Hello and welcome to the Arts Link Assembly 2021, Future Fellows. We're speaking to you directly from Lenapehokin, which is the unceded land of the Lenape people. And we wish to pay our respects to the elders of the indigenous population, both past, present and future, on whose land we are now occupying. As you know, the Arts Link Assembly is our annual meeting of transnational artists, curators and arts workers. And for this session, we're delighted to partner with the Virilis Centre for Art and Politics. And Karin Kourni, the director of the Virilis Centre, will introduce this session in an extended format. So, welcome. Thank you. Thank you very much, Simon. And thank you all very much for joining us. I do want to take a few minutes and just give you a bit of background about the Virilis Centre. The Boris Laurie Foundation Fellows and the program this afternoon. But I do want to start by thanking Simon and CEC Arts Link very much for the partnership. It's also been lovely and delightful to partner with the team at CEC Arts Link, in particular Maxine Tumanev, the program's manager. As we know in these times, it's both been challenging and also incredibly necessary to develop and deepen the partnership collaborations that we are able to celebrate with this particular program this afternoon. And it's been wonderful and rewarding to partner with CEC Arts Link and us, the Virilis Centre for Art and Politics, a platform for public scholarship at the new school on this program this afternoon. We've partnered with CEC Arts Link before. We were lucky to host one of the Fellows, Fatim Farhad, about two years ago. And this afternoon, we are really delighted to present to you, etc., the Virilis Centre's Boris Laurie Fellows, who will follow the distinguished cohort of the Arts Link's future Fellows. And I suspect we'll add a note of exuberance to proceedings that are both very serious and very urgent. Before they present responsibility and manifesto on equal side, let me share a word about the Boris Laurie Fellowship, because I think it matters the discussions that we've had over the last few days here, and I will then introduce all the speakers. The Boris Laurie Fellowship supports an artist or a group of artists whose approach to art making is distinct because they are fearless and bold, they are internationally committed and globally engaged, they situate themselves independently of the for-profit art world, and they have overcome political hardship. These were all qualities that distinguished the work of Boris Laurie, who passed away in 2008, was a Holocaust survivor and the founder of the No Art Movement in New York City. They are also qualities that we've witnessed in many of the Arts Link future Fellows. But a Fellowship that is named in honour of another artist also speaks of a historical lineage of artists or four artists, and that work is building on, and it acknowledges the work that we do, the fact that we are building on foundations that were laid by others before us. That kind of historical awareness that recognizes ancestors in order to break away from them distinguishes again many of the artists we've heard from earlier, but perhaps none more so than, etc., the inaugural Boris Laurie Fellows at the various centre. A word on, etc., the group was formed in 1997 in Buenos Aires. It is a multidisciplinary collective composed of visual artists, poets and performance artists, and it has been led since 2007 by co-founders Loretto Garingus Mann and Federico Zuckerfeld, and we'll hear from them in a moment. In 2005, there were also co-founders of the International Everest Movement, a global organization that proclaims error as a philosophy of life, and we'll return to that as well. They have participated in numerous exhibitions and biennials throughout the world, such as the biennial of Jakarta, Sao Paulo, Athens, Istanbul, and Taipei, and their work has been recognized among others by the Prince Claus Fund for its denouncement of human rights and environmental abuses through theatrical and poetic actions often exercised at great political and personal risk. Under the heading Neo-Extractivism, Protocols of Buen Vivir, Loretto Guesmann and Federico Zuckerfeld divided their four semester Boris Laurie Fellowship into four chapters, and we're thrilled to present you now chapter two entitled, Responsibility a Manifesto on Ecoside. Like the previous chapters, it is based on the indigenous concept of Buen Vivir, collecting existing and creating new protocols to protect the environment today, this afternoon with a particular focus on the notion of Ecoside. Ecoside, as you may know, refers to the mass damage and destruction of entire ecosystems. We will begin this afternoon with a presentation by J Bernstein, the university distinguished professor of philosophy at the New School for Social Research, who has in recent years focused some of his scholarship on Ecoside and is actually about to finish a manuscript for a new book entitled, of Ecoside and Human Rights. Bernstein is an expert in continental philosophy and the leading interpreter of the philosophy of Adorno. He's a co-editor of the journal Critical Horizon and has published numerous books, leading up to the one I just mentioned, among them the philosophy of the novel, Lucache Marxism and the dialectics of form, recovering ethical life, Jürgen Habermas and the future of critical theory, and the fate of art, aesthetic alienation from Kant to Derrida to Adorno. And I'm just quoting or reading a very brief excerpt from Professor Bernstein's faculty page on the New School website where he says, quote, philosophy for me means interrogating the foundations of our life together, how we make sense of the world and how we fail, how philosophy profiles the human as upright and as failing, as knowing and as blinded, as world making and as suffering, as flourishing and as dying, and how those competing images are bound together in our morals, politics, ordinary life and art, end of quote. After Professor Bernstein's expose, we'll hear from etc. in an exchange with performance artist and scholar Larry Bogat, who specializes in humor, imagination and theatrics in progressive movement activism. A professor of political performance at the University of California Davis and the co-founder of the clandestine insurgent rebel clown army, Professor Bogat also is the author of several books, and among them are Electoral Guerrilla Theater, Radical Ridicule and Social Movements, Tactical Performance, The Theory and Practice of Serious Play, and Performing Truth, Works of Radical Memory for Times of Social Amnesia. Professor Bogat is the recipient of the Guggenheim Foundation Fellowship. He was also the Art and Controversy Fellow at Carnegie Mellon, as well as the Humanities and Political Conflict Fellow at Arizona State University and has performed and led workshops in mischievous activist pranks internationally, most recently in Brazil, Chile, Latvia, Spain and of course Argentina. I'd like to thank the founders for the Boris Lurie Fellowship, they are the Boris Lurie Art Foundation, as well as the Schena and Josefina Lurie Memorial Foundation. Our work at the Verlis Center is also made possible by the Borla Verlis Center and the New School, as well as by our tremendously resourceful and accomplished staff and I'd like to single out Cure the Areola Pira, who has really been instrumental in organizing this event this afternoon. But our indebtedness goes further. At this point I'd also like to acknowledge, following Simon's lead, that in New York in this lovely room, floating high above Rockefeller Center in Manhattan, we are in fact leading on land, that is not ours, but unceded territory of the Lenape people and other indigenous peoples. Bearing this debt in mind, I think will be helpful as we now listen to etc. and their proposals for when they'll be here. First however, I welcome Jay Bernstein and look forward to his talk. Thank you Karen, thank you for inviting me. I am more than honored to be performing with etc. They share my passion for the problem of ecocide and the need for us to think together about it. So what I want to do in my small talk is introduce you to the concept of ecocide. Some of the background, some of the ways in which it has been formed. Ecocide is mass damage and destruction of ecosystems, severe harm to nature which is widespread or long term. Now rather remarkably and fitting for this occasion, in June of this year, a panel of 12 lawyers from around the world, sponsored by the Stop Ecocide Foundation, proposed a new definition of ecocide as a fifth crime against peace. We should think of this proposal as a response to what has happened at the Glasgow Climate Summit. Nothing. I want to quote and quote accurately Greta Thunberg. What has happened is blah, blah, blah. You recall of course after documenting that carbon emissions are on the track to rise by 16% by 2030, according to the UN, and rather than fall by half, which is the cut needed to keep global heating, under the international agreed limit of 1.5 degrees centigrade, Thunberg said, build back better, blah, blah, blah. We need economy, blah, blah, blah. Net zero by 2050, blah, blah, blah. She said all this in Milan about a month ago. This is all she said we hear from our so-called leaders. Words that sound great, but so far have not led to action. Words and ambitions drown in their empty promises. The notion of ecocide is meant to be action rather than the promises of statesmen. The idea of adding it to the crimes against peace would be to say that it would become one of the core international crimes. They now are genocide, war crimes, crimes against humanity, the crime of aggression. Those crimes are ones dealt with by the International Criminal Court, and you should know by the way that the criminal court has only been functioning since 2002, which is to say the very idea of international crime of a serious kind is still new, still being born. Here, and I want its only 168 words, is the new proposal and we deserve to hear it in its full. For the purpose of this statute, ecocide means unlawful or wanton acts committed with knowledge that there is a substantial likelihood of severe and either widespread or long-term damage to the environment being caused by those acts. And because these are lawyers talking to other lawyers and judges, they go ahead and define all their terms. For our purposes, just the first two will do. It is rare that one hears the word wanton in a legal setting, but wanton is what's at stake here. Wanton means with reckless disregard for damage, which would be clearly excessive in relation to the social and economic benefits anticipated. That means we're talking about anticipation, proportion. What's happening to the earth is out of all proportion. And severe means damage which involves very serious adverse changes, disruption or harm to any element of the environment, including grave impacts on human life or natural cultural or economic resources. Where did this concept come from? Where did the idea of ecocide come from? In fact, it emerged out of the war in Vietnam. The United States was trying to get rid of the Viet Cong and they could not find them. They were hiding in the forests and jungles. So what did the United States do? Blew away the jungles, flattened them. Ecocide was a military tactic using Agent Orange and Blanket Bombing. More than 12% of Vietnam's land area was decimated. In response to this horror, a group of scientists at Yale, led by Arthur Goldspin, proposed a new idea. The idea of ecocide. And as far as we know, Goldspin coined the term. This is his words as he was announcing this at a meeting. After the end of World War II and as a result of the Nuremberg trials, we justly condemned willful destruction of an entire people and its culture, calling this crime against humanity genocide. So genocide is the model. It seems to me that the willful and permanent destruction of environment which a people can live in a manner of their own choosing, ought similarly to be considered as a crime against humanity. To be designated by the term, ecocide. I believe this is still Goldspin, 1970, that the most highly developed nations have already committed autoecocide. I'll come back to that in a moment. Over large parts of their own countries, at the present time, the United States stands alone as possibly having committed ecocide against another country, Vietnam, through its massive use of chemical defolians and herbicides. The United Nations would appear to be an appropriate body for the formulation of a proposal against ecocide. In referring to autoecocide, Goldspin was in fact referring to Rachel Carson's claim that the use of pesticides in the United States should be called biocide. The killing of life. What Goldspin did not anticipate. He thought there was a military reason for banning ecocide. What he did not know at the time was that there would be ever new forms of autoecocide of what, etc., uses as the term, terroricide that have become industrial capitalist form of life over the last 50 years. So I want to make a proposal about the nature of why there should be an ecocide convention now. And here is the almost irresistible hypothesis. Liberal capitalism has become an ecocidal, a terracidal form of life. Now that's a huge claim. It's a huge claim to claim that our form of life is ecocidal. And in order to give you some sense of how this comes about, why I am making this immense claim that there should not be narrow law, that this is a critique of a form of life, we need, as we often do in understanding things, to put in some background. And indeed, we need to say that there is a tale that like all good stories begins a long, long time ago. And like all good stories, it begins once upon a time. Well, once upon a time, and I can actually give you a date, 11,700 years ago, a new geological epoch arrived. The hollow scene, the new hole. And the hollow scene was remarkable because before the Pleistocene, it was disaster for everyone. Ice ages and then warming and then ice ages. Nothing good could happen in the Pleistocene. But suddenly, the hollow scene brought a temperate climate, a moderately warm and relatively stable set of climate conditions that enabled the biosphere, enabled living nature and its ecosystems to develop these resilient forms of flourishing. And when this happened, suddenly human beings thought, hey, we don't have to chase the animals, we don't have to chase the weather, we can sit still. We can farm. So the hollow scene's moderate conditions enabled human living to be transformed from hunting and gathering to agriculture. And agriculture, this is kind of surprising, but it begins only about 8,000 years ago. It's really relatively recent that we settled down. And of course, this involved a domestication of plants and animals, and it really takes off. Agriculture leads to the emergence of cities. Suddenly you can feed people who don't have to raise their own food. And all the accomplishments of civilization. So here's the first thing I want to underline, that all of human civilization is or has been hollow scene civilization, that it's the hollow scene that made it possible. So that we misunderstand everything that is deep and important about human civilization. If we do not understand how it has been dependent on this bounteous munificence of nature, nature's continual power of procreation that we in the global north have taken for granted, we misunderstand everything if we think that's what nature is. It's not what nature is. It's a small time slice of nature. A little bit of nature that began just a few thousand years ago. 11,700 if you're counting. Which is to say everything we have taken for granted is about historical nature. Nature is not eternal. It's historical. Historical, historical nature is the hollow scene. And that is what we have destroyed. The cost of progress has been immense. And we see it beginning in the industrial age. That's a picture of Manchester already invisible in the mist. And then things really change at the moment. And again, we give a date to it. This is the date of the beginning of the Anthropocene. It's 1950. And if you look at this series of charts, they have what is called the shape of a hockey stick. That is level for a long time and then it zips up. And everything arises at the same moment in 1950. So what happens in 1950 is that world population grows. But so does industry, paper production, water use, energy use. And then all the bad things happen too. CO2 in the atmosphere. The oceans acidifying. The surface temperature rising. The ozone growing. The methane growing in the atmosphere. The more land is taken over. The forests are destroyed. All that begins just 70 years ago. What began 70 years ago was what we now call the Anthropocene. So industrial capitalism has been ecological in the literal sense. It has destroyed the natural bounty of Holocene nature. So the Anthropocene arrives with fossil fuels and coal and oil burning, which has led to CO2 rising from pre-industrial level of 280 parts per million to now 420 parts per million, which is the highest for 11 million years. This, of course, is what generates global warming, because CO2 prevents the heat going back into the atmosphere. The density of particles stops the heat exiting. And of course with that, we get fires. We get ecocidal flooding. We get the Anthropocene ecocide. We get the current rate of extinction of species which is estimated at 100 to 1,000 times higher than the natural background extinction rates. We are in the midst of a sixth mass extinction. I mourn the Costa Rican golden frog gone forever. I mourn the other species that we will never know. But it's ecocide. It's deforestation, air pollution. It's oil spill pollution. This is pictures from the disaster in the Gulf of Mexico, the Deepwater Horizon oil spill. It's plastic pollution that is destroying our oceans. The United Nations Ocean Conference has estimated that the oceans might contain more weight in plastics than fish by the year 2050, and that might not be reversible. Ecocide produces eutrophication. This is too much nutrient spill-offs from fertilizer in the water and what happens is the dying off of fish. Ecocide includes mining and mountaintop removal. Citizens who have undergone these things have said it's like living in a war zone. But look at the pictures. A world without life. A world without life. Ecocide generates industrial agriculture which destroys the soil, destroys the animals, and destroys every bit of nature as we know it. So my thought is simply this. Here's my hypothesis. Is there really any doubt that industrial capitalism has been ecocidal? We are now facing a triple planetary crisis. Climate change, biodiversity loss, pollution and waste. All leading to the destruction of viable habitats everywhere and as the Glasgow climate summit showed. Blah, blah. What is necessary now, what all sane people on the earth know is we need an ecocide convention. We need the idea of ecocide to be on everyone's lips. We need a message that can say you are killing the earth. This is not a matter of managing some bad practices. This is a stopping of a continuous killing of living nature. And to make it a convention with trying to send a message to corporations and states, enough, enough, enough. Now, law is a powerful, powerful tool. But law is only as good as the politics that support it. It is only as good as the politics that demand it. And it is only through activist radical politics of protest against ecocide that we'll let a truly earth conscience arise. A conscience of and for living nature that would make ecocide become visible as the crime it is. It is this that, etc., fights for. And it is this you will see majestically in the video you are about to witness. Thank you. My name is Yampingen. I am from Inche. I am from the Piliamahuista. I come from Puell-Wilimapu. I come from Puell-Wilimapu, which is what is called Patagonia Argentina. From the south center of Patagonia Argentina, I am from the Piliamahuista Mapuche. And also founder and member of the movement of indigenous women for the good of living in Argentina. I came from a walk that I started doing in 2013. I was traveling all over the country, literally walking. Sometimes I knew. I came to different territories in conflict and I met with women. I wanted to be able to generate the first march of indigenous women for the good of living. I never thought that I would derive this in a great movement. I only thought that we would make a march that would bring visibility to our existence and to our demands that were secular in relation to the men of our people. So we organized 36 nations and we went out to march. The walk was against terrorism. We had a consensus that while we did not have justice for them, there would be no peace. They are generating terrorism. This word, terrorism, had emerged from a meeting of all of us, the sisters. We talked about sisters because we said that we were human, that we came out of the same uterus. So there is a brotherhood. The word companion does not identify us, but sisters. And they reflected in all those stories of pain, many elements that are directly linked to the colonization. So we say that not only is it perpetrated in the way of killing the ecosystems, not only is there feminicide or feminicide, there is also the murder of a way of understanding life differently, that epistemicity. We are fighting to preserve our spirituality. We find this word that synthesizes terrorism. It is the synthesis of the ways in which the system has built hostilities for death. Obviously we want to treat that the totality of the populations, the people of the world can accompany the demand that terrorism be considered a crime of that nature. But at the same time we are aware that the national states are the protagonists of terrorism. And above all we ask that terrorism be applied to the governments, the government of terrorism, as well as the terrorist companies can be judged and condemned. We believe that this will not happen easily, because both the states and the transnational states, that in the end the governments in the world respond to that multinational corporacy that operates in the territories, will not allow it to be approved by a legal instrument that condemns them, that limits them, that allows the people of the world to observe, judge and condemn. So we believe that on the one hand we have to implement it as an agenda and also to walk in other alternative ways of justice from the people for a truly emancipatory path. So we would say a strategy of visibility, of recovery, also of our right to decide what are crimes and what not and also to explore our propositive capacity to build alternative or not only legal tools but also of social condemnation. For example, in the case of companies, they are enabled in a definitive way to operate in the territories, that is to say that once such a company has been bought, it has caused ecocide, it has also caused, because it is related, because the most important thing about terrorism is the ensemble of life that the terrorism is exposed to, the ecocides, the epistemicides, everything, everything is part of a mega-great project that is the extractivism. Let's do a little more context of how it's structured this way. Now, first of all, I would say thanks for Meravis Foundation, for all the people that is organizing this event, for CEC, it's like that, Erling's, also to bring us here. I want to thank also Moira Mian, who was super kind to give us that fantastic interview that we are showing in a little version. And to you two to come here, and now Federico can answer the first question. Thank you. And to all of you for being here inside doors. Well, thank you, Larry, thank you very much. Yes, it's a pleasure to share this moment with you, since we know each other for a long time, and doing it here in New York City, you know, finally. So, well, yes, I mean, to introduce a little bit the program, the concept, the general concept of this program, when we started, I mean, to imagine this proposal for the Boring Glory, Verali Center Fellowship. The first idea was to try to establish a global dialogue, but especially from the south to the north, and vice versa.  Even if we come from Argentina, she's from Chile, I'm from Argentina, one of the epicenters of Ecoside. For us, it was important to divide the project, the research in different chapters, to go through the topics, the most important topic we found for this, which are the neo-extractivist model, extractivism, not extra-activism, but extractivism, the policies of extraction, which include not only the mining, but as well the uses of GMO, and well, all but she detailed it very well in the fantastic presentation he did. So, basically we're coming from a background of making art not only in the institutions, but in the street, in the protest, related to the social movements, and for a long time we were close to movement of human rights. So, time ago we started a kind of shortening from the human right to the rights of the nature and other species. So, just two or three or four topics. And I mean, you have, like, this is chapter two, and there's different, what are the other chapters? Like, how is this going, what's the shape of this now? Yes, the first chapter, it was about a viewer to understand what is the term of neo-extractivism, which is a new term that was developed in the south of South America, because we know, everybody knows what is coming, this extractivist term, even all the colonization of South America and Africa, is coming because extractivist reasons and capitalist system is coming from extractivists, from miners in Potosi, in Boliviano. So, but we really wanted to understand how was this new process of extractivism that arrived 10 years or more than 10 years ago, again, to the south, to the southern countries. We wanted to understand also which companies were part of this new process of extraction and which countries or states are also part of this new way of extraction and why in our territories it's so easy to go and start to exploit. Things that in several countries, like European countries, are impossible to exploit, like fracking or certain kind of mining and things like that. So, we did a long-term research before the Betalist Fellowship about the extractivist model, but we wanted to introduce our research in Betalist starting with this term of neo-stractivism. So, we invite Eduardo Budinas, which is an Uruguayan theorist, environmentalist too, and he's one of the, there are a lot of other South American theories that introduce this term, which is very interesting because it's a concept that involves policies of extractivism, but not only thinking in this kind of right-wing capitalist government, it's also involved in this new progressist government that needs to be involved in these extraction policies because the deep crisis economic crisis is had and deaths with FMI and international banks and things like that. So, we create the first chapter about neo-stractivist, the second chapter is Ecoside, and the third chapter is about when we build, which is a concept that for us it was important to introduce because it's a long-term discussion in our countries about which kind of system could exist after capitalist system or after this hyper-developed societies exist in our country and how we can create some kind of balance, how humanity can live in balance with other beings and also how humanity can be in balance, live in balance, or the societies can build economically and culturally in balance with the nature. So, basically there are the three chapters and the final chapter will be the next year, around May and we expect to finish this process with some kind of final result of everything in different forms like intervention, exhibition, performance, so the three chapters are the first, neo-stractivism, second, Ecoside, which are the consequence and when we build as a kind of potential solution. I do because we really wanted to talk about the use of the body in this resistance because of course we are coming from the performative art and what we realize why we also engage as an artist was not only because we feel really told by the history of the mothers of Baruito Sango who were resisting Monsanto in Argentina in a time, but for us it was how this resistance against Ecoside, against extractivism, it's really a resistance that needs to have the body in the territories. To resist Monsanto plans, the people have to be there in the body and we really discovered that it was huge social, environmental imagination growing in these struggles that are in different points in Latin America, but also here in America too. So, we invite you because we know that you were involved in... in the heart of the empire, where it's an interesting relationship as we have a dialogue between north and south. These questions is of course the climate disaster doesn't have boundaries. It's for everybody to enjoy the destruction. And then here we are in the heart of the empire where a lot of these headquarters of these corporations are. So, it's a problem and it's an opportunity to go to their headquarters and do creative things. And I think that's been interesting. Taking leads, I think the social movements have been inspired by the south and by your work and other people's work here in the north for years and decades have taken the inspiration, the lead from the south and then said, oh wow, we better catch up and start doing things. And here of course there's incredible performances happening based in the north. And I refer in this case to the performance of corporations to infuse the conversation around climate disaster or climate science or the reality that we can feel on our own skin as the climate becomes more unstable. They're still sowing seeds of doubt with cultural work. I would call it cultural work that the corporations do. So maybe you can tell us and to the audience which kind of experiments or strategies or tactics you will find interesting in order to fight this. I mean, it's similar to work done around the world, but here it's an attempt to use what I would refer to as tactical performance. And so this can include blockades, but creative blockades, creative campaigns that are sort of mediogenic pranks or actions. And I have an example that's very high tech here. You know, like this is an action that I participated in outside of the world headquarters of Wells Fargo. And of course Wells Fargo is a major investment bank and they're invested very much in fossil fuels, etc. I have to watch when I say etc. because I'm referring to you now. But this is an example. So I've worked with people blockading the headquarters. And of course you want to fairly represent the perspective of the CEO of the company if he's not nice enough to come to your protest to talk. And he didn't come. So I spoke up and if we can get a little close up of here, I showed up at the protest with something that looked more or less like this. This is an explanation speaking on behalf of Wells Fargo at the demonstration. And as you can see their fossil fuels plan, they're tracking how fires are going up. This is a very sophisticated chart. Of course floods are going up. We can see that profits are going up. There's a problem. Popular rebellions are also going up. So what is the plan? Of course is your question. You've got our money. It's driving profits. All of these things are happening. But what's the long-term investment plan for this corporation? You'd want to know. And I'm glad you asked because we have an answer here. And of course there's a very large spaceship that the CEOs are going to go on fueled by the money. And it's the ship is going to planet B. A lot of people say there is no planet B, but no, there is one. And the CEO is planning to go there. And we understand that the sort of the sun sets on the beaches on the methane oceans are just spectacular. So we're looking forward to that.  And that's a fair question. And of course this is a paper point presentation, by the way. This is very high tech, high budget sponsored by Wells Fargo.  You can choose between those two fates. This is the kind of presentation you would do at a demonstration to entertain people who are blocking the door in the cold for hours and hours. You want to make them laugh a little bit, obviously. Make a point, maybe passersby get an idea what's happening. Maybe it's a little bit menogetic. You earn a little media. Do you mind if I do this one more real quick? This is fascinating. This was, so my first day, I go by El Embo Gad for whatever reason of my life. But, you know, I go by Larry Thunberg. And this is the kind of thing I'm doing in my Guggenheim Fellowship, by the way. So the project I'm doing is called Disastrous Theatrics, Cultural Conflict and Climate Change. And so this is another example of very dignified work. BlackRock has a wonderful headquarters here in New York. And during their annual shareholder meeting a few years ago, you know, that CEO's name is Larry. You can look that up and mine is too. So I just stood outside in a nicer suit than what I'm wearing now. As Larry, not lying technically. And me and my besuited colleagues were giving out an improved version of the shareholder statement. As Larry giving it to people saying, ask questions inside. I just had a brainstorm. This is the actual text of the thing they were getting. We gave it to all the shareholders as if we were really them.  Do you know what I mean? Like this is, he's just thinking about it rationally. And we gave this out to everyone going in and said, please ask questions inside. But inspired by examples of work like yours, of course, we had indigenous activists in the shareholders meeting using shareholders proxies that they legally had to ask the serious questions. We disrupted with this kind of playful intervention and then opened it up for the, I would say, the smart people inside to cause the serious trouble inside. So this is the kind of action we're trying to do to leverage. It's almost like the performance is a crowbar. We don't have that much force to change policy. So we try to use this kind of action as a little bit of a conceptual crowbar to force an opening, you know, that kind of thing. So which actually leads me to ask you all a question because I watched the videos before and I watched them. Matt, I really love the work you're doing. And I saw your, and I just think this is interesting. I know of your work in human rights, of course, and after the repression in South America. And I followed that. And then I'm seeing you dressed as a corn, which I think is really interesting. And speaking to the Mapuche woman activist, and we talked a little bit about your shift there to environmental concerns. And I'm wondering, is there any, you were starting to talk about that evolution. And I don't know if you had anything else to say about that evolution. You were beginning to talk about it. It was a counter-revolution. No. Well, yes, I don't know. You want to go first? No, I'm not going to go first. Well, I mean, we can choose carrots, potatoes, but corn. Right. Argentina is a big exporter of corn. It's, I mean, but of course when, I mean, the first time we started to, we discovered how to feel, how to be a corn. It was a strange, strange sensation. Because, well, at the early beginning, we understood that, of course, transgenic food in Argentina was growing a lot. And as you saw in the video, the power of Monsanto, today buyer, no, buyer company was so big. And then, well, it was a time when, when we were traveling around the world like we did before COVID.  And, okay, we were in a talk about farming and farmers and agriculture and so on. And they say, okay, are you from Argentina? We are from Argentina. What we are doing here in Germany, in Castle, in Documenta, we are artists. They are not. But they say, okay, we are here. So when they start to tell us about the disaster, I mean, we felt very ignorant. It's our own country, the province of Córdoba, not so far away from Buenos Aires. But we are in the town, in the city, and at that time we didn't got that the Monsanto spying of glyphosate, I mean, the combination, which is called random, random technology, is the seed plus the poison. So this is a full package, they send you everything. And you have to renew, you have to pay every single year to have the seeds, no? You cannot distribute like before. So that was something we know from the political and economical point of view. But we never expect such damage in the health and nature. For example, Sofia Gatica, one of those women, she told us that, of course, she had problems in the family because the spying was through the water and the air and everything and the family started to get sick, the sun and then the ice and so on. So then we understood that it's a problem of human rights, no? Because it's a violation of the right of the people to exist and to live. But with the pretext or the reason of the economically make increasing the economy of the country, no? Save the problems of the country, the debt, no? How? By producing more transgenic food and commodities. The best exportation. It's not to feed our people. No, it's to export. So then magically we become... No, then we... It's possible, everything. We were talking to them and said, okay, when you go to Buenos Aires, when you're all there, we should make an appointment and come to Córdoba, don't stay in Buenos Aires, come to see with your eyes and maybe you can help us. But in that time we were human beings, did not come. But then, of course, we asked them, what can we do? We are running a festival which is Primavera sin Monsanto, Spring Time Without Monsanto. Just to... In order to make Monsanto factory, was one of the first factories producing transgenic seeds, go out from Argentina. For that was very ambitious. Like, sounds like impossible, but it happens at the end. So they start to make blockades and protest in front of the company. The company didn't pay attention, but they streamed the methodology of making, putting the body directly in the highway and cutting the highway and so on. Had problems with the police and was a little bit criminalized also by the mass media because in the mainstream media they say, the only way to recover the economy of Argentina is produce and sell our commodities. So, why do you want Monsanto to go out? It's the logic of neoliberal. And the people from the old town, when we went to the protest, many people was against the protest because they said, I need to keep my shop. Can you imagine what? So then they say, okay, but you are an artist, so maybe you can help us with the children's. I don't know why they say that, because we have a lot of children from their family and during the festival we need to do something with them. So keep them, make some entertainment, entertaining, you know, another industry. Specifically contemporary art. So then we say how we can keep the kids playing or doing something where we make demonstrations and so on. So that was the moment when we decided to make the costumes and the first experiment was not with ourselves, it was with the kids. Very nice. Infantry, the army is composed of infantry. So always in the first line, we made some kind of competition place for the kids. So someone will dress in this white stuff throwing poison in and the other one will be the corn poisoning. So it was very funny because in the beginning when we asked the kids, okay, which kind of costume do you want to use? Like which team do you want to use? All of them, they want to be the poison. They want to be the background. Then it was one of them without dress because it was more kids than the costume. So he had to be the corn and he arrived there and he saw Federico dresses as corn with very nice sunglasses, like ribbons and sunglasses. And he was like, he's cool. I will be the only corn. And then all the kids, because he said I will be the only corn, become corn. And nobody want to be the Fusato stuff. So it was very funny. It was a very nice experience. Then he was to teach or to be... How do you say this? Didactical. Didactic. But at the end we... It was easier than we expected because at the beginning no one wanted to be corn and at the end... Corn was cool. Corn is cool but the problem is it's a transient corn or not. We don't know that yet. But what we really understood with the corn costumes is that for example now there is a big movement of farmers that they are doing amazing since they are in Argentina it's a huge movement of farmers that are changing completely the culture in a very good way and also they are really changing the structure in urban cities. We eat organic food because they are really teaching also this industry of organic and bio because they are saying to be bio and to have organic food you don't need to be expensive. So they are doing it in a very social and popular way, in a super good way. So they intervene sometimes the big main train stations where the worker class go into the city and they give in a very, very cheap prices this organic amazing food they are doing and they are doing also medicine, something like that. So they asked us, they saw us we interviewed them for the first chapter and they saw the corn dresses and they asked, okay can we have two of these dresses? We said of course we give our corn costumes and they started to use in their demonstration. So now they call us, can we have more? And one of the things that we realize in this relation between how to develop change also in a symbolical way I don't know if you saw in the interview of Moira Millan she talk about this terricide as also as a kind of way of killing other ways of thinking to talk about epistemicidio epistemicidio epistemicide epistemicide So what we are discovering with these dresses of corn which are very funny and very bad done very bad done is that when you use that you immediately became a corn and the people love you especially in South America imagine also in other countries like Turkey it will be the same because the corn is so important for our culture and even it's so important for the people that came from native nations because the corn in the big part of the history of South America and I think North America too it was the beginning of the humanity it's not like actually to come from corn and we discovered that dresses are amazing and they are super cool super cool it's very trendy now don't call them but maybe they will appear that's right they might very well don't call them because maybe is that foreshadowing and I want to ask you something about that I like a lot but I want you to kind of get into it I've heard you refer to John Cage and this idea of responsibility as was the responsibility responsibility and then I'm like well why are you so interested in this like postmodern artist composer how does that connect with your ideas of resistance and creative resistance well at the early beginning we were trying to keep in silent for 4 minutes 33 seconds as a quotation of John Cage but we will make the people so boring and this is like streaming and people is in 4 minutes 33 seconds of silence so then we understood that in by the way it's also really hard for us to say quiet for that long I don't think we can do it no well we I mean the need of be able to respond the responsibility we have to play in that way and when we saw that John Cage used this concept time ago it's also really important in contemporary art to quote a bit the fetish of the footnote in 1957 he chose to use this word shifting the emphasis from an ethic of accountability to an aesthetic of engagement that is the full quotation and we understood that yes what's mean an aesthetic of engagement perhaps is what we are doing I think of accountability what we described it before so we thought that perhaps the only way to make this manifesto alive is talking about who have the responsibility and who is able to respond I think that's great because there's such a talk about how we're individually responsible and that's a game that's the game that the corporations are playing I think we can go over and be responsible if I can you're going to have a little moment now as change occurs you all look fine here tonight that was a great presentation thank you sir who is responsible if we all recycle every day that's fabulous and of course the US military is the biggest polluter in the world if we don't change that we can recycle all we want I mean recycle I'm not trying to be obnoxious I'm also vamping for time for the transformation that's occurring thank you thank you flanked by corn oh yes you tell us how we look composition some question from the audience there around the world manifesto sobre el ecosidio the responsibility eco side manifesto 1 el ecosidio es un crimen contra la naturaleza de la tierra perpetuado por un grupo de humanos pero no por toda la humanidad eco side is a crime against the earth committed by certain specific humans and not by all of human kind produced by multinationals we individual people on the earth do not expect responsibility for the socio environmental damage caused by the multinational corporations 3 to counteract colonial violence of neo extractivism actions will emerge with response ability and socio environmental imagination our collective seeds will germinate buen vivir the right way of living sustainable living our bodies will be the stones through which water is filtered nature is not wrong it defends itself and transforms itself 7 we can start now by saying the specific names of the specific perpetrators Basf Bayer Monsanto Unilever Gazprom National Iranian Oil Total Petro Brass Abu Dhabi Oil Petro China Saudi Armaco Pemex Chevron Tex Petroil Pine American Energy Halliburton BBB Shell Baker Hughes and Slobberberg Barry Gold Pan American Silver Shell Monsanto the concluding event of the CC Arts Link Assembly the concluding event of the CC Arts Link Assembly it might be lovely just to reflect for a few minutes and then we must bid you goodbye on these different kinds of discourses that we witness just now and I thought it was really, really poignant how every presenter this afternoon was so efficient and so effective and had so much to say in their own voice and their own language and starting with UJ, it was an absolutely superb manifesto in itself, you know, for what needs to be done, and then this soft transition thanks to you, Larry, from one professor to the next, and then to the artist. So I'd like to hear from you maybe even just close the remarks. What does it feel like for you to come at the end of any of presentations as we've witnessed and be the artists, you know, who dress up in corn, a costume that, you know, first the kids modeled, and have the last word and see the scale of the problem and the interventions assuming such different roles, you know, from a scholarly, academic exposé that leads to an entire book to this performance in a conference room for, you know, a small-life audience and a vast audience online, maybe could you share a little bit of your experience with us? I mean, we're still on the experience, yeah, we are most, but... But you're human again. Yes, half human, but now I've become a little less human. No, post-human, no, post-human. Well, so they did promise the next time we're together that I shall be corn too. Yes, as is important. Yes, thank you. It matters to me and I think to my friends that there not be a gap between the academic and the performance. To imagine that is to take us back to a time before there was ecocide, before we were all placed together in a condition we did not make, but will make us and our children and our children's children, right? So we are responding to the same level of threat of terror, but also, and this seems to me what we tried to rehearse together, as you notice we all dressed together, organized, very important. You know, it creates a collective that the difficulty creates our being together and creates the possibility and the necessity of conversation so that we learn the necessity of sharing good living together. I think also what you just said about being together, and it speaks to what you said earlier that we enact these roles and you describe it so beautifully what happens when you put on this, forgive me this ridiculous costume, but you do it. We do it. We do it. We do it. We do it. To some extent. So the need to have the individual body commit to the fight is important shared by all of you. I said we are coming from very long tradition. I think in Argentina it's a very long tradition. And I think here everywhere, like the social movements and even the anti-global social movement, more than 20 years ago, we shared something in common that it was like this idea of, of course, if we have to imagine another society, which is not this, we have to make an effort together of change, of think about what is imagination, what is a social imagination, what is next. Because to imagine another society, you need to make a big effort like the artists do, even with lawyers, we have many good friends, lawyers that they said we are like you. We have to invent several things to win a human rights trial. Because sometimes you have to invent, for example, if you are a lawyer and you have to put in a trial, for example, the condition of being disappeared by a drone without any person responsible. You have to invent something. And we, the artists, I think all the artists, especially the artists who have been part of the social movements as one more of the social movements, we often talk with people which is coming from biologists, scientists, lawyers, farmers. You have people, different people, because as you said, we are part of a collective at the end because we wanted to change something. And in that sense, it's always a collective exercise. And I think for us, of course, we always, from the beginning, as I said, from 1997, we used to play a lot of humor, grotesque, and even the surrealist way of doing it because we also felt that the system we want to change, the one we are struggling, it's a system that plays in a very sophisticated way, like, for example, advertising. And even for us, we always said, like Federico, I love when Federico presents himself in some kind of seminars when he said, like, I'm a theater performer playing as a visual artist. So it's very nice when you can change that condition as a stereotype. So I think for me, the con for us, it was the only way to enter into such a movement that we were not part, for example, we were not ecological people. We come from social movement, and then we understand how important it was to keep this environmental... To talk about serious issues, sometimes you have to do funny or humorous things. I would even say sometimes you have to take a situation seriously enough to be ridiculous, and it's not trivializing if you're working hard at it, it's actually hard work and it's dire. And it's functioning because even when you want to be attractive or you want to be as a social movement, you need to have something which is not... Because politics is very serious. Of course, we are talking about something super serious when you are involved in political struggles, but you need to have something that the people will join you. Inviting, as we say. And also, and I think it's a very important aspect of your work now, is you have to, as a social movement, show what you're for. Of course you have to show what you're against, but a lot of people know. They know people aren't completely lost. They know, but then it's like, well, now what? And to be able, as you're doing, to provide, okay, well, let's move towards WNVD or something that's... But at the end of your presentation, what I really... I really appreciate it that there is an exit, there is a place to go. I mean, fighting, protesting and so on. It's not like describing a description of the problem and that's all, no. That's all for that. And every single moment is important. Create consciousness and push. No? Not only that, but to underline what you said so beautifully, it's a moment of invention. The very concept of ecocide is an invention. And unless we understand that even law has to invent, even politics has to invent. So it's not as if the business of invention is done in the artist's studio and the rest of us can carry on. Invention is the necessity of inhabiting the present. Which ties us back very, very lovely to the subject of this entire assembly, which is dedicated to future fellows. And of course, you are really enacting and embodying a future for all of us. So maybe with that, I just want to thank you all for coming and I want to thank you for your incredibly important work. Thank you very much.


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We have an interesting afternoon, and we'll go ahead and start. Sean Tunis, CMTP. Well, good afternoon, everybody. I do want to thank you all for inviting some unruly guests to your party who may not be speaking on exactly the same wavelength. And we'll see if we understand each other after the next set of talks. Just so you know a little bit more about my background, I'm trained as an emergency medicine physician, and then background in health services research and clinical research, then kind of went off the rails and worked in Washington as an aide in the US Senate for a few years, and then ended up as the chief medical officer at the Medicare program. So probably a slightly different pedigree than some of you all in here. And that's probably why what I'm about to say will seem as incomprehensible to you as a microassay photograph seems to me, which just looks like a bunch of gray and blue and stuff. So we'll just try as hard as we can. I do think it's important to try to have the conversation, because I have a little bit of a feeling listening to this that I'm just hoping that we're not doing one of those transcontinental railroad things where we're building from the east and the west and just hoping the golden spike actually falls in the middle. But I do worry a little bit that we are in some danger of ending up not completely aligned when it comes from some of the perspectives of the way the, well, certainly the payer community, but some of the regulatory community as well is looking at this. So I'm going to try to talk about developing evidentiary standards for determining clinical utility of genomic based diagnostic tests. And I think already in that title, it's clear to me from listening to folks today that we think of what the word standards means differently. So this is not the kind of standards that I think you generally talk about. So this is evidentiary standards in terms of the design of prospective clinical studies. And I also think the notion of clinical utility you'll see is quite a bit different. But we'll see where we go from there. So let me just start with a quote from a paper that I think, Ned, you might have been a co-author on. But it was from the EGAP working group and sort of an assessment of essentially the quality of evidence for clinical decision making and policy decision making in the field of genomic tests. Of most concern, the number and quality of studies are limited. Test applications are being proposed and marketed based on descriptive evidence and pathophysiologic reasoning, often liking well-designed studies, but advocated by industry and patient interest group. So kind of a fairly blanket grade of C minus for useful evidence across the field. And I don't know, Ned, you might say whether there's a feeling at EGAP that this has improved significantly in the last four years. But my general sense is that maybe there's still some view of a room for improvement. One of the things that you may have heard of, and I'll be talking a little bit from the perspective of comparative effectiveness research. How many folks in the room have heard the term comparative effectiveness research? Oh, that's very encouraging. Good, good, good. Well, there's a lot of ways to understand comparative effectiveness research. But one way that I would characterize the premise behind the entire enterprise is that gaps in evidence will be reduced by greater engagement of decision makers, such as patients, clinicians, and payers in selecting and refining research questions and developing study protocols. In other words, the notion is if you get decision makers more involved in the clinical research process from the beginning, there's less risk that the research that's produced won't be actually addressing the critical questions from the point of view of decision makers. That's a premise. Now I thought for this audience, you're unlikely to believe anything I would be able to say unless I could explain it at a molecular level. So I actually have come up with the molecular basis of uncertainty. And this reflects molecular biology as it was taught in 1981 when I went to medical school. So I apologize to those of you who know that this is somewhat amateurish. But let me show you the way this works. So you have your decision makers inside the cell here on the left, and then your clinical research enterprise out there in the extracellular milieu. And this is a bit exaggerated, but it's to make a point. So you have that little orange cloud of intellectual curiosity that drives clinical research. Its investigator-initiated studies leads to published evidence in that little purple oval that slowly diffuses towards the decision makers via KT1 that stands for knowledge transfer 1, but it's just meant to sound molecular and sophisticated. So that's a slow diffusion process. And then you have a field called health technology assessment, which is what Naomi Aronson and her colleagues do, which is packaging published evidence so that it's more digestible for decision makers. So that's a active transport mechanism via KT2, which was cloned in a lab, I think, at Hopkins. But anyway, that's the mechanism, accelerated transport. And then that goes to the decision makers who are coated with these little yellow balls, which are low affinity receptors for evidence. So that's called the knowledge translation blockade. But really, the real issue is that most systematic reviews and assessments actually identify, they basically say things like eGap said, which is we don't have the evidence that we really need to make good decisions. So that's the gaps in evidence. And then you have defective transport at KT3, which means that those gaps in evidence don't get systematically communicated to the research enterprise. So you have defective transport, accumulation of ignorance inside the cell, which is toxic over time. So this is actually the notion of comparative effectiveness, or what I sometimes call decision-based evidence making, where the knowledge gaps as perceived from the point of view of those who makes decisions are not consistently acted upon or don't become the agenda or the guiding force for the next generation of research. So hopefully, if you didn't believe me before, you're now convinced because it's a molecular model that's been published, I think, in the Asian Journal of Hospital Management, as far as I can tell. I think it's the only place this appears in the literature. So let me talk a little bit about it then. What is it the decision makers are looking for with respect to evidence of clinical utility in the domain generally of molecular diagnostic? So I'm not going to talk very much about the FDA regulatory regulation of in vitro diagnostics, particularly because there's a FDA person here. But I'm mostly using this for contrast to what the payers are looking for. So here you have they're looking for reasonable assurance that the benefits outweigh possible risks and reasonable assurance that the use of the device of the diagnostic will provide clinically significant results. So keep that in mind. So what there is not in here, you will notice, is something that definitively states some kind of evidence that suggests that health outcomes are improved, that patient health is improved as a result. This is reasonable assurance that benefits outweigh risks that could be thought of as health outcomes, but clinically significant results. So here, let's go and look at what Medicare says is the kind of evidence that they're looking for when it comes to diagnostic tests generally. So this is back from, I think, 10 years ago when they actually articulated their framework. But basically, this is not really much different from any other payer, which is two questions. Is there adequate scientific evidence to determine whether the test provides more accurate diagnostic information than an existing diagnostic? So is it accurate? And then the second question, which is the hard one, is if it changes accuracy, is it adequate to determine how that change in accuracy affects health outcomes? So looking actually for does the information change how the patient feels, something quality of life, morbidity, mortality, something of that nature. So that's kind of Medicare's view of clinical utility of a diagnostic. And then Naomi may talk more about this, but this is Blue Cross Blue Shield Association, one of their criteria for determining whether something is medically necessary. And I would point to the second paragraph, which is evidence should demonstrate that the technology can measure or alter physiologic change related to disease injury illness. In addition, there should be evidence or a convincing argument based on established medical fact that such measurement affects health outcomes. So again, there's an emphasis on does this information influence presumably through some kind of clinical management decision impact on health outcomes. So this is a slide that's kind of meant to illustrate that across multiple payers, you're going to see that they come to this determination of what's adequate evidence of improved health outcomes at quite substantially different times. And I don't really have a working pointer, but this is the rate of adoption or reimbursement for the Oncotype DX in node negative breast cancer. So it goes from 2004 all the way through 2009, 2010. And basically, at least the way this was compiled, Kaiser was the first payer group to actually adopt Oncotype DX, followed by a Harvard Pilgrim, Premier and a couple of Blue Cross Blue Shield plans. And then there was a sort of the percentage of the population that have covered lives that were actually had access to reimbursement for Oncotype DX sort of sat stable for a while until the Medicare contractor, a local Medicare contractor called the NHIC, it's the National Health Insurance Corporation, which is the California Regional Contractor for Medicare decided that they would pay for Oncotype DX. And because the company that does the tests is in California, that effectively became the national policy for all of Medicare. And once that happened, I think what you're seeing here is that's the domino effect, because once Medicare is paying for something, it's virtually impossible for private payers to no longer pay for it. But this has a laser on it. So following that, you have Aetna here, and United is there, and Reed, for whatever it's worth, Aetna beat United. So at least in this race, whatever that's worth. Anyway, and Naomi, I'm not sure if you know when was it that the Blue Cross Blue Shield Association technology assessment? But it was somewhere closer. Oh, sorry. I'm not sure. Eh. OK, so probably over in here somewhere where it was sort of determined formally to have met the criteria of the Blue Cross Blue Shield Association. But as you can see, there were some blues plans that were already paying for it down here. But really the point of this is just payers are different in terms of when they decide that the scientific evidence is compelling about clinical utility. So it suggests that there's not a great uniformity across different payers. And I couldn't resist actually giving you a little bit of insight. This is actually one of my favorite slides, maybe the only one you should remember, which is actually how the National Health Insurance Corporation, the California contractor, made their decision on ankyotype DX, my friend Bruce Quinn, who was the carrier medical director at the time, made this slide. So basically there were some meetings with genomic health, with CMS folks. This was the New England Journal paper, the first major paper, I think, on the prospective retrospective study of the clinical utility of ankyotype DX and no negative breast cancer. Bruce looked at all this information, as well as, I think, an early Blue Cross Blue Shield tech assessment, and said, OK, we're not going to pay for that. That was down here in early 2005. The response to that was the California branch of the Clinical Oncology Association went berserk. And going berserk meant they went to Sacramento. And what also happened is that Medicare coverage decisions can be appealed to administrative law judges, lawyers who can review. And every single one of the denied claims was overturned by an administrative law judge, a lawyer, or a judge. And so Bruce decided at this point, what's the point of having a non-coverage decision? So he changed it to a coverage decision in early 2006. And that's what launched that entire cascade of the rest of the private payers following along. So what I'm really trying to illustrate for you is there's some work to be done in terms of getting our arms around a genuine scientific evidence-based framework for what constitutes sufficient evidence of clinical utility in this domain. And I'm mindful that I don't want to go too far over, but let me try to do a couple more slides. This was around, I think, well, several years ago, the Secretary's Advisory Committee on Genomics, Health, and Society, which was doing a lot of work around personalized medicine. And Reid, I think you might have been the chair of this committee when this report came out. So you got the right people in the room. One of the recommendations in a report that this committee did on coverage and reimbursement of genomic tests was information on clinical utilities, critical for managing patients, developing guidelines, making coverage decisions. So HHS should create a public-private entity of stakeholders to establish evidentiary standards and levels of certainty required for different situations. So the notion was what we ought to do here is get the test developers together with the payers as well as the professional societies and patient advocacy organizations and actually try to come up with some guidance, some description of the evidence necessary to define clinical utility. As far as I know, Reid, this never happened. There isn't anything of that type that's moved forward. But at our center, we thought that was an interesting idea. So we're trying to do it in a kind of a private sector way. So we're a private independent nonprofit that is now trying to work on developing guidance for how to design prospective studies of the clinical utility of, in this case, we're using molecular diagnostics and oncology, and that would reflect the information needs of patients, clinicians, and payers. So by talking to patient groups, bringing in the ASCO, the other relevant professional societies, as well as Medicare and private payers, the notion is, can we come up with something that's analogous to a regulatory guidance document? And for those of you who are familiar with this, if you want to get FDA approval, you can generally find a guidance document that would say, well, except for the case of in vitro diagnostics for and in this space, there's not yet a final guidance. But generally, you can find an FDA guidance that says, if you want to get regulatory approval for an asthma drug, you have to study it in this kind of population compared to this alternative intervention and measure these outcomes. What we're trying to do is develop a comparable guidance document, but that's written from the perspective of what kind of evidence you should bring forward for purposes of reimbursement. And the notion would be to try to describe studies that would provide a reasonable level of confidence of improved health outcomes. Several folks in the room are actually on the technical working group, the group of experts and clinicians that's developing these recommendations. And so actually, you can see the names of a number of the members of the technical working group that's helping come up with these study recommendations for molecular diagnostics and oncology. And just to finish up, we're jointly hosting with the Institute of Medicine Roundtable on Genomics later this month a kind of a multi-stakeholder meeting to present the draft recommendations for study design, for input, refinement, et cetera. But what we're trying to do here is pretty much what the Secretary's Advisory Committee suggested, which is to get stakeholders together and define the kinds of evidence that would be necessary to establish clinical utility. Hopefully those would become widely, at least consulted in the process of developing these tests, and would reduce the amount of variability in terms of how, reduce the uncertainty in terms of how test developers would need to go about demonstrating clinical utility. So I'll stop there. Thanks very much. And then. Questions? Mark. Mark retained Chicago. So that was very helpful, but at least in the context of germline genotyping and sequencing, I think CMS has it wrong. And let me tell you what my logic on this is. There's as much utility demonstrated for genotyping and sequencing now as hard evidence as there is, for example, for electronic health records. And CMS, of course, is requiring EHR for all practical purposes. In fact, paying institutions because of the belief that there's long-term value here. And I think you can make the same case for genotyping and sequencing. You have upfront costs to develop the infrastructure. You have costs per patient, one-time costs, essentially. And then lifetime value. And I'm not talking here about Oncotype DX and tests like that, which don't fall under that construct. But has there been any consideration at CMS for sort of looking at this kind of germline testing in a different context than a traditional diagnostic? Well, just a comment on the premise that one would assume some consistency from CMS in terms of policymaking. So whatever they do in EHRs, there's no reason to think that they would be consistent in terms of what they did about around genomic or genetic diagnostics. But the answer to your question is no. I mean, of course, they haven't thought about that. And part of it is in the same way that 95% of the Medicare agency is devoted to processing bills and paying claims. It's not really a policymaking organization for the most part. But you have the problem, which is stuff doesn't get paid for unless they decide to pay for it. So my point here wasn't to defend what CMS or Blue Cross Blue Shield or Etna or anybody else does. My point here is you all have the technical knowledge and the understanding of this field to sort of be able to propose what ought to be an intelligent, sustainable framework for thinking about what's clinically useful. And you're going to have to go to CMS and the private payers and have that negotiation and discussion yourselves. It's in the same way that there's an ongoing dialogue and interaction with the FDA around what the regulatory framework is. And the FDA may be a few years behind the cutting edge of technology, but however many years FDA is behind, I can guarantee you Medicare is twice that behind. And the private payers are probably somewhere in between, certainly better than Medicare. Again, all that's doing, I think the point you're making is you may very well know better what would be an appropriate framework for identifying what are clinically useful, important tests in this field. But there's not going to be some magic way that Medicare or any of the private payers understand that unless there's this dialogue and communication. Did that at least address your? Well, I'm trying to distinguish the one-off diagnostic test ordered by a physician for a particular patient for a particular clinical indication versus more of what many of us are talking about, genomic medicine, sort of preemptive sequencing or genotyping, which, as I said, is very similar to the EMR and the basic concept that there's long-term value here. And I guess the question is, how does one elevate the debate around this to the same level to get at the same visibility that the EHR has gotten to the point that actually institutions and physicians are being paid to do it, as opposed to being told they can't do it and nobody's going to pay for it? Yeah. Well, I mean, it is certainly true. And maybe Joanne or Reed will either want to pipe up now, because with Reed having chaired the committee, maybe this came up at the Secretary's Advisor Committee. But the framework for reimbursement decision-making for the most part in payers is around kind of individual specific technologies and services, and not in this kind of broad what you're describing. So I think the points of dialogue around that are probably going to have to be at senior levels in the administration, in HHS, possibly in CMS. But I honestly don't think that they're not really equipped with the policy mechanisms that would really enable them to do that at the Medicare agency level. I don't know, Reed, did you want to weigh in on this? You got a? OK. I'll just give you very two concrete answers. First of all, CMS is not paying for the electronic health records. DHHS is through HITECH and ARA. So it's not specifically that CMS made that decision. So that's one distinction. The second thing is that Medicare has to operate under its enabling legislation. And there's nothing in the enabling legislation that allows it to account for this type of an application. It's all on a test-by-test basis. And so even if they said this is a good idea, my understanding, and Sean, you can correct me if I'm wrong, is they would not even be able to consider the question because it's not reflected in the enabling legislation. Yeah, I mean, I think that is probably right. I mean, it would be on the order of a question like reimbursement for telehealth. It's sort of a body of related technologies. And it turns out that Medicare doesn't have the statutory authority, the legal authority, to pay for telemedicine. So that has to either be addressed through a legislative mechanism or possibly through a regulatory or a mechanism or a demonstration project. So it probably is more relevant there. So one way or another, again, the main point of the presentation was that in terms of a framework for clinical utility that fits what you all are talking about, I think we're a long way off from having something that's a hand in glove there. I think we'll move on, Ned, if we can have the other end of standard discussion.


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Hello everyone, welcome to the Mad Mac dialogues today. I'm here with Leo also known as the Swedish historian I highly suggest you subscribe to his channel and today We're going to be talking about the pros and cons of letting Ukraine and Georgia enter into the NATO alliance So how would you like to begin this? Right. So if you think about Ukraine and Georgia, they're both pretty peripheral nations They both border Russia as their main Neighbors and they're both kind of in this NATO-Russia conflict for the last few years the case of Georgia since 2008 and in the case of Ukraine since 2014 Invasion of Crimea, right, right? So Russia came over in the annexed it and there's also they also have some of their military over in the Duznetsk and Luhansk. The politics in Ukraine have also been very influenced by ethnic tensions and Whether they want to stay with Russia or whether they want to integrate with Europe But it seems that in modern Ukrainian politics, they have been shifting much more towards going with Europe What do you have to say about this? Well, I think that's basically right, you know there's a big difference between Eastern and Western Ukraine historically, but those views have also harshened over the years as this war with this kind of like Proxy war with Russia has been going on a lot of people has turned towards joining the West outright so I checked from a couple years ago and it's about 70 plus percent that wants to join NATO and the like and the government wants as well But of course this also spells a lot of conflicts I've seen the statistics saying that but I the main concern when it comes to joining NATO for a country like Ukraine is I think it's article five of their treaty states if one allies Invaded then it's an invasion on all and they must come to defend it I don't think many countries would really be willing to defend Ukraine when while they were when they admit them to the Alliance, so what do you think would happen if they join would the allies actually Follow through with this part of the treaty or is it not worth letting them in? I think to a large degree. It's not worth fighting over the parts that are already lost So I don't know if the French military and the British military and the US military would necessarily want to go into Crimea and those parts, but I do think there's a lot of will to kind of prevent further losses. So one of the things that has been discussed is letting them in but not Doing so the article five covers the conflict regions right now. So that's the part that I'm more sympathetic to Yeah, I think that Ukraine has a lot to gain from joining the Alliance Especially protection, but they may have to do a bit of bargaining and after they may have to compromise With Russia and like let go some of those lands before they join Yeah, so I think Ukraine it's kind of stuck in this limbo right now, right? So it has this conflict It's has these ties to Russia, but it also has some ties with the West and Right now it's it can't grow its economy It doesn't really know quite what to do and it's kind of left out in the cold So something really needs to changed for Ukraine Well, it's interesting because Russia. I mean I respect Russia a lot But to a certain degree let's say I mean I think that the partnership between the United States and Russia is almost necessary going forward But I'm gonna speak in the present here or if Russia is trying to gain Ukraine and Georgia on its side But the way it goes about doing it is they're doing it all wrong because they're repelling The countries that they want as allies away from them both of those countries used to be part of the Commonwealth of independent states I was created right after the Soviet Union fell But then with the subsequent invasions of both those countries they've left like They're not doing a good job of getting them on their side by being aggressive towards them Yeah, and it's kind of been a loss for Russia I mean they've lost a lot of Eastern Europe that hates them now Poland and circled Baltic states and I think big degree of Russia is very fearful losing more influence So that's part of why they went in in the first place and a lot of it has to do with their demographics too because they have a very low birth rate and if they can't get their demographics under control, they won't have enough people to actually Get those lands back under their control in the future But not only that, you know have such a large elderly population such a small young population that they'll turn completely inward due to their economic problems Yeah, it's it's really a free strike against Russia. There's so many problems coming and I think a lot of the solutions that Russia are going for is they're pushing too hard when they need to be a little bit softer But it's also kind of it's gotten to a point where they've burned so many bridges that they don't really know Quite what to do. It seems like to me. Yeah, they're not really gonna get Ukraine and Georgia back onto their side At least for another half century. Those countries are some of the strongest pro-West Pro-American countries. They're all out there these days. Yeah so kind of one thing that's been a big problem for NATO and West is how Russia's been Going into these countries and it's kind of soft blocking countries by Occupying so that they can't join NATO, right? So you talked earlier about Article 5 and how if someone in Sweden where there's conflict everyone's brought in But the flip side of that has also been that Russia starts these cold conflicts that then kind of locks them out of The Western system. So I mean with Georgia you have a calcium and South Ossetia, right? So they haven't hasn't happened much there for pretty much Over 10 years, but it's still kind of they're out there and nothing's happening in in Ukraine It's the same and this kind of salami slicing or like soft veto rights is I think Pretty bothersome to a lot of the nature countries, but they also like you said Why would a Frenchman fight for Ukraine? I'm not talking about morally like they wanted uphold shared values like democracy But in terms of actually security interests Russian Allied Ukraine is really not an issue for France as much as it would be for see a country like Poland or Romania Eastern countries like the Baltics are the countries that care more Because they already border Russia and they could use some less pressures But if you go further and further away, it's kind of like Why are you disrupting these business ties and why are we fighting for people? We don't know and when Russia is a lot more committed than we are personally Yeah, and these countries can't really do a whole lot because Their entire foreign policy is completely influenced by Russia's strings because if they say the wrong thing or They do the wrong thing than Russia can just easily Go in and intervene. Yeah. Oh, I was actually gonna say something interesting about Georgia. They I've talked about Georgia actually in a few of my videos First of all in the video that I made specifically about Georgia and then in the one I made about Turkey becoming a great power there is a chance that Georgia would actually opt to have an alliance with Turkey against Russia because Turkey actually respects Georgia's Territorial integrity and Georgia also has a great alliance with Azerbaijan So they may ally with each other against Russia, but this could be bad news for Armenia Yeah, for sure. Armenia and Russia has pretty big ties But like for Turkey I mean, they kind of have that on-off relationship But for them if they could have Georgia joined it would put a lot of pressure off them personally as they wouldn't be the only NATO country in the Middle East For sure, so I could see that Yeah, the way I see it though is that Turkey is trying to gain influence in a lot of these countries and they're Almost starting proxy war I predict that there will be many proxy wars between Turkey and Russia in the future like Ukraine might be another example because Turkey is a staunch supporter of Ukraine and Turkey may also have interests in the Balkans like with Kosovo and Russia is allied with Serbia So I could see something happening there, but also in the Caucasus and they've even central Asia Right because I mean there's so many like of the Turkey people everywhere and Turkey's been reasserting so many of the powers. So there's so much potential for Turkey pretty much anywhere now Yeah, ever since the Soviet Union fell a lot of these Turkic majority areas have become independent and Turkey has been able to use its leverage to get them on to their side. Yeah, I do wonder about like I think Central Asia is hard for Turkey to kind of break into because it's such a Like a high conflict Area that's been fought over for between like China and Russia But I do think the potential for Turkey is like he said It's pretty much endless and I think they're taking a lot of that potential and influence and like Syria and Iraq in pretty much anywhere they can find it these days Yeah, Turkey may protect Islamic interests in Central Asia Because the way I see it is China is probably gonna win out there But if Turkey wants to defend the interests of the Islamic minorities there then well We'll call them minorities because they'll be under Chinese influence Then Turkey may send in some troops to help them out there I don't see why they would allow their Turkic brothers to come under a country like China Which actively persecutes Turkic peoples within their own borders currently. Yeah, right the Turkey brotherhood But Turkey has mostly stayed silent about the Uighurs currently But I'm thinking that once China comes closer to their doorstep Then they'll take a much more aggressive stance against that And I don't see you really Turkey and China having any partnership in the near future Interesting. Yeah, cuz I mean Turkey is really that gateway between like Asia and Europe But they also have so much In those parts of Asia, I do wonder how much Chinese influence will grow in these parts of the world It seems like China's is rising and rising but meanwhile they have all these issues with demographics and You know the legitimate of their government is based on GDP growth So there's so many of these things and same with Russia that makes you wonder like what's going to happen in the future I think the as I explained in my last video Russia and China just so insecure About themselves because they know that an impending crisis is coming because the demographics are just gonna kill those countries And they need to get a grab on the land and the resources as quickly as they can Right you grab it and then it's locked and then no one can touch it Even if you grow weaker. Yeah, I see China is maybe gaining a small sphere of influence in Central Asia and maybe Siberia, but that's only if they can succeed But as I described it's just so many factors that will go into that that Even though it seems like a logical possibility. I just think they're gonna mess everything up. Yeah, I mean, yeah for sure There is the Belt and Road initiative, but I mean China does have kind of tendency to push their luck a little bit Like Russia Like they have such a big domestic audience that they need to kind of show that they're doing these things in order to Kind of prove that they're the right government and prove that they're doing the right things So sometimes things end up insulting or being too hard on who could be their friends really Yeah, they have a lot of they a lot of their closest neighbors are enemies Japan South Korea, I don't know South Korea is not as big of an enemy, but still it's more allied with the United States and of course India is a big enemy and then Vietnam and All the countries in the South China Sea like China is just such an aggressive neighbor. They don't want to Be part of it. They are actively fighting against Chinese influence If China messes up its relationship with Russia, then they're done because they're surrounded on all sides basically by enemies Yeah, it's real true. They have pretty much a border dispute with every single neighbor of theirs Have you seen the Caspian report video on that? Oh, yeah You made me think about that They've got so much stuff going on. I think it's almost like a power play They're just trying to tell those countries that they are the dominant Country in the region and their culture has been spread to all these different areas and therefore all its surrounding nations should respect its authority Right, but when you demand respect, it's also kind of Has the potential to backfire, right? That's true Yeah But I mean in the case of China, they have all these this money while for Russia. It's kind of They're kind of running out of the money China's economy is growing for the time being I don't see it growing in 20 years But yeah, it is hitting stagnation and their demographic problems Couldn't be worse. Like I can't think of another country. Maybe besides like Belarus and Ukraine that have such serious demographic problems Yeah, for sure. So, I mean like some of the issues with like Ukraine and Georgia Journey NATO and these things is kind of people talk about it pushing away Russia Do you think Russia can kind of be Gotten back into the fold, you know, kind of ally with the West again. Do you think that? Yeah, because they might want to that it would be for Russia's interests to be allied with the United States However, I don't see how they would want to do that if Ukraine and Georgia are NATO members. I think that Russia would be very Indignant about that in many respects. I see Ukraine and Georgia is almost leverage for the West to I Don't even know give to Russia If they desperately wanted Russia on their side if China was just getting out of control They might use those countries say hey, you can bring your military in here as long as you ally with us against China Yeah, that's really interesting Yeah, there's there's so much potential there. I mean in many ways It's such natural like allies if they just overcome the differences with like Ukraine and part of Eastern Europe there like they both really much fair China and the West isn't really interested in Central Asia It's only pretty much East in Europe. That's a big conflict zone. And of course, I mean Middle East and other parts But it's too many ways. It kind of seems like it could be overcome to me Yeah But it also seems like the the main or China could actually open its own front in the Middle East like its own Neighborhood of allies like it already has Iran on their side. I don't see why Russia would Not try to defend its interest there because Iran is literally on Russia's doorstep And if they are allied against each other, that's just another window for Russia to that's just another weakness for Russia like in all seriousness The United States and Russia need to stop their quarreling Yeah, there's there's so much potential there Exactly So I think that's about enough. I think we did a great job today. All right. Thank you Yeah, it was a little bit hard for me. I'm not really used to doing it like this, but It's a little bit. Okay. You did a great job. Thanks. I thought it got a little bit interesting there with the end Yeah, we should continue this in another video. I'm gonna be doing like the regular Geopolitics videos every for every two weeks now and one of these videos on every other week, too So I hope that you will be in one of these upcoming interviews again. All right, try Yeah, man, we're really cranking out that contents. Yes, sir All right. Well, good luck with that. You're doing a great job. It's a channel. Thank you And I wish you the best of luck for your channel, too. Yeah, I should get back to that Doing that All right. All right. It's been great. I'll see you next time. Yeah. Thanks, man. Bye


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