So welcome everybody for the Women's Wellness lunch series. I'm excited to talk to you about urogynecology. This is the first lecture in the series. And so we're excited to have you here and to join us to learn a little bit about urogynecology, which is what I do. So I'm excited to share with you. So just an introduction about myself. I am a urogynecologist. My name is Nina Batia. I'm physician that is board certified in both OBGYN, obstetrics and gynecology, as well as urogynecology. My practice consists of urogynecology only. So I don't do any general gynecology, meaning annual exams, breast exams, pap smears, and that sort of thing. My specialty is strictly urogynecology. So I trained first as an OBGYN for four years of residency. And then I did a three-year fellowship in urogynecology. And we'll talk a little bit more about what that means and what types of patients and conditions that I treat. I do have an office in Old Bridge. We do have a satellite location in Shrewsbury as well. I am affiliated with several hack and sack learning hospitals, including Bayshore Riverview and Old Bridge Medical Center. My specialty includes vaginal surgery and robotic surgery for conditions like prolapse and urinary incontinence. So today, these are objectives for the talk today. We are going to learn about what urogynecology is. We're going to learn about some common urogynecology conditions, which include prolapse, or active bladder, stress, urinary incontinence. We'll talk about signs and symptoms that should prompt you to see a specialist like myself or any urogynecologist. And then we'll also talk about treatment options, which include surgical options, as well as non-surgical options. So we'll start first with what is urogynecology. So we are a subspecialty of OBGYN or urology, and we provide comprehensive care for women with pelvic floor conditions. So urogynecologists may have been a urologist or an OBGYN before subspecializing into urogynecology. The conditions we treat include pelvic organ prolapse and urinary incontinence. When you're looking for a urogynecologist, you might find some other type of wording, such as female pelvic medicine and reconstructive surgery, urogynecology, sometimes even female urology. In general, you want to look for board-certified physicians who are specializing in these conditions. So what is the pelvic floor? So the pelvic floor is what we are helping our patients with. The pelvic floor consists of muscles, ligaments, and connective tissue that are supporting some vital organs in your body. The organs that are being supported by your pelvic floor are your bladder, the uterus, the rectum, and the vagina itself. So this image just shows you where those organs are and how close and proximity they are. So your vagina supports the uterus, the bladder, and the rectum. So we'll learn as we go through these slides, when the vagina starts to fall or loses its support, organs such as the bladder, the rectum, and even the uterus can actually start to fall down as well. So our pelvic floor is very important for women and it really gives us a lot of our supports, but unfortunately over time and with age, the pelvic floor can actually weaken and lead to other significant problems. So we want to know, or what you think, what is the likelihood of or what's your chance of getting a pelvic floor disorder? So for women, the likelihood of getting a pelvic disorder is probably more common than you think. Is it one in three women that get this, one in eight, or one in 15? So normally if I were to present this in a front of a live audience, we would pull to see what the thought would be in the audience, but since this is virtual, you'll just have to kind of come up with an answer yourself and I'll give you the answer. The answer is one in three. So it's more common than you think. One out of three women will develop a pelvic floor disorder. So between yourself, your mother, your daughter, one of you will have one of these conditions. Or amongst your friends, if you're sitting with two friends, one out of the three of you will probably develop a pelvic floor disorder. It's very common and unfortunately we don't really talk about it that much, but hopefully with webinars like this and just kind of getting the awareness out, women should know that these are really common conditions and they're very treatable. So we just want to make you aware that it is quite common that you may experience a pelvic floor disorder in your lifetime. So what are the pelvic floor disorders? Urinary incontinence, pelvic organ prolapse, urinary urgency, frequency, and nocturia. We're going to talk about each of those, what they mean, and how do we address them. So urinary incontinence is just leakage of urine. So it can range from small drips or small drops of urine leaking. It can be your entire bladder that's letting out or anything in between, but any unwanted loss of urine, whether that's if you cough and sneeze and a little bit of urine leaks out. If you have that feeling that you need to go to the bathroom and you just can't make it in time and you just start to lose urine, that's incontinence. So whether it's a little bit or a lot, it's all urinary incontinence, which is just leakage of urine. What are some of the symptoms of this? So again, any leaking with things like coughing, sneezing, running, jumping, exercising, lifting, I've had patients tell me when they are at the gym and they're exercising, that's when they leak. When they're lifting their children, they might leak. When they're bending down to, you know, empty out the dishwasher, they might leak. So those are all forms of something called stress incontinence. Sometimes it's more of a frequency urgency issue where you get a very strong urge to go to the bathroom and it's not an urge that you can defer. So when you have to go, you have to go. You get that urge and you instantly just really, really have to run to get to the bathroom. And if that happens to you quite often, that's called frequency. For some women, they can make it to the bathroom in time. For some women, they cannot you know, so if you're getting that urge to go and you can't make it to the bathroom in time, that would be called urge incontinence. Waking up in the middle of the night to go to the bathroom, some women can make it and some women cannot. So if you cannot make it to the bathroom at night, that would be another form of urge incontinence. And for some women, unfortunately they wake up already wet. So they wake up because they've noticed that they've lost urine.  So that could be another form of incontinence. So if you suffer from urinary incontinence, just know that you're not alone. It again is quite common. So for urinary incontinence itself, how many women over the age of 18 will actually suffer with urinary incontinence? And again, this is one in four. So these conditions, whether it's a pelvic floor condition or just urinary incontinence, it's quite common. Unfortunately, as we get older, our incontinence or risk of incontinence actually increases. So incontinence will increase with age. As you get older, you may find more urgency, more frequency, more need to go to the bathroom. Urgency can present itself in so many different forms. It can be you're at the sink washing dishes, that running water is what triggers you to get that urge to go. You're out shopping or out with friends, but as soon as you pull up to your driveway or put your keys in the door, all of a sudden you really have to go to the bathroom. That's an urgency. And eventually that may lead to urge incontinence. We can't get to the bathroom time and all this increases with age. So over your lifetime, approximately 50% of women will experience some form of urinary incontinence. But the good news is it's very treatable and you know, you're going to call just like myself and others in the area are all here to help treat this for you. What can cause urinary incontinence? Pelvic floor conditions like weakness of the muscles, urinary tract infections, drinking lots of caffeine, lots of coffee, alcohol, certain diuretic medications can all make it worse. If you suffer from constipation, this can be problematic. Some women have neuromuscular problems such as if you've had a stroke that can increase your chance of urinary incontinence. MS can increase the risk whether you have anatomical problems such as prolapse or kinestones can be a risk factor as well. How is it diagnosed?   We can diagnose you with lots of these conditions. So there's no special testing that would need to be done to confirm that you have these problems. It's really based on your medical history and your physical exam. When should you see a urogoncologist? You should see a urogoncologist if you're bothered by these conditions. Some women unfortunately wait a really long time before they see a specialist.  So let's say you don't drink as much water because you're afraid that you're going to have to keep going in the bathroom.  So if you're bothered by this, there's help available to you. Whether you start that conversation with your primary care doctor or OBGYN or if you call us directly and make an appointment just to be seen to talk about your problems that you're suffering with, there's treatments available for you. The types of urinary incontinence we touched on a little bit, but stress incontinence and urgent incontinence. So those are the two most common types. Now there are others, but those are the most common. So again, stress incontinence is when you leak with coughs, knees, laugh, run, jump, lifting, things like that. Urgent incontinence is when you leak when you get the urge to go or that feeling that you have to go and you just can't make it in time. Within the umbrella of something called overactive bladder, there's urgent incontinence, urgency, which is that strong urge to go and you can't defer it.  Now someone wouldn't have both. Some women have both stress and urgent incontinence and that would be called mixed incontinence. For some women they can't tell. They can't tell what's causing them to leak. They just know that they're wet, that the urine's just coming out without any sort of warning or any kind of control. So those are all things that we can help you with. What are the treatment options? So there's lots of treatment options, whether it's conservative therapies like exercises, physical therapy, there are medications, there are surgeries, there's office-based procedures. There's plenty of things to help treat these problems and often we'll use a combination of therapies. So there may not be one solution for everybody. There's a combination of different things that we'll use. It might be a combination of physical therapy and medications or a procedure. It really depends on you specifically and what your symptoms are and what your goals for treatment are. But the good news is that a lot of this is curable. You don't have to live with incontinence. You don't have to wear pads while it's common and it's something that you may hear is something that women have to deal with or that they do deal with. So the truth is you don't have to live with it. You can treat it and there's pretty simple ways to address it. So some of the non-surgical treatments, what can you do? Just simple lifestyle changes, whether that's decreasing the number of cups of coffee a day that you drink or if you're someone who let's say drinks wine in the evening but you get up a lot at night, you might want to cut that down because that may make a difference for you. There is some simple bladder retraining exercises that we can do where we have you keep a log of how often you go to the bathroom and we look and let's say you're going to the bathroom every hour. We're going to try to push you by about 15 minutes to see can you get yourself to let's say an hour and 15 minutes. Little by little by making those changes we can get you into more normal range. You're not going as frequently. Physical therapy is very helpful. You can work with the therapist to strengthen your pelvic muscles and these are specialized therapists that work on the pelvic floor only. So it may not be the same therapist that does shoulders and elbows and knees. It's a specific pelvic floor therapist to help you train those pelvic floor muscles. There's other types of therapies that a physical therapist may do for you including something called biofeedback where we work on the nerves and the muscles of the bladder and there's also support devices. So if you suffer from something called prolapse which we'll talk about soon prolapse is something that can be supported without surgery by using something called a pessary. There are medications that help with urinary control so if you're having trouble where when you have to go you have to go and you have that strong urge to go or you're going frequently going to the bathroom all the time not making it a time waking up at night that condition is called overactive bladder and there's some really good medications out there to help treat that. Now there are older medications and newer medications and they all have different side effects which we'll talk to you specifically about. We'll look at the list of medications you're on to see if there's any interaction but there are some really good medication options out there for this for this condition. The medications work by blocking some of the extra bladder spasms so when you have overactivity of the bladder the muscles are overactive they contract and then spasm too much and by taking the medications you can decrease those muscles spasm. By doing that it allows you more time to get to the bathroom less of that strong urge you'll still get the urge and you'll still know that you have to go but you won't have to go you won't have to drop everything and run to the bathroom it's a more controllable situation hopefully you'll get up less at night and just not have to go as often. The office-based procedures work really well for urgency frequency nocturine overactive bladder. There are several options there's Botox. Botox is something that we use to inject into the bladder it's a very short procedure takes less than a few minutes to do it's right here in the office we do numb patients a little bit to help them with any discomfort. Most patients tell it very well and it works very well for most patients it lasts about six to nine months so it is something that needs to be repeated it's not something that is just done once and it works rather it does eventually wear off but it is a it is a very good treatment option for patients. We also do a procedure called urethral bulking so if you leak with stress and continence where you leak when you cough and sneeze your urethral bulking is something that can be done either in the office or in the hospital with sedation where we use a gel type of material in the urethra which is where the urine comes out of to help block it off a little bit to help prevent that type of leakage and the success rates are pretty high for that as well. PTNS is another treatment it's also called tibial nerve stimulation it's similar to acupuncture there's a small little needle similar to an acupuncture needle that's placed at the level of the ankle and it helps control the signals that your bladder is getting to help decrease the urge and the frequency so PTNS is a treatment that we do in our office it's it's for most patients completely painless it's a short procedure and that does help with the control as well. We also have surgical options which you may have heard of you know from from other physicians if you if you bring up your incontinence they may talk about some surgical options available to you so slings are a common procedure that we use for stress incontinence for leakage with coughing and sneezing for most women who get a sling their success rates are quite high and they it's it's considered you know something that that will cure the stress incontinence so the likelihood of still having any kind of stress incontinence after having something like a sling is very low it's a it's a about a 30 minute simple outpatient procedure with minimal recovery time and patients do very well there are other ways to suspend urethra with sutures or stitches there's also a procedure called sacral neuromodulation now sacral neuromodulation is a wonderful procedure that does help with the overactive bladder or the getting to the bathroom in time waking up at night going frequently sacral neuromodulation is a simple outpatient procedure as well it it's basically sort of like a bladder pacemaker that's controlling the nerves of the bladder it lasts for about 15 to 20 years so it's not something that needs to be redone yearly or often and it makes a huge difference for most patients there's a test that we do for at first to make sure you're a good candidate for it to make sure it actually helps you but the key takeaway i think is that there's many options so if you're suffering with incontinence it's not something you have to live with it it really is something that's treatable and in most cases curable where you can come in we would get your medical history we'll do an exam we'll figure out the best options for you and together we'll come up with the plan that's best for you so that we can help you in achieve your goals whatever those goals may be we haven't talked yet about prolapse but when we do we'll talk about some of the options for that too which are sometimes surgical and sometimes non-surgical so that again if you're suffering from incontinence you are definitely not alone one in four women over the age of 18 do suffer from incontinence so it's a common procedure i'm sorry a common condition it gets worse with age so if you do have it it's not going away it most likely will just get worse with time if you get older and there's typically not much benefit to waiting till it gets really bad to come in and fix it so while we may not talk about it that much amongst our friends or if you go to the doctor it may not come up it might not be a question that they ask you about but if you're suffering from any type of urinary incontinence just know that it's common and you don't have to deal with it and just because you don't really hear anybody else talking about it it doesn't mean that you're the only one that has that problem it's so common and i think you know as the years go on if we talk about it more i think patients will be more willing or open to to some of the treatment options that are out there but feel free to talk to your primary care about it your obgyn if you wanted to come in directly to see us you can always do that too but just know that there's treatment options out there it's not something you have to live with and you're not the only one that has it it's so common um and it's also quite treatable most women are suffering for years before they seek help help so about 33 percent of women wait somewhere between one years to five years to to ask their doctors about it or to look for some sort of help um 26 percent of women wait more than five years so the majority of women are waiting you know a long period of time before they're actually even bringing it up so um i hope that a seminar like this will help bring some education out to the population so that we know that we don't have to suffer with this we don't have to just live with this there treatments out there and it's okay to ask for help it's okay to bring it up with your primary care or your objuan or even come to a urologist or your gynecologist directly to bring up the problem so that you can be helped this is um from voices for pfd.org and i have that website on it on one of the upcoming slides um this website is very helpful i think for patients because it comes from the american gynecologic society or augs which is um our medical society and and they have this website that's dedicated for patients with just information for you so um this is a life impact tracker for overactive bladder so if you're suffering from the urge to go going frequently waking up at night and um you know kind of want to gauge how much it really is bothering you it's a nice little tracker where you can keep track of you know is it making you feel anxious depressed embarrassed angry um how often is this happening is it affecting your intimacy and um it's just a and i think a nice little tool to just kind of help figure out well how much is it really bothering me and it might be bothering you more than you think um the other condition i wanted to talk about today is pelvic organ prolapse so the majority of what i do as a urologist is helping women who are suffering from urinary incontinence but also women who are suffering from pelvic organ prolapse so prolapse is quite common it happens to many women and it tends to get worse as you get older um some of the risk factors for prolapse are pregnancy and childbirth just aging going through menopause certain health conditions such as obesity chronic cough constipation women who do heavy lifting there are tons of risk factors for pelvic organ prolapse so genetics isn't the only reason um if your mom didn't have this but you have it you know there's so many reasons why that could have happened or just because you have it doesn't mean necessarily your daughter will have it because it's not just genetics so what is prolapse prolapse is when those pelvic floor muscles which we had talked about earlier um start to weaken and as they weaken the floor of the the vagina actually starts to fall so when the vagina loses its support the nearby organs can come down as well so if the top or front wall of the vagina starts to fall the bladder can come down with it if the bottom wall of the vagina um loses its support the rectum can actually start bulging into the vagina and that creates um a prolapse the uterus itself can lose its support and the ligaments are just not as strong as they used to be and over time the uterus can fall down and for some women who have had a hysterectomy where they've had the uterus removed they still have their vagina intact and the vagina itself can lose its support and fall and when it does things like your small intestines or bowels can come down too so there's lots of different organs that can be affected by prolapse for a patient what you may notice is that you feel something some sort of bulge when you go to the bathroom to wipe you might feel something that that wasn't really there before or when you go to shower or clean you might feel that there's something in the vaginal area that feels different or feels like it wasn't really there previously some women describe it as sitting on a ball so they feel like they're sitting on something um it can feel like a pressure and heaviness in the vagina it can feel like a tampon that's sort of either stuck or starting to fall out so it feels like there's something different and something coming down generally prolapse is not painful so most women who have prolapse don't feel pain they feel more of like a bulge sensation or something coming down um and again there's so many different reasons why it can happen um the important thing is to come into have it evaluated whether that's with starting with your gynecologist your primary care doctor or coming in to see a specialist like a your gynecologist or a urologist who deals with prolapse um we will let you know which organ is prolapsed and usually it's a combination where it might be both the bladder and the rectum so the terms that you may hear are cysticeal which is where there's vaginal prolapse that's bringing down the bladder or recticeal is where there's vaginal prolapse that brings down the rectum and then uterine prolapse where the uterus comes down or vaginal vault prolapse which is where you've had a hysterectomy and the vagina itself is is falling down so this um this sheet that we're looking at on the slide is again from that same website voices4pfd.org and again it's a really good website for patients to just do their own research to um learn a little bit more about these conditions but you can see there's pictures showing you what each of those conditions are and it just talks about what the condition is and and how to treat it so from a treatment standpoint what can you do about it generally we tell patients there's about there's approximately three different choices one would be conservative treatments or or sort of living with the prolapse and not necessarily intervening in any way but doing things observation watch and see if it's not that bad it's not really bothering you do you really need to treat it not necessarily it really depends on how much it's bothering you some women opt to do pelvic floor physical therapy to try to strengthen their pelvic muscles um the other choice that some women make is an intervention called a pessary so in these images you can see what a pessary looks like a pessary is a silicone device it's either shaped like a ring and we have tons of different sizes and shapes um and that's something that you get fitted for when you come into the office so if you're looking for a pessary a pessary is a supportive device um and it's placed in the vagina to help push the vaginal walls up and lift those organs that are falling so a pessary can be left in place um depending on which type for sometimes three to four months without needing to be removed um there are pessaries that patients themselves can remove clean and replace as needed and um so that's an option and then the third option would be surgery so there are surgical options as well and if you can see the list of options on this page there are vaginal surgeries there's abdominal surgeries there's robotic surgeries there's lots of different options and the key is to come in to get evaluated so we can figure out what the best option is for you most of the surgeries that we do are typically either outpatient or overnight stays with a you know minimal recovery in general uh I would say it's sort of similar to childbirth in that there's no heavy lifting no intercourse no swimming and things like that for usually about four to six weeks um but patients are up and walking right away so when they have surgery they're walking around immediately that night there's no reason to be in bed rest from a pain standpoint most most patients do quite well um and usually take just over the counter pain medications occasionally they might need something stronger um but from a surgical standpoint most patients do quite well and um it's a it's a pretty simple recovery for most patients so whether you choose to do exercises to do physical therapy to wear a pester or even have surgery there are options for you if you're having a prolapse it's a good idea to get it checked so that way you know what exactly is prolapse which organ what stage how bad is it and and what are your options these are some resources that I think are really helpful for for patients so AUGS.org is the american urologic society with a lot of information fact sheets for patients most of the um information that I've given you today is from this specific website voices for pfd.org um there's an online community that's been developed by the urologic society to help educate patients and caregivers about the pelvic floor disorders um and there's opportunity for um involvement with an online community there's videos there's apps there's printable resources I think it's a very good uh site if you're looking for more information um there's also another site called yourpublicfloor.org and that's from the from iUGA or the international urologic association and um this site is nice because they also have fact sheets for patients in different languages um so I think these are some really good resources if you're looking to do a little bit more online research to understand a little bit more about these conditions


Let's do this and then we're going to go about it. Yeah, well, I'll do it too. Yeah, let's start now. So we'll do 20 minutes of work and then we're all done. I'm going to apply for a few 10 minutes of work. Okay? Okay. All right, so we're going to have to work like extra fast out. Okay. Same. Okay, so let's start. Now.  You get some impacts. In it, it's just fine in a different way. And it's also okay. Right. Yeah, he's working on his play. He's having some difficulty. And because he's written one scene with a lot of characters and now he's on another scene with a lot of characters. And because they all have to be in the same scene, they each take sort of a turn and he says it's kind of like a concerto. It sounds kind of... It sounds complicated. No. It sounds complicated. I'm just trying...  I mean, the tricky thing is that sometimes work comes easily and sometimes it doesn't come so easily.  And I think when we're blocked, I think that's the best thing we can do. Even if it doesn't feel so great. Show up with the time. That's so important. Because a lot of times we think, oh, yeah, yeah, yeah, yeah, I'll wait until I feel good. With, you know what I mean?  Right? I mean, really.  And yeah, because you know, you know. I mean, a lifetime. People go, right? So I think the best thing to do is just show up and put the time in. Even if it's just like 30 minutes. You know, even if it's 15 minutes. What's your deadline? Everett's got a deadline. Okay. And so, working down my counting pages, you have to do a day. That's good. Right. So he's got a deadline. He's got people waiting for the play, which puts a... I mean, it's a good question. You kind of got it. You kind of got to get it done. Are you going to feel okay? Are you going to feel okay? Handing it off to them when it's not really done? Okay. Okay. Yeah, it's a different way to write, but as long as you're comfortable handing off a quote, unquote, unfinished, you know, peace to your folks. I mean, you trust these people. They're adoring. They love you. They're supportive. Okay. Well, that could work too, because then they're not going to sit around and... That was nuts. That was that one. I hope everybody's okay with that. So it's a grad school application. So that could work also, because they're not going to sit around and tell you how to fix it. Do you see what I mean? So that's actually okay. As long as you feel okay about it, it's all right handing off something that's not completely baked, you know? So I would just say keep putting the time in. That's the most important thing, you know, because a lot of times we sit around thinking, okay, it sounds like you've gotten over that. You know, you've got to put the, you say five hours in there. Yay. So, I mean, I guess I don't know if it's helpful, but know that you're not alone in the process of having a hard time and just, you know, and what happens is if you just keep putting the time in, you're going to get some, like, wow, that scene works. Oh, that's a mess. Oh, that bit's good. Oh, wow, I figured out that part. You're going to get, like, it's going to be like that? It's hard, but it feels like you're just sitting there. Well, you're not staring at the screen. You're putting in five hours.  I would suggest go ahead and just, well, not randomly. Randomly was, well, actually, Durham wasn't randomly typing. He was typing great effort. But I would say, tell the stories the best you can, given how much you know and how much you don't know. So I would say instead of sitting there staring at it, just like when he was learning to walk. Right? I mean, we would have quit. I would have quit. Shit. But you know what I mean? Sometimes it comes to us, you know what I mean? Sometimes it's like perfect. A year.  But you know what I'm saying? So I think we have to just put the time in.  And it's going to feel like, have you ever had blood taken where there's an inexperienced, what do they call it? The bottom. The bottom. The bottom. It's right, right, right, right. Okay. So there you are. Hi.  Or he is jabbing. You know? Like that. And that's what it feels like. I always think, oh man, that's what it's like. You're just jabbing away. You're trying to find the vein. I got to keep jabbing until I find it. You know? Just that's necessary because the flow will come. It will come.  You just have to put the time in. You have to be willing to not be very good. Sometimes. No, sometimes it's easy. You know? Sometimes it comes in. Okay. Keep showing up from 15th of December. So come back when we're back on the, after Thanksgiving, whatever that Thursday is, come back and visit us and check in. I just want you to put, get some pages. Because when you write it, then you can rewrite it. Okay? And if you think of, try to think of the end points of the scene. Where do you want character A to B at the end of the scene? What do you want him to discover? What do you want character C to discover at the end of the scene? So you get those end points and then make it flow. Flow more effectively. I'm dancing sideways. It's very, very frustrating. Yeah? I mean, I try, I try to dance forward. Like you said. Right. All of a sudden I just started. You didn't just write to me. See? You just have to. You know what I mean? Everything I've ever written.  Have you seen, have you ever seen like the Olympics? Yeah. Like the Olympics? No, the Olympics. You know when they go to the finish line? Like that. That's how they do it.  And then you can make it better. And then you can rewrite. But if you're kind of sitting back there going, well, it seems a hundred-yard dash, you know. Well, the finish line is where you finish telling the story for the moment. They reach something that seems like the end. Right? I mean, we know, we know where the finish line. You know it. It might be different when you do your rewrite. The finish line for now is what you decide on. You have to hurl yourself toward that. You can't sit back. So you just kind of know what's going to see it, but you walk around. You walk around the city. When you walk around during the day, tell yourself the story of your play. I play about a woman or a man. And then the debt. And then the debt. And then this happens. And then this happens. And in the end, this happens. Man, my play is about you do that over. I do that over and over and over. I'm always talking, telling myself the story of my play or my novel or whatever. You know? But you really have to hurl yourself toward it. It is act of courage. You know? You just got to do it. In none of this. Just write it out. Oh, wow. Write the crappiest dialogue. The dumbest resolution. I'm in a contest with me. No one's going to see it. No one's seeing mine. Did anyone see what I wrote today?  You know? Then it will start to take shape. You know, the primordial slime, you know, where we can believe in that sort of thing, believe that we all came from. What is like, you know, slime was like, well, I don't want to be slime, man. I don't want to come out and step in.   They won. It was like slime. It's a wonderful, just a wonderful production of 59 East 59th Street with Eileen Akins and Michael Gambon. It's a, it's a reading of a Beckett radio play, but it's staged. But Eileen Akins, and it's, of course, his same themes about death and what sort of, but she was often going like this, just, you know, this, this, this. And that's what it feels like. I'm thinking, oh my God, I understand. You know, this is just, yes. But that's no excuse. Yeah. I saw that in a Beckett play. So like, Beckett didn't do that. He was actually in this. He was throwing himself across the finish line. Yeah. You know, that would, but. No, I didn't mean that. Yeah, I know, I know, I know. I'm just doing it hard time. So we didn't get to do it, like. By the time we come back. Okay. Just, just write the worst, you know, try to. And it is hard. It is a difficult place to go. You don't. When Stacy was like. That's not my. You know, it's not good. And because I'm a. Like, just, just do it. Just go ahead and do it, girl. And she threw herself across the line. And now they have an opportunity to come together. She's got yourself a chance. Right. I know the baby girls. My thing today was a distraction. But I think we're kind of out of time. I really want, I did, but I did want to talk about distraction and how you can, how to get your work done in the midst of, oh my gosh. You know, I've got a busy day or a busy thing going on. Like that. It's amazing how you can actually get your work done even with a lot of distraction. It's actually possible. Conditions for work do not have to be perfect.  And it's not always going to be possible to be so determined. But just know that it's very possible to get your work done. So we get out of the cycle. Not that any of you have suggested this, but we get out of the thing of blaming. Like, I can't do my work because my spouse wants me to, because my kid, because my job, because, because, because, because, because, because. We get out of that cycle. And we get into the, you know, the sort of rather Malcolm, you know, any means necessary. We got a cup. Hello. We can get this done. Right? Because that's how important it is to get it done. So, and, and I would suggest that, you know, things like fear and worry and writer's block, all those things are really distractions. Just, it's just you telling yourself that you don't know. Or you can't, you can't write until it's perfect. And I have the same issues, you know. That's why I talk about them all the time. But, um, yeah. So, just about distractions. Right. You know how to do it. Yeah. We watch them work downstairs when they were doing the construction and the lobbying.  And it was almost nice. And that's why I brought it just like, simply, you know, try to throw me off my game. Not unless, you know, we wanted to. Yeah. Okay. Well, um, I'm going to, so I can, uh, shout out, surprise, happy birthday to someone who's turning 70 today. She's very excited. I know someone, I've been gaining, I was impressed.  Have a happy Thanksgiving. And we'll see you the Thursday after. Thank you. Thank you.


All right, well, it's great to be here. I can testify to the incredibly warm hospitality from the Berkman Center that completely counteracts the freezing slush and blowing snow that one has to navigate to get here. Been a very warm welcome, thank you. I'm going to talk to you today about these meetings, technology, poverty, and law. It turns out that the intersection of these three is incredibly important right now because of the fact that we're looking to technology for almost all of the answers to the big global challenges that we face in the coming decades, particularly in the space of climate change and poverty. They all have technology components to it, and this intersection is really an important place to get some things right. The problem is that right now that field, that nexus is characterized by a sort of sclerosis. What's going on in that field is probably most evident in the intellectual property right field. If anybody who works on intellectual property right in developing countries knows what I mean by sclerosis in this field, it's a very polarized field. We're coming up to a place where we really don't have practical, innovative solutions. People have sort of dug into the trenches in positions, and they're missing huge opportunities, and they're also in some ways operating in the past. A lot of their models that they're using are based on things that under our noses in the last 10 years have changed radically. So what I'm going to do today is talk about the motivation for why we need this Global Access in Action project, which has a very practical bend. It's designed to look in the middle space there to say with a particular focus on the impact side. If we want to impact poverty with the technologies that we've got available, let's back out what that means for the law and for the legal tools and for the policy tools. So let's not start with the IP system and work downwards. Let's start with the impact that we want on the ground and try to work backwards to some practical solutions. And you'll hear a lot in the next half an hour or so, 40 minutes, about how this is different from what's going on in that field now. It's a fairly large departure. So I look forward to interruptions and challenges and questions throughout, and I'm totally happy to be derailed and go off into rabbit holes. But where I'll start is with this photograph. When I teach at UC Berkeley, I teach a really fun class on the economics and product development of technologies for the poor, and I usually start my lectures with a mystery picture because it tends to sort of pry the students away from their digital devices and focus them on the lecture. And I ask them what's going on in this photo and why is it important to the lecture? So at the risk of insulting your intelligence, what's going on in this photo? What is this woman just doing? What's she just finished doing? Voting, thank you. It turns out is a Timor-Lest elections in 2012. She has just voted. And the reason I wanted to start with this photo is because I want you to think about the word technology very broadly as we go ahead in this talk. Think about all of the ways that technology impacts developing countries. And it turns out that election monitoring and actually the implementation of elections has been really importantly changed by mobile phones, by SMS, by georeferencing technology. It started with a sort of more efficiency brought to the parallel vote counts that they were doing and the monitoring. But it's now to the point in the last few elections in Sub-Saharan Africa where we've got these really interesting systems that are actually in real time coming up with sort of these sourced information about what's going on in the countries. So that's just a good example to start with that the impacts of technology are hugely diverse and we need to think about them like that. Vaccines are often, you know, access to medicines, often where people go when they think about this intersection between poverty and technology. They think about agriculture, they think about health. And these are definitely, you know, on the table for this discussion. Diagnostics, essential medicines, all of that. But you should also be thinking about off-grid energy solutions. Huge impact in the poor populations in developing countries and emerging economies. Water. Water is going to be, as we all know, one of the really, really important factors in terms of the next couple of decades. So access to clean water, irrigation technologies. We have really important potential here. But you should also think about housing. These kids are from the slums in Calcutta. We have really incredible advances in material science. Whether we translate them and how well we translate them to change the housing conditions for the poor, I think, is an interesting subject. It turns out that just replacing the dirt floor in a poor household has a pretty big impact on the health of that household. Food. It's an area where I work a lot on. I work on every side of it, from the nutrition side, with supplements like plumpy nut. Some of you have heard this sort of miracle, nutritional supplement, through to biofortified crops, through to simply better farming practices and better technologies, better seeds, better fertilizer, better soil diagnostics. You could go on and on about how you could improve how we can deliver better and more food to the poor. And information and communication technologies. Most people now understand that mobile phones are ubiquitous in developing countries. It's not that they have reached all of the markets. We certainly have a lot more work to do in getting them into really rural markets. But they're an incredibly powerful tool when you start combining them with some of these other technologies that's going to make a big difference. But mobile phones are not the only piece in information and communication technologies. I also work on advances in remote sensing, advances in mesh networking, advances in wireless sensors. All of these technologies have really fascinating impacts on the poverty. And this is just scratching the surface. We haven't even talked about sanitation technologies or technologies that support citizen journalism or you could go on and on. So that's just to say that the word technology is very broad, and I'm hoping that with the diverse expertise in the room that you'll be thinking of a lot of these different pieces and not just focusing in on the health and the agriculture side. And it's a good thing that it's broad because we're going to need it. This figure on the right is familiar. 9 billion people on the planet by the year 2050. The estimates are that we're going to need 60% more food to feed those people and 20% more water. And that's not even mentioning the differences in the health side of things. So this is, you know, we're really running up against very difficult challenges, particularly in our global food system. And we're trying to do it in the midst of climate change. If you think about the fact that 80% of the food supply for Asia and Sub-Saharan Africa is supplied by smallholder farmers and many of those smallholder farmers farm on marginal land. They farm on rain-fed land that isn't irrigated. Climate change is going to have a really big impact as the climate gets more variable, what they plant, how they plant it, and how much they can grow. These 11 countries are considered the top 11 in the next couple of decades for disaster-induced poverty. But it's not just in agriculture. If you think about where the storms hit, the increasingly powerful storms, they hit areas where the poor are. If you think about where the sea levels are rising, those are areas where the poor are. So we tend to have a discussion about climate change in this country that's very focused on western parameters. The fact is that climate change really impacts the poor disproportionately, and it's going to make things very difficult for our jobs in the coming years. So I get very excited about new technologies with an alarming degree of regularity. I like to learn about new technologies, and I like to work on them, but I also like to have a sort of reality check on them because the fact is that despite this incredible wealth of technology that we have, we've really sort of failed to apply them to the most basic problems of poverty so far. And that's just to sort of bring into the picture here that this is not just about the innovation part. It's not just about the cool design that's made in the lab. It's about trying to figure out whether that product has value to the community where it's going. Try to engage the community into expressing whether or not that's something, instead of saying, we think you should be using this, bring it back into that loop. But it's also about commercialization. A lot of these technologies we have, and many of the technologies that you are sort of bumping around in your minds that you've seen, either as prototypes or as good examples, if you went back and checked on them, they haven't scaled. They're out there in very, very limited quantities. And I'll talk a little bit about why that is. But the best place to sort of check your hubris if you're working in international development is Sub-Saharan Africa. This is an incredible continent to be working in right now, because the innovation, the entrepreneurship that's going on here, it's drastically changed in the last 10 years. But the statistics I'm about to show you illustrate that even with the wealth of technology we have, and these are recent statistics, we've really failed to make a difference in the poverty there. 80% of the cultivated land in Sub-Saharan Africa is formed with a hand hoe. So we're talking about the technology of an oxen work. This is a good reality check for us in terms of how we're moving forward. 58% of Sub-Saharan Africans don't have access to electricity. 4% of the land is irrigated, 4% of the farmland. Even if we just solve the irrigation problem, even if we just come up and break that into some real numbers, we would make a huge difference in poverty. And 330 million that's, I think, over a third of Sub-Saharan Africans don't have access to clean water. So that's the reality check to say this is not just about innovating a really cool new technology. Getting these technologies into products and services that the poor will use, and getting them manufactured, and getting them distributed into these markets is a really big job that we have so far mostly failed. And the law and policy issues here are really at the center of these pieces. So this is a big question. How do we get global innovation and commercialization systems to deliver value to the poor? It's very centered around what the poor value and then it backs out the fact that it's both innovation and commercialization. And global access and action is about the law and policy issues that are involved in trying to figure out how to do this. So what I'm going to use the main part of this talk is to walk through three big trends that I think have really changed what's happening on the ground in innovation and commercialization. And to try to get across why the field right now is so far from providing really good practical, usable, innovative solutions. Because I'm hoping that the end of this will have a good conversation in here. Not only questions, but good ideas about where global access and action should be heading. This is a new program. It started at the World Economic Forum in their Global Agenda Councils and then comes just recently to Berkman to find a new home. So we're just in the process of designing it and it would be great to have collaborative input on trying to figure out where this should head. Any questions before I start talking about some of the big trends? Paul Pollock involved in any of this? Paul Pollock is a great mentor and friend and he certainly is very involved in the evolution of my thinking. He hasn't been involved in this particular project but Paul is the one who as I'm sure you know says if you haven't talked to 100 farmers then don't even try to think about a solution. And that's of course what part of this is about.  What is business that has to make money? Exactly. So yes, his ideas have been very great in this. What are the major impediments that you feel that are affecting the effective delivery of such technology and commercial systems? I think that question actually is going to come out. The answer to it may come out. It's a good question but if I don't cover it then pick it back up at the end. So these are the three topics that I think have changed so much. The geography of poverty has changed. So we're no longer at a time where poor people live in poor countries by their GDP, by their national GDP. That model is what we base a lot of our legal and policy analysis on on the nation state model of looking at the poor as separated by national boundaries. So I'll talk a little bit about that. The landscape of innovation has also changed. We need to move past the idea that things are invented and the innovators are in developed countries and all of our language of technology transfer and getting things into the south. It's not that that's not a huge source of the R&D engine but we're now looking at a much more complex picture of innovation. Innovation is happening in a lot of different places and particularly for these technologies. The last one is the biggest bubble because I think it's the biggest impact. The role of companies has changed and we all know that that's been a really big shift in that many companies are working on social and environmental activities in ways that they haven't been before. So I'll talk a little bit about the drivers there and where that may afford some opportunities and some new roles for us in the public sector. The geography of poverty right now this is an institute of development studies I think out of the UK. It reckons that four fifths of the population of those who live on under $2 a day live in middle income countries which is a pretty amazing statement. If you're used to dividing the world and saying well you can have the vaccines for these markets and here's the poor countries and you leave out something like India. You're leaving out huge numbers of the poor because India is both a commercial market as well as has incredible numbers of people under the poverty line. India will be the most populous country in the world shortly. 76% of Indians currently live under $2 a day. So that's where we are right now. Lots more poverty in emerging markets, lots more poverty in countries where there are this sort of dual commercial markets as well as large numbers of poor. There are some people who believe that this is a temporary a temporary shift and that if you look ahead to say 2030 we're going to be back at the point where an estimated two thirds of the population of the poor are going to be back in fragile states. That's mostly based on whether India can grow. Which I would say no one knows the answer. So what does this mean for us in this nexus that we're looking at and this technology poverty and law it means we have to come up with some better models. We can no longer look at the divisions and the ways that we've done licensing in the past for instance. Terry and I were talking last night about intra-country differential pricing. How do we figure out things like that? Because otherwise we're not going to be able to tackle some of these big problems. I think the other thing it says about our field right now is that we have to figure out how to work with the private sector. There's a lot more opportunities if the poor are in places that have commercial markets that are functioning to be able to work in that way. So the second major trend is that the landscape of innovation is changing. There's a Boston Consulting Group study out this year that says 28% of the top multinationals revenues come from emerging markets. So that's pretty well known that everybody is entering into these markets. What I find and I work with a lot of companies is that they're not only entering into the emerging markets, they're entering into low-income markets almost everywhere that I work companies are looking at Sub-Saharan Africa as a commercial market or as a pre-commercial market. So that's one trend that's happening. A second trend is this incredible growth of emerging market multinationals. So these are homegrown in emerging market economies and it's an entirely different trend. This is not the old school multinationals that we often think of in this field but there's incredible innovation happening there. And the reason why that trend is particularly important for us is because the emerging market multinationals really understand rural markets. They know how to deliver products, they know how to design products and deliver them in markets where there are lots of poor people. So it's a really critical piece that we're not, to my mind, we're not really making use of yet. So then these are not entirely in the BRIC countries. This is Thailand, Malaysia, South Korea just as an exercise.  The word is tractor. How many of you thought John Deere? Okay, the largest tractor company in the world is Mahindra and Mahindra out of India. So just an example that in every industry there are emerging market multinationals that are not as well known to us in terms of our sort of old understanding of who's producing what. So the last trend here I think is a little bit slower trend but I think that it's going to have a big impact and that is the tools for distributed innovation and manufacturing. We've all heard about the revolution in manufacturing and whether or not that actually gets translated practically into developing countries and the technologies that I work in I think remains to be seen but they're powerful tools. If we could actually make some of these work for the kinds of innovations that we need to get out there and these go from innovations in crowdfunding so new sources of funding for these it goes through innovations in prototyping which would be amazing to have closer local manufacturing so that's a trend that I think is slower but I also think it's coming and it would be interesting and important to integrate into this. So again that question of what does it mean for our field what are the what should we be paying attention to if innovations is going to tip and is already tipping into developing market economies and into developing countries and of course there's also a tremendous amount of innovation that's very valuable that happens within developing countries and within the communities and the markets that we want to serve which just hasn't scaled there's great products out there there's great ideas there's great innovations but they don't have the resources to scale and if we can change that then an area is in finance I think we need to figure out what is the legal and policy framework behind being able to get better financing to innovators in developing countries and innovators in emerging market economies but I think another piece is intellectual property rights when you have a new innovation to come up with a strategy for how it's going to be commercialized to get out there into a product so intellectual property rights in the informal economy is something that I think we haven't paid enough attention to so we tend to spend a lot of time looking at the formal tools and trying to bring up countries into the formal system I think we haven't done enough analysis of how things actually work already people protect their intellectual assets in lots of ways that don't have to do with the formal system particularly even things like trademarks I think have not really been explored well enough in their use in developing countries they're very powerful tools much more powerful I think than we give them credit for trade secrecy contractual arrangements there's lots of things that that's the way it works there so it would be really interesting I think to understand how to move that forward the last topic this last trend is the role of companies and understanding sort of what's driving companies to to work on more social and environmental activities is a semester's worth of lectures I think or possibly a library of books but I'm going to try to hit some of the highlights here just to sort of get you thinking about what if you're studying the legal aspects policy aspects here you're trying to figure out how you can at least in my world I'm trying to figure out how I can push companies to do better in these particularly in the technology and the access to technology field and so these are the drivers if this is what's making them work in these markets it's making them produce products and deliver them I want to know how I can lower the risks for them to be there how I can make sure that they're actually delivering something that has value to the poor and how you can create some incentives for them so I think that's a sort of new field where we need to be looking it's not happening right now the public sector largely it is changing but the public sector in this interface between law and technology and poverty has been pretty resistant to trying to figure out this public-private interface so go back to socially responsible investing this dates back to I think 1921 the pioneer group was the first mutual fund that decided to screen out alcohol, tobacco and gambling investments so this is a sort of very passive strategy but it's the first one that starts to link at least in my mind it's one of the first that starts to link social environmental activities with a value to the company so we're moving from the sort of world where corporate social responsibility is a marketing tool and it's it used to be mostly in the marketing environment of companies and we're moving to a place where it's actually integrated into the corporate strategy as adding value in particular ways so socially responsible investing was one of the first pieces to move in that direction last year more than 11% of managed assets in the United States could be called socially responsible investments so the growth has been massive and then you look at things like integrated reporting this is a movement to start figuring out great, you have your sustainability goals, how do you report on them how can you actually start measuring what a company does and pulling that sustainability report in from the marketing world into the mechanics of reporting for a company most stock exchanges have ESG, environmental, social and governance reporting requirements if you float your company on that these are interesting pieces that have been used in some ways in climate change I think the Dodd-Frank bill had an extractive mining disclosures for that field but they really haven't been used to push companies towards more in the access to technology sites and we haven't seen sort of an exploration of a lot of these drivers so that's some of what's going on on the big corporate side some of that was about public companies public companies I've learned are very different to deal with than private companies which should have been really obvious to me but it took me a while to figure out that there's an entirely different set of things you can and can't do with a public company and I think that there's a lot of really interesting points of law and policy that we could be using there the second piece I'd like to talk about is that there's a lot more financing available there's new sources of financing this in particular refers to the impact investing world still very small compared to the big the total assets that are out there but it's growing and it's an important player and it's taking on really interesting new forms in private equity and venture capital it's sort of moving out from it's started in the foundations and in program related investment we need to start figuring out those new sources of financing and there's a lot going on there but yeah comparisons in how much this financial sector liberalization of a particular government's policies with respect to capital controls capital flow outflows insurance markets secondary offerings derivatives and so forth how much of that matters in terms of the innovation that delivers down to poor we certainly know it matters in terms of just the emerging market attractiveness for corporations in general but how much of that matters and which of these types of financial sector regulatory policies should we be focusing on if we're I think that's a great question we don't know that's exactly the kind of question that this nexus should be asking because this stuff is happening and we should be trying to figure out I'm not saying that somewhere out there that and I haven't and I just haven't read it but it's true that we talk about those kinds of questions for a different sector of business for a different level of business but I don't think we brought it down to who's actually reaching into these markets with technologies that make a difference yeah so the financing piece I think is and both of those topics that I just talked about are on the investor and finance and there's a whole host of other reasons why companies are moving into these markets and this comes from you know the Porter and Kramer shared value literature but but what's interesting is that these are pieces that I see every week when I'm working with companies and those are expanding their markets as the first one obviously reaching into to these new markets is is not cheap though and so trying to figure out access to supply chains there's another and secure those trying to figure out brand equity to build value in their brand because there's a lot of assumptions that these markets are going to rise in income and this is particularly true in places like rural India but also honestly to this true in sub-Saharan Africa that are a lot of places where you wouldn't expect commercial expansion and they're there because of the brand equity issues they want their brand to be the trusted one when people start coming out of poverty into having some more disposable income there's also an interesting piece at least in the agriculture sector where it's become very hard to attract and retain talent that's one of the constraints to companies right now and operating in these markets ends up actually making your company more attractive and people are happier to stay there they're happier to come work for you so that's another these are all examples of you know how these drivers are actually adding value to companies on the input supply side of course companies are trying to secure as well as diversify where their inputs come from you've heard lots about this in the news in food for instance in cocoa most of the cocoa supply for the world comes from smallholder farmers so the big cocoa companies in the world that you look at every time you eat one of those chocolate bars they have a huge interest in getting better technology to smallholder cocoa farmers so there's a lot of crossover we're no longer in this sort of world where public sector is operating kind of in parallel to the private sector and you think about the way that we've typically or often think about technologies for the poor being invented in a university lab amazing new idea it comes out and non-profit maybe forms in the university or spins out and like non-profit tries to distribute it, tries to get it out there that's no longer the model which is good because that has a really hard time scaling we now have the chance to leverage a lot of innovation and commercialization capacity if we do it right and this is where a huge number of the legal and policy issues are so there's this sort of crossover now and it is not of course as simple that they were operating in parallel before but if you look at the public sector by the public sector I mean institutions that operate in the public interest so I include universities because they have a public interest mandate I include government I include foundations, aid agencies if you include that sector there's now this sort of crossover where there's a big piece maybe a small piece but it's a piece where their goals are aligned where the technology that I want to get out the product that I want to get out to the population that I want to serve actually has a crossover with having commercial interests and what's happening is this is changing the role of the public sector so I want to close with before I do some questions to get the discussion started is just a look at how that role of the public sector has changed because it's another example of sort of how far behind this field is and this is just sort of my hypothesis for what could be happening on this public-private interface but I think it's important in part because a lot of the legal and policy tools that we talk about are the public sector responding to market failures to what we think the market has failed and therefore it's our responsibility because we have the social goals, we have the environmental goals and we need to step in and try to correct it as best we can and this is true in intellectual property rights you think about compulsory license you think about patent pools but it's true across the boards and if the role of the public sector is changing then it fundamentally changes the kinds of legal tools that we need to be thinking about and the policy interventions that we're thinking about so there's four pieces to what my admittedly really simple analysis is for possible roles for the public sector the first is to identify where the heck these overlaps are because if you're spending money working in parallel trying to do the same thing that a company could be doing you're wasting money so to try to figure out where that overlap is because that's sort of much more smart spending of resources that are limited the second piece is to push the boundaries so the company of course operates on those boundaries as to what markets they'll go into as to what products or what services they'll deliver are based on risks and returns it's a very simple calculus if you can change those risks and returns and that's a really interesting place where the legal tools come in and where the policies come in and you can draw them into markets where they wouldn't otherwise be and get them to produce products that they wouldn't otherwise be producing I think there's an interesting lots of interesting pieces there the third part is to recognize where these other sources of financing are coming from and this is impact investing crowdfunding pay for success bonds there's just a whole host of things that are out there that are not your typical financing mechanisms and the public sector I think they need a lot of help on the legal and the policy side to really understand how to make these things work and how to compliment those sources of financing and the last one is after you've looked at this picture where are the pieces that the private sector is never going to go because there's a lot of those you often hear these sort of evangelists of how the private sector is the answer to poverty in certain areas will always be populations that are not served and products that are not created by companies because it just doesn't make sense for them, doesn't make commercial sense so it will always be a role for the public sector in getting better technology to the poor but if we can target that and use our resources smartly to understand that I think that's the important piece because at the end of the day as you can tell I identify as a public sector person coming out of universities and foundations and my work isn't driven by risks and returns thankfully my work is driven by the needs of these ladies and whether or not their kids are in better health and whether they have better access to education whether they don't go to bed hungry at night those are the things that the public sector and that I care about at the end of the day so that's my summary of these three drivers and hopefully I've painted a picture for you of just how far the real world is from some of the models that we see from some of the work that's going on at this nexus of poverty, technology and law and how many opportunities there are out there to really get involved in very practical ways I'm going to put up one more slide that has some ideas for research topics and these are mostly topics that I'm already working on and it would be great to hear at some point either today in this room or email me as we start to move this project forward at Berkman, it would be really great to hear sort of your responses and what you think are priorities for this kind of targeted project that we've just talked about so starting in the upper left hand we talked about emerging market multinationals so I won't go into that again but I think there's a lot of really interesting issues given how powerful they are as players and how well they could be serving some of these markets intellectual property rights in the informal economy also something that I'd be interested in and I'm already starting some work on I think there's a lot of interesting questions there the one at the bottom right we haven't really talked about much or at all which is access to data for the poor this seems to have pretty high affinity with Berkman there's a lot of issues here so it's sort of a different lecture I think one of them that I've worked on just to give you an example is genomics data in crop sciences the future of crop sciences is of course dependent on genomics and on the bioinformatics tools to process the data and how that interaction has changed over time between the public and the private sector and who owns what and what the partnerships look like is a really important piece of the puzzle because it fundamentally determines whether we can make the advances in the crops that poor people plant or whether this becomes that just the crops that developed countries need get access to that kind of data and those kinds of bioinformatics and that sort of question is paralleled in many many types of data across the board and the last one is this idea of looking back at the mechanisms that we typically think about when we think about intellectual property rights and poverty so these are patent pools, clearing houses compulsory licensing humanitarian use reservation of rights all of these tools that we've been talking about for a long time which hopefully by now you understand that my perspective is a lot of them are actually outdated and that we need a lot of new thinking in this place but what I've started and you'll see this in the first quarter of next year is a survey of these tools which doesn't go very deep into the should side of things but it does at least catalog what these tools are, where they're being used for instance and we don't have this anywhere in terms of the models that we use to get access to technology for the poor so if you wanted to go someplace and find out what patent pools are out there, it turns out that there's only a couple for all of the time that we spend writing about patent pools the impact of them has been tiny and there's been a lot of expense spent on negotiating the licenses for them, a lot of time has taken so this is just sort of a perspective to say you know, here's the set of tools we have and here's kind of that reality check on what's out there which I think is the first step is kind of rethinking what tools we really need to be talking about so that's the end having bent your ear for almost an hour it would be great to hear not only questions but also ideas for for like marks where what are the questions that are out there that we think haven't been looked at yet yeah yeah, so so you could actually look back to before the patent system started to how inventors used to protect their intellectual property rights and that difficulty of how do you share an intangible asset without giving it away and those still exist in a lot of places in the world where we don't have the rule of law up to the standards that we do in the formal system where the formal systems work but I think a lot of it has to do with trade secrecy which we haven't really explored as a tool just understanding how things function if you're an innovator in a village or in a small city in a developing country and there's no way even if you've got a patent the institutions aren't there so it doesn't have value to you so what do you do you build contractual relationships you use trade secrecy you invest in your brand so that you become someone that associates your company or your name with that so I think those are the kinds of tools and as I mentioned before I also think trademarks within that picture are a really under explored tool yeah so the question is that they're much cheaper are there and I think we should do some work and maybe it's been done but I don't think it's out there how could we make those more accessible rather than talking about the patent system which has such a long way to be accessible by the kinds of innovations are there other tools that we could make more accessible that would be cheaper yeah I was wondering if you can elaborate and I guess my question is also how we can help so that is in process in discussion great question it's what I am in town to try to start forming the first place to help is just email me with ideas we obviously have a really broad field that we're looking at and to get anything done we're going to need to be focused but I think we really want to find what the priorities are here at Berkman and so that's the first thing and the second thing is to watch this space because in the next few months you'll definitely see a strategy for moving forward yeah hello everyone sorry for coming late so I've been here for the past half an hour listening to you I've been kind of wondering if we'll be thinking along the same line but I should start by thanking just who I don't even know who sent me an email two days ago if I wasn't interested to come here to listen to this because a year ago I had a similar dream as you were just mentioning here about IPR and innovation in Africa I'm really from Sierra Leone most of what you said is actually me as if you knew what I was thinking almost a year ago so I actually helped to run an innovation competition being run by a US based organization here called Global Minimum so I had a project in Sierra Leone and apart from doing that work I'm also a law student in Sierra Leone West Africa and whenever we go to radio stations we go to press conferences people always say you run this innovation competition for high school kids to think of ideas how they could solve their community problems but have you ever thought of how you can think of having these ideas that these kids are coming up with because these are brilliant ideas they might end up having something that could be skilled and is there any protection for these ideas so I started thinking so yes I'm a law student by then I was just in my first year in law school so I had to call the the president of my board who happens also to be at the MIT and he is to Israel Union how can we help with such a thing right so I thought secondly that maybe because I'm a law student we don't have the legal framework in Sierra Leone to help these kids because I had to do research right so because of the numerous calls and complaints that we receive how can you protect the ideas of these kids after when they come up with this thing if they are scalable how can we protect them so I had to do some research when I did this research I found out that we don't have the legal framework they could encourage even if we work with this thing for years or 10 years into the competition there is no legal policy or framework that these kids or our competition could rely on to encourage more innovations and stuff like that so I talked to my president the president of the board and he had to link me with somebody who I've actually not met again but we had to have conversations right on email and who said they would help me to have like a guided research on IPR intellectual property right which was like something I'd always wanted so I had this like a framework I reached such objective which is just in line so when I've been here for the past half an hour listening to you it's like just in line email me to something that I can just share all of you may be on email so that you can see the idea the idea that I've been thinking of two years ago is just what you guys are just putting on the table now send it to me and I'll send it out to people who are interested something that I'm just so interested in great I'm so happy to be here today sorry you were next the emphasis the role of companies part your emphasis on socially responsible there are enough adaptations of existing technology and that sort of specific tools that the gap is really in funding I'm curious, I don't think that's what you mean so but impact investing I think maybe a lot of those investors would say the opportunity set that they're looking at is pretty limited so then that becomes circular how do you think about that and what are some sort of particular examples of adaptations that you like yeah so I mean it's a good because I wasn't suggesting that and I was more introducing it as one of the places where I think we haven't really used yet in the technology for poverty space that has been used more in the environmental and sustainability space that I think it would be interesting to explore what kinds of incentives does that need to happen if you're going to do this and not so much I think the venture capital where it's focused on for instance ICT I think that is happening in some ways but there's a different calculus of risk for financing companies that are technology that are going to produce technology for these markets so what does that mean for us looking at the environmental impacts which is often where we've seen it so I don't know what the answer is to your question but I mostly wanted to highlight it because I think it is it's one of the levers which we're not using right now even at the level of stock exchanges and reporting requirements straight down into impact investors and what do they need so I don't know what the answer is yet but I think it's a field that we just haven't especially when I talk to donors I think that because I talk about the technology side of things I find that they really don't they understand of course the innovative financial mechanisms side of things but not so much where it's trying to fund this kind of stuff so once I further identify a few of the types of new technologies that these new financial mechanisms could be applied to like your irrigation example or the pest control examples some of these that you mentioned have not scaled up but if advanced could be beneficial that would be helpful so Terry is referring to the Sproxel model which maybe some of you are familiar with this was developed to look at the counterfeit drug problem primarily in developing countries and it's basically on the packaging of pharmaceuticals there's a scratch card that's embedded in the packaging you then use your mobile phone to text in the number and it kicks back and answers to whether or not it's counterfeit so this particular piece was of such interest to the major pharmaceuticals because they do have a lot of counterfeit products that didn't have the financing problem or at least to my knowledge that it was a fairly easy one to launch and of course doesn't take a lot there's really interesting applications however in taking that out of the pharmaceutical and it's been used in many different areas it's been used to test whether electrical wire is counterfeit or not it's been used to test whether crop chemicals for crop protection are counterfeit or not so it's now that everyone has a mobile phone it's an interesting model I'm working on it to try to verify the adoption of a technology so right now we don't even know when a product gets to a low income household if you ask a donor yes you've funded this incredible amount of research into this new variety of seed they can't tell you how many people are growing that crop of how many poor people are growing it in their fields I think there's a lot of possibilities on this particular model but I think coming up with a sort of set of technologies that meet some of the requirements for scale some of them don't some of the technologies we look at in the US that look really cool and are sort of touted as having a big impact on poverty is unlikely to scale but I think we could do that and I think there are forums where connecting the investors to those but more importantly there's probably legal vehicles and legal questions in that investment space that would help to try to start negotiating those deals to try to understand where we're running up against particular types of risk are we running up against why aren't they investing in that is it just because they don't know the opportunities are out there or is it because of other reasons yeah I would like to share two points here identifying the local technology as you have stated there are some experiments going on in India I hope you must be knowing about Anil Gupta so in Indian Institute of Management we've been doing wonderful work on identifying local innovations and protecting them making it sustainable for the people and work for the poor there are two initiatives he has come out with one is the Honey Bee Network the other one is Shristi so the major work of this is that village to village they go and identify who are innovative and what are the technologies they operate with and they are trying to model it and sell it to people and also protect it by way of a simple registration type of thing and they're trying to protect it through policy initiatives but that is not happening so far but at the local level they're trying to protect the innovators and to replicate to the various other communities this is one thing happening thousands of innovations it's not one or two it's a big catalog available maybe I can share that information to you and others also the second thing is that when you were talking the leveraging the IP instruments work for the poor I think many people are thinking and writing for example, patents how it can work for and copyrights there are many initiatives like the open access and categorizing the IP that will work for poor creative commons initiatives because you yourself as an author you can open up that you can leave certain part of your copyright that can be free that can be shared that can be replicated I mean copied or modified whatever versions different versions instead of being too rigid one example is in this that the policy is being questioned here in India if anyone knows about the Delhi University copyrights case so now it is going on you know as you said that 76% of the people in India live less than two dollars and it is this huge population they need education and India is known for education they have a strong desire to go to universities and learn the higher education when they come to these universities they find it very difficult to get the books and resources how can you imagine that these people and for example I am coming from Delhi University 80% of people I know that they don't have any resource to buy the books and I in my whole life I studied based on the library books here it is the library books and most of the people they study by taking photocopies and the universities themselves they allow certain small photocopy operators to set up their own units within the university so that at the very cheap only the operating cost they will charge and they will make the photocopies and give it to the people and the students and these have been questioned by all the Oxford University Press, Cambridge University Press every university press stating that the university is conniving with the people, the photocopies and they are infringing the copyright this is going on and none other than Gopal, Gopal's surname is the lawyer who is fighting the case now yesterday was the argument which is going on in Delhi High Court so this is being questioned, so this is coming out like right to education versus IP after all the IP it is to promote the knowledge of the society as well as in the by back you also protect the rights but it should be it should be flexible and it should, the larger interest should not kill the the lesser interest should not kill the larger interest, isn't it this is what is being questioned, I think this is happening and this kind of a discussions should happen the same thing should happen in patents and trademarks I think all the instruments that we have so far developed and which are being operated now they were designed for different time, different age different situations but now we are in a different life I think now we need to rethink about it absolutely, I think in some ways that I understand your framing of the argument, another framing of it is a market segmentation that market segmentation that Terry and I were talking about in differential pricing for drugs actually has much more broad applications across a lot of different technologies so first off I work with a group convened under the International Center for Trade and Sustainable Development that is working in conjunction with the WTO to think about how we should be changing trade rules to better foster both sustainable development and trade and it is really assuring to hear you reach some of the same conclusions we haven't publicly stated but we have been discussing internally which is part of the problem is financing and there is a much bigger role being played by trade secrets that has been emphasized so we should definitely stay in touch with all of this. There is two points and comments that I wanted to make both in response to the conversation but also to an issue that we have been grappling with that I wanted to get your input on. One is this issue of access and where some of the problems are and so forth. Part of what we have been finding is that a lot of this comes down to distribution networks and that where the web and technologies and mobile technologies allow for circumventions of market failures along the distribution networks technology has been playing great gains but where you still rely upon physical goods to deliver those distribution networks these are often times public sector failures in terms of providing for those distribution networks as well as providing for in some states failed state security along those networks that the private sector is not going to choose to enter until those types of public sector failures get cured and some of these are issues of scale particularly within Sub-Saharan Africa in terms of innovation where we have been looking at, even if you look at the markets and growth that is coming out for the South from the poor, they have been largely coming out from large scale markets like India particularly but also China, Bangladesh and others to some extent that you just don't see the scale here within Africa to be able to deal with and so this partially comes down to the political configuration of Africa which we have no abilities to redress. I just wanted to point out, I think that's where we are seeing some of these issues and difficulties come into play. The other thing that I wanted to point out is a comment. Can I just make one comment? Just articulating that though changes the dialogue. It clarifies things trying to sort of map out all of the different pieces and some of them you just brought to the table I think shifts the dialogue away from a sort of black and white access issue into the reality which is really complex and changes technology by technology and country by country so I think it's valuable even if it's not something that we can necessarily do something about without a very long national policy process I still think there's value and sometimes we think about these as capability issues but really they're historical remnants of colonialism that are affecting certain market dynamics today and that's not something we have the it's within the bandwidth tools we can have so the second thing that I wanted to observe was that when it comes to technology solutions for the poor we're finding actually that there's a lot of funding but potentially more room for funding when you're talking about being able to provide a differentiated product that the quote unquote I mean I don't know how many of you here saw Elysium but those who live in the first world Elysium elites we have no desire for so for example I think a great success has been talking about solar solar power basic stoves that don't require you know they're using solar powering for stoves that for poor markets which aren't necessarily on the grid today but don't require this gathering of firewood which saves actually it's really gender positive because it saves women from having spent so many hours in the field to gather firewood and so forth right but that's something that none of us here in the first world ever seeks to purchase right this is primarily a southern solution for southern problems right and so this leads me to I think the observation or the conundrum the problem that we've been facing is if I can borrow a marker for a second is in certain goods like when you talk about textbooks or drugs or even say seeds right essentially from a more point of view we aren't saying the south should get an inferior product to the north right and then when you look at the cost curves for those or the demand curves right they look primarily like that sometimes with greater shifts out and so forth but where for the private sector actor the most efficient point to price is up here for this because this is where you reap the greatest amount of profits right and so for us I think what's been most difficult for us to grapple with is how to think about what's the right way to be thinking about IP models to address these types of cost curves because the types of IP solutions that are being proposed in academia patent pools creative comments and so on and so forth they don't work in this type of market because the private sector firm has an option of exit right and particularly within while we have differentiated jurisdictions of markets right so as long as they have the option of exit whatever types of creative solutions we come up with for that doesn't seem to work and one thing that we have seen work in parts of the developing world is if you're able to shift this cost curve through growth right as we've seen in China or as we've seen in India actually the pricing drops right because the efficient pricing these are rational actors the efficient pricing from where they can reap most profits would be to drop this such that access increases but it requires a shifting of the cost curve here right and that's for us has seemed that that's why we tie the trade innovation piece of it because trade is the part that's actually more responsible for shifting this curve than the IP part of it but the question that we've been grappling with is if we're not able to shift this curve because of public sector failures in many of these states right is there an IP solution around this given that what we thought about today hasn't seem to work so that's what we're grappling with I don't know if you have any additional thoughts or of the processing since so forth right compulsory licensing patent pools right on price funds and so forth whether anything right seems to work better or worse our sense is price funds in the like work very well when we're talking about southern solutions to southern problems right but when we're talking about non differentiated good or about I mean morally whether or not we want to introduce a differentiated product when there's truly leakages here right that can be had how we grapple with those types of problems but I just wanted to share that's a little bit some of where I think intellectually we're really grappling and searching for solutions I'd love to hear any additional thoughts that you have the answer is a fantastic question and it's exactly you know where this project is that that problem is exactly and there's of course five different sides to that problem that would require walking through so the answer is we should connect okay thank you very much thank you


I'm Adam Cranfield of Cal OES. This week, Governor Gavin Newsom proclaimed a state of emergency in 13 counties to support the ongoing response to recent winter storms. The governor has activated the State Operations Center to coordinate around-the-clock operations to protect Californians. California National Guard personnel from the highly specialized Joint Task Force Rattlesnake are now activated to help bring stranded residents to safety. In addition, Cal OES is working with local governments to provide resources to residents that are impacted by this winter weather, including warming centers, shelters, and other comfort items. As the storms continue to pass through our state, please follow these safety tips to keep yourself and your family safe. Avoid non-essential travel and heed advice from first responders. Do not drive or walk around barricades. Check in with your friends and neighbors who may need assistance. And sign up for County Alerts at CalAlerts.org. Please remain prepared as winter storms continue to impact much of California. Pack a go bag with important items for each member of your household, including pets, in case you're evacuated. In the instance, it's safer to stay home, add items to a stay box to prepare for at least three days without electricity. To see more from us, visit our website news.caloes.ca.gov and follow us on all our social media channels.


The study examined the incidence of interseception among infants in Canada before and after the introduction of rotavirus immunisation programmes, using data from the Canadian Institute for Health Information Discharge Abstract Database. The results showed that annual hospitalisation rates for interseception ranged from 20 to 30 per 100,000 infants, with no evidence of a trend over time. Interseception hospitalisation rates were highest in infants aged 4 to 8 months and lowest in those under 2 months or between 10 and less than 12 months. Males had higher rates than females both overall and within each age group. The rate of interseception hospitalisation after rotavirus vaccine programme introduction was 22.4, 95 per cent CI, 18.3, 27.4, compared to 23.4, 95 per cent CI, 21.5, 25.4, per 100,000 before programme introduction, indicating no significant change in rate after implementation of routine rotavirus immunisation programmes. This article was offered by Stephen Hawken, Bob Indoshan, Laura C. Rosella and others. We are article.tv, links in the description below.