitable use of resources. >> great. and i know for a lot of you who aren't technologists, hearing as talk about healthcare, it's kind of a a hard thing to wrap your mind around that healthcare is not actually the same thing as health when you look at media and read about it that those two things often get conflated but they are, in fact, to completely things. a lot of what you're working what my work and thinking about

a fight and the stars for investing in where interested in addressing these issues like how can we alleviate though sources of stress, like working technology address transportation? working at address of the sources of stress and the social determinants of health that are really driving a lot of stress and problems. you are obviously officiating but a researcher at heart so where can technology help playable doctors, advance practice and would accelerate potential interventions or things that can really help to address this problem? >> i think one of the challenges, i'm an internist, you know, the paradigm of medical care is sort of like these 15 minute interventions in a cubicle, you know, where this doctor sort of this gorgeous this information, you do, takes that and applies it in their daily lives. that's a failed paradigm, and the notion that sort of experts

hold the answers i think is a flawed notion. and so many of the community in which we are working on trying to we designed a healthcare system, trying to think of healthcare more from the perspective of how do we bring people together in a way where they can help each other, as opposed, and many of the challenges, the 21st century challenges are challenges of chronic disease. they are not challenges of infectious disease or acute problems as much as they were in the 19th century. our healthcare system is to a 19th century design where you go into an expert an expert gives you a drug and that drug solves your problem. the 21st century problems are heart disease, cancer, stroke, chronic lower respiratory disease, chronic diseases which are more related to the environment and the lifestyles to which people living. those lifestyles are shaped

oftentimes my policies where in some cases is the absence of policy in the face of abject need. to bring people together to essentially create the political will to solve problems is a health intervention, and the healthcare system can participate in that. in many sort of health systems in the vanguard are doing that. >> so what are some of the successes that you've seen with calling on more political will and bringing people together? >> the simplest thing to think about is where in the silicon valley right now, and housing is a big issue, right? housing is an enormous stress of the i don't know about for the people in this room but for my kids friends that are either in school here or out of school looking for places to live, they are struggling dramatically to find those kinds of sources. some of them are looking for healthcare institutions, some academic centers.

and those institutions have a role in helping create policy that facilitates the ability of people who want to live here and work your being able to do so in an affordable way. what is a new about the participate in sort of that policy is that we now know that the absence of meaningful policies in this way actually creates adverse health outcomes in the lives of people that live in these communities. so i know a lot more now, and the question is how do we use that information to apply it? there's health institutions around the country now that are engaged in housing policy, gaged in education policy, not just because they feel like they can, because they feel that's actually critical to the health improvement of both their workforce and their patients. >> sure, and definitely have seen growth of this i just

talked to a major health system the other day that was saying if only there was a startup that address this issue of they know when the discharge patients and get housing and stable patients, these medications who are homeless, just living in some situation where it's violent, dirty, simply transient, fisting with them and it's not permanent. and because their patients housing is in stable they were not followed the orders necessary in terms of medication and all the practices that the knee. for them as a health system they want a startup that would match people who went housing benefits with inventory that was on the market that to those particular benefits. but when you look at silicon valley and a lot of the start it's out there, that's not a problem that pops up on peoples radar because there's a lot of entrepreneurs that have lived through housing instability or don't have enough experience to be able to understand how to tackle that problem. like you said there are plenty of opportunity for lack of a better word to really look at how we can leverage institutions

to really address some of these sources of stress. i think we talk about institutional level but isn't anything from a a patient or consumer generated data or action like that can be driven through technology to actually do the same thing to get a bottom-up solution? >> i'm not an expert in that so i will disclose that. there has been an effort more recently, and let me just explain they do for folks don't know what the social determinants of health are, but the social determinants of health are things like housing, transportation, employment, access to healthy food that are essentially the drivers of health conditions at a population level. and those social determinants are fundamentally now being recognized as critical even down to the individual level. ansell healthcare institutions are starting to collect information about peoples social

conditions. and the kind of resources that they are able to access. and there's some cutting-edge work happening in johns hopkins, at harvard, some of the places groups, what of them is called help lead which is a technological base organization that is focus on essentially taking that information, incorporating into the medical record, and then matching patients with resources in the community that they need to be able to address the housing issues, or their issues around access to healthy food. the next step beyond that is to sort start to aggregate some of this data and use it in the policy space to push for policies that will essentially further the access at a community level to these kinds of resources. so there's a recognition that we've kind of exhausted the medical model in terms of trying to push essentially that model into improving healthy populations.

where it's as healthy as we going to get from the traditional medical technology. probably some breakthroughs that will come along that will help at the margins, but for the most part if you want to improve the health of our population we are not going to be able to do it in the doctor's office. we're going to have to do it in the environment, in the community, changing the way that people interact with their environment and facilitating essentially stress reducing lifestyles for people living in communities, particularly and low-income communities. >> yes, of course. and for those of you who are not familiar, part of his recent work trying to say health and health care is because when you look at the statistics, in terms of actually contributes to our life expectancy of course is public health interventions like what of these behaviors come social and of bimodal factors up to the point of the last 30 years in the increase of life

about 25 years were attributable to public health intervention, not access to medical care. when you look at the financing, like what we spend in terms of health care in this country, only about 3% of the public health intervention. the things dr. iton is studying and ability and building healthy communities. we are getting what we pay for because we are not paying for things that actually work. so it's a lot of the reason why like of course looking at policies, you know, the sort of things to live in the shadows of policy is talking financing and talking about money which of course drives everything. so on that and what kind of policy changes are necessary to support innovations that are going to address social inequalities? >> yeah, , so i showed you the maps of place where people are living less long. we call that really a death tax. people pay a death tax for living in the neighborhood that's essentially bereft of the

kind of resources we all know that people need in order to be able to pursue healthy lives. these two researchers, one at harvard and one at yale by the name of elizabeth bradley and lauren taylor, that they were looking at that traditional analysis that showed the u.s. on a per capita basis spends one healthcare than anybody else in the world. we spend basically twice with the oecd average is the oecd are other economically advanced countries. we've been looking look at thir over a decade saying why are we spending so much, and other countries that are similar are spending so much less, and their health is better than ours. ..

>> to the u.s. it's way out the end the big spender and everybody else is down the other side. when they added social benefit spending the u.s. were in the middle of the pack. we were no longer the big spender. when you add social and health, we are no longer the big spender. and in the new york times, eventually a book, what they pointed out we had the accent 0 on the wrong syllable. and we're getting worst health results and they're spending two times on social benefits have better outcomes. that's the right ratio, spend more on social services and

social benefits than on health care if you want to improve health. so, this is the american health care paradox. and the role of technology in this, a, that they could do this analysis and kind of show it, so easily now. it's relatively well-known. the role of technology really is how do you get the health benefit of that social services and social benefit spending? and that's what things like health leads are trying to do now, are to try to take the clinical encounter where we've invested all of this money and this effort and tried to start pulling in, sort of social benefits and social services to the population that's consuming a lot of health care services because ultimately. what's driving that consumption of health care services is the lack of social support and social spending, so it's how do we bring that into the health care setting to drive down that, the medical acare costs

and improving those essentially showing up in the emergency room for social services? >> and it's definitely going to be a long, long, long effort. there was a piece written in health affairses, actually today, that just came out from jeffrey levy, formerly head for trust for america's health. and as well as karen desalvo normally at health and human services and federal government, and former head, national coordinator for health i.t. and so, the article really talks about basically public health 3.0. how can we start investing in the infrastructure necessary to achieve the same goals, but at scale. how can we take what they're doing and have that be relevant for the rest of the country? so a lot of what they were talking about was the same thing. it's not so much that there is enough money about you there need to be a reallocation of

funding. and the second piece that they were really talking about is this upcoming wave of public-private partnerships. who you can you leverage basically the know-how that's in silicon valley and apply it to the huge gnarly public problems. and if you haven't read that, how does technology play into this. so getting into this from your perspective. like what role do you think that the sell silicon valley data scientists can do to help scale your work? >> well, i think that the wonderful thing about what we're discovering in looking at population health and the things that improve, the health of whole communities is that it's really not rocket science. it's the kind of stuff that your grandmother taught you. and so, the challenge, i think, is taking, you know--

taking sort of technocracy and apply it to democracy. we want that in our communities. that has the effect of people giving agency, some control and a sense of, you know, that they-- that they have some sort of way of shaping their own destinies, and when you see communities that are suffering from poor health, typically they feel like they have very little control. so, how can technology help optimize democracy? i think that those are the big challenges for us. we've seen clearly, and i don't want to get political, but we've seen clearly that our democracy is kind of broken and the challenge with that is that it's not just bad in terms of people wanting to manifest their particular policies and express their ideas, that's a

problem, but it has health implications. it has pretty profound health implications. so, if we care about optimizing the health status of our communities, we have to optimize how our democracy works. and to the extent that technology can help, and you know, again, i'm not a-- i'm not a silicon valley, you know, technologist like you and your friends. [laughter] >> but something like voting, you know, the last set of elections we had something like 28% of registered people voting. how can technology help that? how can we get more people to vote? how can we make voting easier so people can participate more easily not just in national elections, but in local elections and local conversations how to use resources? all of these things are very technologically possible. i mean, can you vote from your smart phone? you know? can you create technology that

allows people to essentially express their opinions and views, much more easily so we get a much broader range of participation in decision making? that will have profound health impact at the population level. >> and a lot of what we see from smatartups, they're trying to address what you're talking about, how can you get people to nonclinical resources, outside the doctor's office and some are trying to address issues unmentionables, how can we use technology to address addiction. how can we use it to address mental illness or loneliness, that has profound health impacts on not just the elderly, but those living in rural areas. i think a lot of what my co-founder and i talk about, when we talk about the intersection of public health and tech is that, yes, public health is very underfunded and technology really hasn't really paid attention to some of the

problems, but that represents an opportunity to solve problems and solve very important problems, so for those of you in the room that are looking for start-up ideas and curious about it, like i would definitely encourage you to definitely look, take a look at the doctor's work and also look at net, there's a lot of research published about in-person interventions that are effective and could address some of the same problems with the populations, like low income, like homeless, kind of populations and so, a lot of what we see, too, when we connect with different universities is that they say, you know, we've done the research, like we've proven this thing and it's published in the journal and we don't know what to do to actually, you know, get this out of the ivory tower and have this show up in real life. to the extent that all of us can start looking outside of our doors, both technologists in the valley and yourself in the community, and really

coming together. i think that's going to represent a great opportunity to move things forward. with that said, what do you think is one thing that the audience can do today to support your work, and support the work of making communities more equitiable. >> yeah. so-- hi. [laughte [laughter] >> so, will me explain our work a little bit and then, you know, in questions and answers if you want more specifics i can go into more specifics, but so my job is a very strange job. i was hired, you know, under the following conditions. my boss, who is a pediatrician, said, hey, tony, i like the work you're doing in alameda county and we have this plan. we have a billion dollars and our goal is to improve the health status of californians in a measurable way over a

decade. and i'd like you to come in ap design how we do that. and just before i said yes, he said there's one caveat, and that is, you cannot spend a nickel on health care. so you have to do this entirely through the so-called social health. improve the health status of californians over a ten-year period of time, with a billion dollars, focusing on 14 low income communities around the state with no money being spent on health care. and i said, i'll take it! and the reason that that was really exciting for me is because over the years of having practiced medicine and then, you know, working in health policy, i realized that this notion at that fundamentally, that's really detracting from people's health across the board, across race, across class, across geography,

there's a sense of feeling connected. a sense of feeling that they belonged in a society where people work together. where they were working on something that was bigger than just their own self-interest and bringing people together to work together on issues that are challenging, not just individuals, but a whole community, not only is that good for creating policy, but it also improves the individual's health. the people who are working on that work feel better. so you get sort of a double bang for your buck. now, the question was, what can this audience do to help advance that? well, first of all, you are amongst the people that we, at the california endowment, perceive as-- our obligation is to help improve the health status of everybody in california and part of the way we do that is, we think that it's critical to rebuild california's social compact. and when i say social compact,

i'm talking about that bundle of policies and strategies that essentially are investments in the well-being of the entire population across the age spectrum. across the race spectrum, across the geographical spectrum. things like universal health care, things like subsidized post secondary education. things like paid sick leave. paid vacations for people who are employees. investment in public art and community facilities. those are health protected investments. and the challenges that most of us see health and health care, and our argument is that health care is necessary, but it's not sufficient. >> it's woefully insufficient to actually improve the health of populations, so, the role of larger communities in improving health is essentially

rebuilding our social compact in california and that starts locally. that starts with local schools, that starts with parks, that starts with transportation systems. that starts with infrastructure, water, in some of our communities. so, we want to change the narrative about what health is in california, we think that that's already happening. and we can only do that when folks like you are engaged in this conversation to essentially change how we think about health, and move it away just from health care and individual behaviors. >> thank you. and to add to the statistics for you guys, you invest $10 per person per year or $2.9 million in communitien had based intervention, that yields net savings of about $16 billion. so this definitely is the case of investing in this social compacts pays not just of

course in outcomes, but in terms of dollars as well. and so, just as i think we're getting close to questions now. is he just to close this out. what's one tweetable call to action that you want to share with our live streamers, and as social media as well? >> good god! . >> host: it helps. >> well, you know, my fallback tweet is always, you know, when it comes to your health your zip code matters more than your genetic code. that should not be the case. help us change that. so, that's the tweet. >> we've got it. >> this work is about decoupling that unholy pairing of zip code and health status. the reason that those things march together is because we have allowed it. we have created policies or in many cases, we have ignored the need for policy in the face of

abject need, that has created conditions for people that are essentially stress incubators. we have stress incubators throughout the united states, people are struggling to find the resources that we all know that people need to be healthy. it's not a mystery anymore. you take some of the prestigious health institutions across the country, johns hopkins, cleveland clinic and look at where they're located and you see that the communities in which they're located are the most unhealthy communities in the united states. we have to understand why that isment we can't turn a blind eye to that. health care is important, but it's woefully insufficient to address the fundamental health status of americans. >> definitely, and we are seeing that all the time and they're starting to whisper and say, we realize that we're not actually doing enough, in terms of whether it's addressing the

needs of their immediate community or broadly serving their mandate in terms of patients and consumers and communities. so, for us, it's really looking at, you know, the key to saving lives and money, just, requires looking upstream. like, how do you leverage technology to determine the social determinates of health and assure that everyone has a fair shot at living an entire lifetime. >> i should say, this is not tweetable, but i should say that many of you have heard about this phenomenon of white working class mortality in the united states, sometimes referred to as the opiate epidemic, sometimes referred to as death of despair and it's primarily a-- it's a dramatic epidemiological phenomenon. we've seen probably about half a million excess deaths in the united states in white, rural americans, which is about the same number of deaths as the entire u.s. hiv/aids epidemic

and this is over the past 20 years and it's driven primarily by three things, drug overdose, suicide, and alcohol-related morbidity and mortality. so, self-inflicted injuries is driving one. largest epidemics, we've seen in modern public health in north america. i put it to you what is driving that epidemic is exactly the same thing as is driving the epidemic of premature death in all the maps that i showed you, in places like east palo alto and east oakland and east baltimore, and it's fundamentally people losing hope, and losing a sense of control over the things that are impacting their lives. and that is being driven by the lack of a social compact. the lack of solidarity across this country, which has led to the absence of universal

policies. that's why we don't have universal health care because we see people as my tribe needs to benefit and we can only benefit if that tribe loses. and that is an american phenomenon that's literally killing us. in california, we have the ability and we have a narrative in this state to actually approach this issue collectively to recognize that we all do better when everybody does better. and we're moving that narrative to create policies that is rebuilding our social compact which will ultimately take the burden off the health care system and improve the health of all californians. that's our charge and it's no small charge and the gentleman in the white house is not helping us in that regard. so we're going to do something different here in california and we're going to show the rest of the country how it gets done. [applaus

[applause] >> all right. well, we have a huge stack much questions here, so i'm going to try to get through as many as possible. this one actually has two, so, can you share good examples of municipalities or regions that acleveland policies and better health care outcomes and other one, do health insurance companies understand and what are they doing about it? >> great examples, richmond, california is one of them and richmond is, well, you probably know enough about richmond, but it's got chevron in it, it was a ship building community for many years and then it experienced enormous white flight and capital flight and disinvestment and it's now rebuilding itself into a 21st century model. one of the things that richmond has done that the rest of the state since followed. richmond looked at the general plan, the bible for how development happens in a community. and richmond introduced the first health element in a

general plan in california. and what that health element does, it requires all development to look at health consequences of that development. it means that we know now that sprawl, for instance, creates obesity. sprawl kills. there's a book sprawl kills. it's a design that makes it harder for people to walk or use bikes and separating land uses by great distances so people have to get in their cars to go to the grocery store or the school, whatever they have to do. the land use, dominant plan for modern california has adverse health consequences. in richmond and now in some 40 or so other cities around the state, they're now health elements in the general plan which don't allow you to make those kind of decisions, without understanding the health implications of those designs. so, that's one example.

there are multiple examples around the state of cities that are recognized and that health is an asset, that they want to invest in. and they recognize they can encourage people to come to their communities if they promote the health of their communities, both in design, and just the general ethos of health in how they essentially manage their communities. what was the second question? >> just health insurance companies, what do they understand about this and doing about it? >> i sit on a group called moving health care upstream, which has a number of national health insurers on it. health insurers get this. they totally get this. their challenge is, and large health care institutions get this, too. they realize that, you know, that the research that suggests that, you know, what actually shapes a population, says that health care is about 10% of what shapes health. so, you know, somewhere between 70 and 90% of what shapes health has nothing to do with

with the doctor's office and pells. so, health insurers realize this and they have large population data sets. their challenge, they're living in a reimbursement paradigms that has incentives to only look short-term. if we want to change that, we have to create a new set of incentives and requires policy change. they're not going to do it on their own. they're not stupid. they're motivated by their bottom line. that insend advising short-term. not making longer term investments, social services and benefits in the population to lessen the demand on the emergency room and health care clinics. >> and you guys, you see some health insurance companies being more progressive. keiser permanente. >> kaiser. >> they insurer and there's a

greater incentives. and what they spend on care and they reduced opioid prescription 40% and another insurer, intermounted health care in utah, a major health care out there is progressive and innovative and made the same commitment even though they're not an insurer. these institutions get it, but one of the things that i brought up a little bit earlier before, maybe should have clarified is that in terms of aca, a lot of people focus on health care exchanges and insurance and a lot of people don't realize in policies, one of biggest changes, value based care. so right now in terms of health care, people make money off of doing more, regardless of what happens to you as a patient or a consumer, in terms of if you get better, you get worse or pass away, that doesn't matter, they, they get paid by performing things on you. and what they're trying to do now value-based care is based on, okay, we're going to pay

you for performance. does the person get better? do they return to the hospital shortly thereafter kind of signaling you've done something wrong. they're aligning money with behavior and what they're trying to move toward. now that we're in the transition period we have the issue of most, most stake holders are making their money in the old system even while they're trying to plan for the future. so it's still a little bit gray ap gnarl why: and same with the guy in the white house, taking steps to roll back what was an innovative step toward getting our health care system to where it needed to be. so it's kind of a wait and see period. and that's the question. in terms ever your location and analyses have these been done in other countries, canada, japan. >> great question. the question is yes.

it shows how life expectancy decreases over geographic space and the u.s. has a relatively steep social gradient, meaning if you move relatively short distances, your life expectancy gets shorter quick. most countries have a social gradient. canada has a social gradient. much of europe has a social gradient gradients. there are consequences of living in a low income community in other countries outside the united states, but those are mitigated by a social concept, and mitigating the needs of poorer people and low income people and essentially create a basket much opportunities and benefits for them. >> okay, so this is related to how much does capitalism influence drive poor health care outcomes and high health care expenditures? >> i get this question a lot. and i try to remind people, i

mean, i grew up in canada. canada is a capitalist country. sweden, norway, denmark, france. the difference is that they have democracy that essentially is more important than their capitalism. so democracy checks their economic system. in this country, we seem to think and interestingly, the word capitalism does not occur anywhere in the u.s. constitution, but we act as if it does. as if it's somehow this sort of holy motion that trumps democracy. and that's why we have corporations that are people and they can make unlimited campaign finance contributions, there's no other country in the world that has that sort of bizarre construction of capitalism. but we do and it has profound health consequences.

the goal is to enhance democracy to put checks on capitalism, but the countries that have some of the best health in the world are capitalistic countries. >> and i would say even if you're looking at this from a market-based perspective. the fact that we're sicker as a population, particularly parts of our populations, is bad for capitalism. if you're sick it's hard for you to work. if you don't work, it's hard to consume things. given we're a consumption based economy. even if you're a strict economist this is something you should want to support. the question is about agencies, having more agencies doesn't always lead to greater control. how much benefit are you getting addressing agency alone versus looking at other factors or interventions. >> i'm not sure i understand the premise of that question and i may challenge it a little bit. i almost use agency and control synonymo synonymously. almost.

that, let me give a quick example and there may be some doctors in the room that probably understand this, but when you're a physician, there's basically two types of patients. i'm over simplifying, but basically two types of patients. there's the patient who comes specifically, the stereotypical one that's a va patient. see you and they're slumped over in the chair and they have diabetes, they have chronic obstructive pulmonary disease or emphysema. they have high blood pressure, on a whole list of medications and they don't make eye contact with you and you know, you're talking to them and they say, yeah, doc, whatever you say, doc. and you're listening to that and you know there's no way that person is going to follow any instructions you're giving them. so you're trying to find a way in, a way to sort of create for them, a sense of control over what's happening and so they'll participate in this encounter as a partner. and on the other end of the spectrum. if you have them with a stack of things off the internet.

i read this and i think i have this. tell me why i don't have this and why i don't need this drug. okay, can we focus on maybe three problems today and the other 27, you know. [laughter] >> but those patients have agency. they are in a partnership with you. they're looking to you as a guide. not as sort of like somebody who is just going to disgorge information in their waiting beaks. we're going to analyze what you're saying to them. and that partnership is so much better for health than the passive kind of partnership. so agency in the sense that you have some sort of control over what's going to happen to you so you approach the world differently. what we've found in our work is that we have communities that feel like that patient, like they're like, whatever you say, doc, okay. you know? whatever you say, you know, mayor. whatever you say, board of supervisors. they're passive. they've given up. they're lost hope and that's

very bad for the health of that community. so the goal is basically to the agency. the ability to participate. small wins. people can see them making change and you bring them together with similarly situated people and they can start to see that they have some control and not only does that help change policies, as i said earlier, it changes their physiology. it makes them more hopeful and that hope ultimately, it helps. if the questioner was asking about absolute control. none of us has absolute control. it's relative. we're trying to build a relative sense of agency so people have more control over what happens to them, not absolute control. if i didn't get that question right, ask me again afterwards, but i equate agency and a sense of control. >> so do you think that an integration of hhs and could

help on a better federal level. >> i love that question and i will answer that question affirmatively. yes, i think so. one of the most interesting meetings i ever attended was with the british chancellor of the exchecker, which is basically the treasury secretary in britain and they have a kind of accountability roll in the british government. they recognize that their public health system and public education system were the same thing. and so they merged those two systems. and they said that if our public education system is it not promoting public health, there's something wrong. if our public health system is it not promoting public education, there's something wrong so they tied the two systems together and gave them the same outcomes and started to see improvements in health and improvements in education. i think it's similar that when

you siloize or fragment government and give them parallel goals, they send not to work synergisticically. so trying to tie health and housing together i think is absolutely critical and to the extent that it requires breaking down the silos and linking two branches of government, i think that potentially could have some benefit. >> all right. so you're going up against big medical institutions. will they align with social spending? i think really that spending allocation question. >> yeah, so i give a talk at johns hopkins every year, stanford, harvard, about the same basic stuff. same basic data, and you know, people get it. there's no question that they get it. as i said earlier, they're being driven by a set of

incentives. to the extent that the questioner is asking, will they essentially ignore their primary incentives to essentially invest in the things you're talking about? the answer is no. they will not. because they're rational. and they get rewarded for a different set of things than i'm encouraging them to pursue. so, until they can start to see their incentives aligning with this, would, nothing will change. you have very good leaders in many of these institutions that recognize that the future requires them to make these investments, so they're placing some bets now, but still, the overall reimbursement structure is innocecentivizing them to do what they're describing, the short-term kind of, you know, the more you procedurized somebody the more you get reimbursed. the more you do, the more you get. they're business people and they're trying to stay in business and they're trying to compete and so they're going to optimize their current reimbursement scheme as long as

they can. . >> exactly. and that's one of the reasons that we are excited that there are opportunities coming with the shift toward value-based care that create opportunities for basically more businesses. they have an opportunity to meet these-- well, not new needs, they're new in the sense they're incentives to address the needs of low income populations, you know, once again, like money drives everything. and so, you know, i think with you, like one of the things you can do in california, starting to better understand how does health care get paid and starting to understand that and seeing, you know, how that works because it's very complicated. very complex. so where do we find to support your work by becoming a collaborative member of the movement and will it help build single payer in california? >> so now speaking for myself

as tony iton and not the california endowment. i'm a big supporter of single pairer. i hate the term singer payer. call it medicaid for all, and if you ask canadians, what if you love about being canadian, they'll talk about the medicaid system. there's no american that says the u.s. health system is what they love most. singer payer minimizes marketing costs and delivers what we want, which is care. you could have a private system of care, a private doctors, private hospitals. the insurance system in single payer is a public system. so it's not interested in competing, it's not marketing, it's not making profits, it's just administering care. the thing you want is care and

care, i personally think it's best delivered in a privatized system. i don't think that doctors that work for the government is a good configuration. because i think that the system needs to continue to be incentivized to innovate and happens better in a private kind of setting, but as far as insurance goes, there's-- there's literally no other countries in the world that has decided that profit taking in health care delivery is the most important thing. we are very unique in that way. so, single payer is a great system. i forget what the beginning of the question was. >> where do we sign up to support your work being a collaborative member. >> go to our website and there are multiple opportunities for people to sign up for various campaigns. we run a series of health campaigns across the state.

it includes campaigns relate today criminal justice and health implications to immigration, health implications, the incarceration system and trying to dismantle that and implications. the school system and adverse to boys and particularly men of color. we're running campaigns state wide on those issues and you can participate in those campaigns. if you're social media savvy, you can click, you know, support or whatever and then move from there in terms of actually participating in rallies, writing letters, writings op-eds, a whole host of ways in which people can participate in this work. >> so, i guess for both of you. how do you get the communities to invest in healthy food options and still profit? >> okay so one of the things that we did, i'm a doctor so,

you know, we doctors we know a little about, you know, medicine, we know pretty much nothing about everything else. and when i came to work at the california endowment, one of the things, sort of a funny story, we were sort of sitting around eating lunch and we were talking about all the of these food deserts across california. food deserts are communities where there really isn't access to healthy food. you've got liquor stores, you've got tons of fast food, but you can't find a grocery store, can't find a farmer's market or these kinds of things. how do we get them healthy if we can't find healthy food. what do we do about food deserts. and there were a group of investors that work for us, we're an endowment so we have people that actually manage our three and a half billion dollars. and they're sitting here listening to us, why don't you start a fund? and we're like, shut up, investors, you don't know anything about this. this is serious public health

stuff. and they're like, no, seriously, start a fund. so, we started listening to them and they were right. so we started the california fresh, fresh works fund. which is, you know, our goal was to raise about 200 million dollars to help build grocery stores in low income food deserts. so we put 30 million into a fund and asked other people to match that and participate in that and by the end of 18 months we had 300 million dollars. and the california fresh works fund now builds full service grocery stores in food deserts. we've built over 25 of them across the state. i did not know that you could do this. i mean, i-- like i said, i'm a simple doctor and i learned a lesson in this, which is that money loves money. [laughter] >> the second aspect that i've learned is that nobody wants to be the first one in. everybody wants to be the second one in. so, if you put your money out there at risk, which is what we do, because we give away money.

we put our money out there and we say we'll take the first hit, you know, if things go side ways on this, next thing you know, we multiplied our money by ten-fold. that fund division exists today and building groceries stores across the state. it's something that can be done if there's a will and there's somebody willing to take that nerve risk. >> -- risk. >> and people living in low income communities don't buy things. we know that's ridiculous, both on its face and in terms of evidence. so obviously, people need to buy clothes and food, transportation, they're buying all sorts of technologies because they need them both for leisure and for work. so in terms of this idea that providing healthy food options in what, on its surface seems like not a good market, doesn't make money, doesn't make any sense in real life and other

start why ups popped up. propel got funding from horowitz and their app focuses on people who live on food stamps manage their food stamps. manages how much they have left in their accounts and helps to connect them to discounts to other grocery stores so grocery stores are participating and supporting this, see where their consumer buying, what their buying patterns are so they can understand how to better serve consumers and make more money from this and helping folks budget food better and greater access to healthy food. it's definitely one of those everybody wins kind of situations and i think it's a $70 million market or something like that, if i'm remembering correctly. and that's just one example. there's other food related startups. i think that maybe a c or b-funded company. an on-line grocery store kind of like trader joe's, specialty and organic products at decent

prices, but take folks on the food stamp programs. they take that and people on food stamps can buy healthy products on-line and if they're in a food desert and have health needs that require these kinds of foods. there are definitely opportunities out there if you're ready and willing to take them on hand and actually both make money and address some of these really huge issues, whether it's food insecurity or others. and-- let's see what else. we've got. this is in cursive and i can't read that right now. do you support sb-59 health care for all? i'm guessing it's the universal health care bill, not very good at knowing. >> yeah. >> how do you use nurse practitioners in helping the church communities? >> the question about allied health professionals and nurse-- ancillary health professionals

and other forms of practitioners. i'm married to a nurse practitioner, i would trust her much more with my care than i would trust me. she works in san francisco in southeast health center, hunters point and deals with very complex patients. we have just closed up an initiative in california with a $90 million initiative on health work force we've made investments almost exclusively in nurse practitioners and physician's assistants to help california's health work force. i went to medical school and graduated in 1989. at the time and i went into a primary care internal medicine, and one of the first in the country. 70% of people leaving health care and medical schools could go to primary care. i went to a school that

actively discouraged primary care. and so, it was a struggle to even, you know, find the residency that my dean would write me a letter to support. and that was 1989. as of last year some less than 12% of medical school graduates in california chose a primary care career. again, the intensive structure does not incentivize primary care. they're not going to be able to build a health care work force just with doctors. we're going to have to use other forms of health care, delivery, in order to essentially meet the demand, particularly for an aging population in california and across the country. and quite, frankly, i think the quality of nurse practitioners, physician assistants and primary care is very good. they're very well-trained. they have a lot of

practice-based experience and in some ways provide better care because their training is much more focused on kind of holistic approaches to health care. >> and as the daughter of a nursing professor, i would have to completely agree with that. for those of you who don't know, the physician shortage is and will continue to be a problem, but another one that doesn't get as much media attention, i think, is the nursing shortage. we don't have enough nurses, we're all really, really worse off. so, once again, a role for technology not necessarily to replace those people, but to be able to extend the nurses and doctors that we have in the work force and allow them to operate at the top of their licensure and shift better. i was not able to read this. a multi-part question. you mentioned stress regarding health care outcomes as a major factorment if you only have enough resources to address one component of stress, what level should you address that stress

at at the community level, the state level, at the federal level? >>. [laughter] >> i'm not sure i entirely-- i am unless you're talking about policy intervention. >> it's a resource question. if you have limited resources to address the stress like at what level should those resources be allocated? >> so, this is one of those sophie's choice kind of questions. my approach in this work, i used to say when i ran alameda county public health department. i had a budget of about $120 million, part of an agency that was about half a billion dollars. and i use today say i would give half of my budget to anyone could increase the graduation rate to oakland school system to 85%. people would say that's a generous offer, why would you do that? i said if there was an 85% graduation rate from oakland unified, i wouldn't need half

my budget. the point is, there are social determinat determinates, and modify health by far. if we could educate young people and get them through high school and to a post-secondary credential and give them a shot at a meaningful way to participate in the 21st century economy, our health would improve dramatically without doing anything with health care, without any new innovations in technology or pharmaceuticals. and we know this. this is not news. we know this. we just don't do it. so, fundamentally, if i was going to invest, you know, at a jurisdictional level i would invest at the state level. because the state is constitutionally required to assure education for all of the residents of the state of california and i would enforce that. i think it's absolutely critical and would have profound health impact across

the state. >> all right. well, those are all of our questions for this evening and i think we're wrapping up. thank you, guys, for your listening and for your lovely questions and we're here to answer them afterwards, as well. . >> thank you. [applause] [inaudible conversations] >> today a republican senator james lankford of oklahoma releases his annual report on wasteful federal spending. that news conference starts live here on c-span2, 11 a.m. eastern. and steny hoyer, with the emergency management officials in maryland, live at 11:30 a.m. eastern on c-span.

>> the c-span bus is on the 50 states capital tour and hearing about each state's priorities. we kicked off in dover, delaware and now visited 12 state cash amounts. our next stop for the 50 capitals tour is tallahassee, florida. we'll be there december 6th with live interviews during washington journal. next, a look at the political situation in argentina with hector schamis, a professor at georgetown university for latin american study. he talked about the history of argentina's political movements and two-party system which is now challenged by a third party after recent mid term elections. hosted by the hudson institute. thises just over an hour. >> it's a great pleasure to welcome you to our conference on argentina this afternoon. for any student or teacher of latin america,