Good evening, everybody. Thank you for being here for the Harvard Medical School Center for Bioethics public forum this evening. I know you have many options on Zoom these days, so I appreciate being here. I think it's going to be a terrific session. This is part of the Contemporary Books and Bioethics course that we have for the Master of Bioethics program at the Center for Bioethics. This is the second book we're doing this semester. It's Dr. Steve Miles, The Torture Doctors. And as you know, the session is being recorded. Just to orient you at the bottom of your screen, you're going to see a chat box and a Q&A box. So the chat box is live for everybody. You'll be able to see what everybody is saying, and we encourage you using that for dialogue with each other. The Q&A box is where the moderators and Dr. Miles will be looking for topics to address during the discussion section. So any particular things that you would like him to talk about, make sure that you put it in the Q&A box. This is about the fifth or sixth year. We've had the Contemporary Books and Bioethics course. And up until this year, I had the pleasure of teaching it with Dr. Wes Boyd. He's still on our faculty, but he has moved much of his activities to Texas and to Baylor University. But he's sort of making a reprise performance here, not only because he misses me, but also because he has a real specific interest in the work that Dr. Miles has done. And so I'm going to turn it over to Wes to introduce Dr. Miles and the session this evening. Thanks, Wes. Thank you, Bob. I consider this course, by the way, to be the showcase course in the master's program in bioethics here at Harvard. And I was incredibly honored to be able to co-teach it with Bob for the last five years. And no longer teaching it is actually one of the singular regrets I have about my recent move to Texas, even more than giving up my season tickets to the Celtics. I might have felt differently had the Celtics won it all last season, but they didn't. About tonight's speaker, I'm incredibly honored to be able to introduce Dr. Steve Miles. For decades, Dr. Miles has kept sharp focus on the role of health care workers in torture and has been one of my heroes. Dr. Miles is a profile in courage. After 9-11, the entire US, so it seemed, supported any and all efforts to interrogate enemy combatants, including techniques that constituted torture by any definition. At that time, speaking out against any element of US policy, whose purported goal was to extract information from terrorists, was frequently labeled un-American or even pro-terrorist. Despite that climate, Dr. Miles forged ahead with a strong moral compass and shined a light on the underbelly of our war on terror at a time when very few in the academy, including few in bioethics, were doing so. Doing what Dr. Miles did took guts and continues to do, takes guts. And it also required having a moral vision that transcended the sentiments of the day. The book he will speak about this evening, The Torture Doctors, documents and memorializes the extensive worldwide participation of physicians in torture. Physicians are supposed to heal, but Dr. Miles knows more than just about anyone else at times they can and do exactly the opposite. Dr. Miles is a retired internist and geriatrician, professor emeritus in bioethics and medicine at the University of Minnesota Medical School, and for many years held the endowed chair there in bioethics. He is the recipient of numerous awards for his work in medical ethics and human rights. When I asked him what he'd like me to say in this introduction, Dr. Miles replied that he had a blessed career and that he is a passionate gardener with three gardens of his own. He even serves as a Minnesota Ask a Master Gardener Expert online. I assume he provides that expert advice on a pro bono basis, but I did not ask. Without further ado, I offer my sincerest thanks and my heartiest welcome to Master Gardener and humanitarian, Dr. Steven Miles. Wow, thank you. So giving up your Celtics tickets didn't really temper you at all. That's pretty generous. Thank you. I got into this looking at the behavior of US doctors in the war on terror. And what I expected to find was what I was looking for after the pictures of Abu Ghraib prison came out was how the military suppressed what the doctors' protests were to what was going on at Abu Ghraib. And after looking at about 70,000 pages of declassified documents, I found to my horror that in fact the physicians had been built in without protest into the brutal interrogation system. And so the book at that point changed and I wrote a book called Oath Betrayed about how those doctors became part of the infrastructure of torture. After that, what I did was I began to work on the question of accountability for physicians both with regard to the United States and then with regard to the world. Now, of course, everybody as soon as you say that says, well, this means, you're talking about Dr. Mangala and the Nazi doctors trial at half 1946. This was where a psychiatrist coined the term medical war crimes because what they found in the concentration camps was a series of experiments that were basically conducted by using time to death as a indicator for the success of the experiment. For example, how long would it take a person to freeze to death in given types of wetsuits, pilots or submariners or battleship crew was shown down there in the lower left. And so they keep tinkering with the suit to find out how long if they could extend the time to death. How long would it take somebody to suffocate in conditions of rapid decompression for the Nazi program to develop high altitude aircraft? And they had 23 defendants because that's how many people were held in the defendants box, seven were hung and I'm more imprisoned, seven were acquitted, but more importantly, 1600 Nazi medical scientists were brought to the United States to work on Cold War research on biological chemical warfare and aerospace military equipment. Steve, could I just interrupt you for a second? I'm not sure you're sharing your slides. I'm not, hey, are they sharing now? Yeah, now we're seeing the, yep, they're perfect, you got it. Got it, okay. Thank you. You're welcome. All right, so this is what happened as you can see down there in the lower right, that's the experiment with cold suits to protect people from freezing to death. And then the other one is a decompression suit. Torture is a term that has a very specific definition. It's not the same thing as some psychopath who locks somebody in a basement in Philadelphia and then tortures them for a long period of time. Torture refers to the infliction of severe pain or suffering that's intentional, but more importantly, torture in international law says that the infliction of severe pain or suffering is done by a person acting in an official capacity. That is, torture is an act of government against usually a prisoner. Now, after the Nuremberg trial, there were a whole bunch of things that happened. First, a Congress of the World Medical Association, that was, for example, the American Medical Association, the British Medical Association, French Medical Association, South African Medical Association formed in Paris and they passed a law saying that doctors should not violate international law. And they went on to clarify that in various iterations until 1975 with the Declaration of Tokyo that specifically says that doctors should not directly or indirectly participate, help conceal, loan any premises or equipment for, or allow the use of medical facilities for torture. In 1997, after some physicians who were in the Rwanda slaughter fled and picked up licenses in Europe, the WMA said that there should be no license for a doctor who's fleeing prosecution from war crimes. The Britain has allowed two to stay. And then after the United States, where the physicians were quiet on the medical torture and torture of inmates during the war on terror, the WMA said that there was a duty of doctors to denounce and document, even if they had to go to underground connections to human rights bodies. The United Nations essentially adopted the various positions of the World Medical Association as time went by. Now, at the present time, more than 100 countries, probably about 150 countries use doctors for torture. And doctors have several key roles in torture. The first is that what they do is they devise techniques to minimize scars. This is so-called stealth torture because the scars are evidence of torture and the regime doesn't wanna do that. And so this sets up a warfare between pathologists who are working for human rights groups and torturers. For example, for a long time, the torturing regimes we're using and still are using electric shock, but a good pathologist can spot little calcium deposits under the skin where the electrodes go through where the shock is applied. The second thing that they do is they keep alive those who are supposed to live. Some people are not intended to die under torture. People who are being waterboarded, for example, that's a technique that does not leave scars. And then the third thing that doctors do is they conceal torture. For example, by writing false death certificates that say that somebody had a heart attack or died of a hunger strike or something like that. And then the torture disappears. Now, I'm gonna just show you some data from 1972 on where I attempted to chase down this issue. And I was looking for actions by international or national courts or medical licensing boards. And I didn't include acquittals. And I'll tell you, this is easily the most arduous literature search I've ever done. I set up a Google search in multiple languages using the word torture and doctor. And this is a Spanish language search from Argentina. And so then what I did was if you hit the translate this page, then what you get is this story which tells about Dr. Bianco serving at the military hospital at the Campo de Mayo. He was sentenced to jail in 2000 years for the kidnapping of two children. And what happened here was that he took birth certificates while they took women who were gonna be murdered and then they were pregnant in prison and Argentina having laws against abortion waited till they could be delivered by C-section or natural delivery. And then this physician, Bianco, wrote a false birth certificate saying that the parents were guards or soldiers in the prison. And so those kids would be raised as military offspring and their natural family would never know that the kid was even born until finally the grandmothers of the women started searching for them and DNA potentially found the true story on several of them. And so that first search, which ended 2010, I found this, which is an interesting pattern if you're into dots. What it found was that medical boards took most of the actions, okay? For example, you see those dots, black dots, and that courts as squares took fewer actions except in Argentina where the medical associations really stayed out of it. And then there were three in South Africa. And then you notice those large circles are international courts. Now, international courts like in Yugoslavia don't play much of a role because they don't dig down to the lower ranks of torturers. They have such limited capacity that they mainly only take on political leaders who happen to be physicians. After Nuremberg in 1947, the first case was 1975, that is it took actually 30 years for one doctor to be found guilty of participation in torture. All of the doctors from 1947 to 75 had complete immunity. And this guy was picked up and nobody paid attention to the fact that he was a physician until a paper was written pointing that out in about 1990. He was called the orange juice doctor because every time he saw a tortured prisoner he'd give them some orange juice and say he'd be back later to give them more treatment. He went to jail, I tracked him down, he's practicing ophthalmology in a suburb of Athens. I don't pay any attention to the physicians who are political leaders who run torturing regimes. I'm just not interested them. I'm more interested in clinicians.  So who are these people? The first question people wanna know is why do they do this? Are they psychopaths or what? And actually what they are is basically careerists. But they're certain kind of careerists. They're highly patriotic. They're on the right wing of the political spectrum. And they accept the argument that there's a national emergency. I'll come to the last criteria in a minute. This is Dr. Lobo. Lobo of course means wolf. He's a Portuguese doc or a Brazilian doc and he wrote a book called The Wolf and the Sheep in which he described his career as a torturer and he said, man has used torture and assassination for thousands of years and permitted it as long as it's socially organized. It's just a moment from the inquisition to the murder of the Jews by the Nazis. This is human nature. I'm not ashamed to be part of it. And part of his argument was that no court has a right to try somebody simply for human nature. These doctors also get groomed into the process. First off, they're recruited for very high salaries and very high ranks. Salaries that are higher than they can earn in ordinary medical work either in the military or in the private sector. They're given orders, they do not, they do not experience fear that if they don't torture, they will be tortured. I only found three cases of that. Four cases, two in Iraq and two in Nazi Germany. The regimes don't wanna alienate their medical professions by creating a climate of fear because most of these countries don't have very many doctors. And if the doctors emigrate they even create a bigger national shortage. These docs are not crazy people. Although some of them go crazy in the prison environment. Governments keep in mind that a torture doctor is needed by the government as I talked about earlier. And so there's a contract between the torture doctors and the governments that say you will be an armist. We won't let it be known you're doing this work and we'll protect you if anybody comes after you. So they pass amnesties. They require military courts to screen cases. They block access to records. They specifically exempt military MDs from licensing punishments, sometimes to the extent of setting up a military medical association so that the doc is in no way accountable to a civilian medical society. And even if the license is stripped, they just keep the doc in military service and let them work in military or based hospitals. As I said earlier, what you see here is a shift. You see initially around three fourths of the cases were medical associations. But when you look at the same time you start seeing that the courts seem to be playing a larger and larger role. That is the Medical Associations Act first. And courts and medical associations or medical licensing boards have much different roles generally. A court prosecutes crimes, okay? Murder, false death certificates, kidnapping. And they can imprison people or impose monetary fines. In some cases they can revoke pensions, especially court marshals. Medical licensing boards have a difficult problem because they don't prosecute crimes. What they do is they prosecute unprofessional conduct. For example, there may not be a law against a doctor having sex with a patient, but many licensing boards will punish that as unprofessional conduct. And their sanctions are entirely limited to either censure or to suspending or revoking the medical license. They do not have the power of imprisonment. The civil society actually has played a huge role, a larger role than either courts or medical associations in punishing these docs. And this is an example of a denounce. These civil society or human rights groups, what they'll do is they'll take pictures of the victims and then they will plaster them all over the clinic and at the doctor's home. They'll write the indictments on the street and then they'll set up a website that gives the doc's home address, his phone number, his office address and phone number. And then those websites will have lists of all the people they tortured with biographies and pictures of them. And basically they try and shame the people out of work. The response to neighborhoods which deal with those kinds of demonstrations in the neighborhood is to demand that the physician move out of their neighborhood to someplace else. And that has been in effect in several cases. Now, what I wanna show you here is the history of how sanctions develop. It's no secret that doctors generally are conservative politically. That is they have a political affinity with regimes even when the regime is a torturing regime. And of course the courts are part of a torturing regime. And the important thing to know about torture is that torture is not aimed at the person who robs a gas station, for example. Torture is aimed at potential political opponents. That's why it's aimed at people who are journalists, people who are intellectuals, heads of political parties, student leaders, union leaders and so forth. That's why Saudi Arabia had that journalist sawn apart by a doctor and an embassy in Turkey about a year ago. And so what happens is under the torturing regime, the medical association quietly ignores and goes along with the program of torture. The next thing that happens is that civil society builds increasing resistance to the torturing regime and starts compiling evidence about how doctors are involved in torture. And meanwhile, the government is aggressively acting to set up amnesties and pardons and destroy evidence and run death squads against civil society who is part of that resistance. The next part is that the civil society is able to awaken the medical association students by saying, look, what is this business about? Do no harm. What's this business about the Hippocratic Oath? And eventually the medical associations also are adversely affected by the climate of torture. And so they side with civil society and they begin to apply sanctions against torturing doctors. At that point, the government then develops a new set of policies which are designed to protect doctors. And then the final stage is that the courts begin punishing tortures and that's why the courts follow the medical associations rather than the other way around. This is more current data running up to 2015. I would make this longer except it's just too hard to build this kind of a graph. And what you can see is that both the number of nations, the light gray and the number of cases is steadily increasing. However, the rate of increase dropped markedly after the United States failed to do anything about the torture doctors in the war on terror. Nevertheless, these cases are really a tiny part of the involved doctors. For example, Argentina, they had more than 200 doctors who had been identified as torturers. They only punished 12 in the Sao Paulo process and 12 in the province of Brazil. They had 110 allegations, only 22 were punished. There were no allegations or punishments in any of the other provinces of Brazil, including much larger ones. Chile, again, only 10 sanctions of 80 really solid allegations. And so it's possible to categorize nations themselves as to various stages of how they look at physician tortures. For example, you have countries like North Korea. Now, if I was giving this lecture in North Korea, the soldiers would be in the house right now and I'd be dragged off and you wouldn't get to see the last 10 minutes of this discussion. And that would be an immense loss for you. That is, there's no discussion of physician complicity with torture. Stage two are countries that condemn physicians' tortures in principle, but have not sanctioned one. They've never punished one. The US, Philippines, Venezuela, a huge number of countries fit into this category. Stage three are the ones that have done a symbolic act against one or two physicians. Egypt has done one. The UK has done one. Sri Lanka has done two. Turkey's done one. South Africa did two, so forth. And then you have the assist countries that have set up partial systems for punishing doctors for assisting torture. Argentina, Brazil, Chile, or Rwanda and Uruguay. Now, interestingly, Rwanda is the country that has punished more of its physicians, the greatest percentage of its physician supply for torture than any other country in the world. This graph I did a long time ago. I think this is 2010 data, but it gives you a verbal picture. The green ones have systems for punishing torture. You can see they're mainly in South America, which is an interesting phenomenon. And there's Rwanda and Italy. The red countries are countries at the time which I could determine had physicians who tortured. And the gray ones had punished torture numbers, token numbers. And then the white ones, I didn't have any data on. I filled in all those white ones now are red. And the green and gray ones did not change. On a more optimistic site, it's important to note that the physicians are essential to the resistance to torture too. First off, we have special skills for detecting torture. We have a special autopsy protocol called the Istanbul Protocol that's designed to look for torture related injuries. For example, ordinary autopsies, they look at vital organs. But for example, if a person is hung by having their arms behind their back and then lifted up by a rope behind their back, there's a twisting tear in the shoulders that occurs, which will not be detected by a conventional autopsy but will be detected by the Istanbul Protocol. We have codes against torture and we have a special network of things called medical associations which could censure doctors who torture and we have licensing boards. But I think our strongest asset is that we have an international community that even medical communities in torturing societies have ways of contacting human rights advocates during and the course of professional meetings and so forth to serve as a monitoring function. And in fact, that set of relationships which is rich and unexplored is the primary means by which the kinds of cases that I was digging out were found. My list is really a minuscule set of cases of physician complicity and also it's got an important bias in it because the more closed the society is, the harder it is to document cases of medical complicity with torture. For example, it's relatively easy to find the many cases of medical complicity with torture in Spain. It's almost impossible to get information out of North Korea. And so there's an overfinding bias that relates to the nature of getting information out of a country. I got to actually go after one guy. We had a good time. The court let Wooder Bassoon off of 200 count criminal indictment and he was the guy who designed the chemical and biological weapons programs and also some special ops against individuals in the African National Congress. And finally, the medical board took him up. I got called down to testify. In the pre-COVID time, we actually dressed up when we worked professionally. And I actually got the board to condemn him for unprofessional conduct. And this case has now been going on for eight years and still has progress. We're working through a kink in the sanctions process. Let me see if I can put you all up and then we'll... There we go. Hi. Okay. First of all, Dr. Miles, thank you so much for the presentation. You mentioned in the book the fact that you can have doctors who torture and might do absolutely heinous things in the course of their daily work and then go home and be perfectly decent family members and otherwise apparently good members of society. Can you just talk a little bit about that split in people that allows them on the one hand to do horrible things in the course of their profession and then otherwise seem like quote unquote normal people? Yeah. I mean, there's actually a research literature on this that is pretty bad. It's really low quality research and some of it uses university students who go into a place and they'll like the, you know, those experiments where they take and turn them into tortures and stuff, but you know, a university student going to Yale who's recruited of a study in the Milgram thing where they torture people is nothing like anybody who is inside a prison where people are visibly taken apart. Okay. So the studies just aren't the same. The torture institution, I think the best description of what it is is basically a total institution and in the sense of a sociologist called Irving Goffman and it also is as a total institution, its ethics is enclosed, but the other thing that's so interesting about it is that as a microcosm, it becomes a microcosm of the political ideology at the time. And that political ideology defines the people inside the prison, the prisoners, as other who don't have customary rights, Jews, Islam, old fascists, take your pick. Okay.  And once you define people as an other that way, then you can define their legal rights as being non-existent, but then when you put them in a special institution and then you remove the accountability, then you've created an environment within which torture can happen. Now, the other thing that's fascinating about these environments is that there are, these oral traditions start, a good example is the ticking time bomb argument that if you torture somebody, you can get information. There's a huge body of research showing that you can't do that. The only people you torture and get information out of our graduate students writing a PhD, okay? And for other people, if you torture them, what happens is they stop telling you the truth, okay? You lose your ability to recruit them as human intelligence, okay? And the other thing that's been fascinatingly found is you cause them to shift from being a political opponent to being a viewing, detorturing regime as transcendently evil. And once that happens psychically, things like suicide bombers happen and also the accommodation, potential political negotiation between the two sides becomes impossible because at that point it's a war of good versus evil. You have another thing happen is that the tortured person starts spilling stuff which finally a tortureer will accept. And at that point, bad policy follows from that spilled information. For example, we took a guy in Afghanistan, we tortured him in Cairo. He said that Saddam Hussein and Al Qaeda were working together on biological weapons and that become part of the pretext of the war and around. He never would have said that if we hadn't tortured him. He said it just to try and get himself not tortured. And so the enormous costs of that bad intelligence actually paid forward. Ticking time bomb is not a description of how intelligence works. Yeah, and to my knowledge, there's never been a scenario where that actually was the case where the time bomb. In fact, the Israeli Supreme Court asked Mossad to supply an example of the ticking time bomb to pursue this idea of torture warrants and said, you can clean it, the clean strip all the side data off you need to preserve the confidentiality case. We just wanna see this situation. And Mossad was not able to come up with one case for the Israeli Supreme Court on the ticking time bomb scenario. We have a question from Lachlan Faro. Your book about the dark sides of humanity, not just doctors is an invaluable compliment to the April 2020 author session we have with Nicholas Christakis about his book, Blueprint, The Evolutionary Origins of a Good Society, which stresses the aspects of human nature that Nick is convinced provide a solid basis for hope for the future. Can you offer some comments about we can integrate both perspectives, our capabilities for good and our capacities for apathy or even true evil as we try to build a better future? Yeah, well, I think Nick is a big guy on social contagion and social contagion is real, okay? And he's applied it to a number of dynamics and it's quite clear, for example, that social contagion, that is the infiltration of ideas within the American culture during the war on terror, including that show on Jack Bauer, what was it called? 24. Yeah, 24. I mean, this concept of social contagion of these kinds of standard ideas winds up actually creating a torture prone climate. Now, the other way of looking at this is in, say the book, The Better Natures of Ourselves by Pinker. And what he talks about is the social contagion of the concept of empathy. And through a variety of means as a way to show that things are getting better. And in fact, things are getting better. If you take, for example, that book, Breaking the Chains, we have to remember that only 100 years ago, something like 50, 60% of the world's population was in debt, peonage or slavery. They're not anymore. Torture basically is, slavery is rare, but still exists. Torture is actually becoming less common at an epidemiologic scale. Largely have gotten rid of amputations, the penal amputations, they're down, stoning is almost gone, executions are going. This and transparency is turning out to be a huge deal. The social media has proved invaluable in spreading accounts of torture that is actually toppling governments. And there was a huge discussion of giving the web to Cuba today in the New York Times, it was just fascinating. Hi, Laughlin. Christine Mitchell asks a question. She says, thank you, Steve, for all your work on this. It must be disheartening. Why do you think there is so little other work on this topic in bioethics? It has always surprised me that bioethicists are loath to call some things like this clearly wrong. There is a habit of mind among ethicists that presents as neutrality, often appropriate, but in cases like this, not so. Surely we can tell the difference. Do you have advice about how to teach bioethics students about when neutrality and when condemnation are warranted? Oh yeah, that's a good question. I mean, I'm impressed with how bad bioethics has been. I mean, after Oat B. Trade came out, they invited me out to give a plenary session at ASBH and I got there and they turned it into a panel discussion with pro and con physicians should be involved in torture. And there were two physicians there taking the pro position, two of us taking the anti-position which is just morally irresponsible considering the state of international law. I also got a review in one bioethics journal by a philosopher who believes that torture by physicians can be justified. This is a alienation from society that is unsuited to the profession of bioethics, that we do not have a duty to do transgressive bioethics to take positions where the moral consensus is solidly on the opposing side. Furthermore, we have people in our ethics community who are endangered by their torturing society. Our ethicists, for example, in Turkey are grave danger and some of them are very close friends of mine. So I think that though the important thing to teach medical students is not about torture but rather to teach them about a spine and that they need one. And indeed we've seen that played out over the last four years in spades but you have students, for example, have to understand that going along with the drug company suppressing bad results on research, going along with an HMO that is denying a beneficial therapy because of its costs, okay? That these instances, these institutions ultimately are gravely damaged by the lack of spine in the people who work in them. And the research scandal at the University of Minnesota is a good example. Somebody should have said no. Somebody should have said no as loud as it took to stop that experiment. And HMOs have been gravely damaged by students without spine. And so we talk about the heart and mind of medical students we should be teaching about the spine of medical students. And among those, I think the biggest error in medical school education is this concept of dual loyalty. There are no dual loyalty ethics. There's a dual loyalty problem. But a physician has a very clear duty to the beneficence towards their patients with the sole exception being some instances like psychiatric care and public health care with regard to the well-worked outward ethics of quarantine and so forth. But you don't have a situation where a physician has a duty to a military and to a patient for the purpose of paying an appointment patient. Could I just follow up on that for a second? Just I'm hearing your point about dual loyalty, but is it possible that clinicians of any sort, doctors or nurses, take on the mantle of that morality when they are in that role, but we don't hold them to that in other situations. I mean, if you've gone to medical school and you have an MD or a nursing school in RN, are you bound to a code of morality 24-7? Or can you think like the psychologist did at Guantanamo, that they were not doing clinical practice and therefore it was a different role that they were playing? It's important to recognize that the code of ethics that said that the psychologist was working for the interrogation system and not the military was constructed by a panel that was three-fourths taken over by the military intelligence community inside the APA. And the APA allowed that document to be constructed by the military and then disseminated to members specifically to grant cover to the psychologist at Guantanamo. Furthermore, the construction of that document as it was being constructed specifically said during the process, there would be no consideration of international law as it applied to Guantanamo. And secondly, there would be no discussion of research relating to the inefficacy of course of interrogation. And so the document was intellectually flawed. It was morally flawed and it was flawed in the sense that it was not grounded within an intent with regard to beneficence, but rather to with regard to the utilitarian purpose of a misguided and intellectually bankrupt interrogation system. Do you wanna know how I really feel about it? Let's see, who else we got here? The WMA, good question. I wish I knew, I partly wrote the book to kind of jab them when they're sick to get them to come out of the closet and talk about it. What happened with the WMA? See, Germany was, right after the war, Germany was critical to the formation of the WMA because which had US, France, Britain. And the Cold War was crystallizing right away and they wanted to grab West Germany for the WMA. Well, the problem was that because so many of the German docs have been members of the Nazi party, the German Medical Association wanted to say there would be a collective responsibility, not a personal responsibility for these human rights abuses. And in fact, the original position of the WMA at its first meeting was personal responsibility. But then in order to get Germany to join, they had to agree to collective responsibility which meant no responsibility. And that's been their position ever since. Torture is not, Charles, when it's torture is not legal anywhere, it's illegal under international law. And there are at least eight major international laws that apply to torture. And there's also, so it's just not legal. Although there are a number of situations that people call torture that do not meet the definition. And then another question pertains to the Hippocratic oath. How much, Dr. Miles, do you think oaths like that or other ones that people might take or even the rules within any state board of medicine to remain licensed? How important are those kinds of things as opposed to say the local culture that one is practicing in, the context that one was taught in and what he or she saw from their teachers when they were coming of age? In terms of the moral compass that I said that I referred to when I was introducing you. Well, I believe there is an internal ethic of medicine. And that's been well-established. That has been articulated since the beginning and it did start with the Hippocratic school and was a sharp innovation from the Egyptian and Arab schools to proceed it. The problem is the Hippocratic oath is not well understood. You can understand it by reading this book, Hippocratic Oath and the Ethics of Medicine, which I did the whole thing out. The last decent interpretation was France in the 19th century. But I think it exists. The question is who's going to inculcate it in the profession? And also you have this problem of, for example, oh, sexism with regard to who the interpreters are of the internal ethic of medicine. For example, the abortion clause in the Hippocratic Oath is not about abortion. It was about something entirely different. And there's a fascinating carve out for reproductive healthcare in the international treaties pertaining to human rights. So I think that the question comes about making medical ethics closer to the human rights movement rather than a standalone argument. I don't feel that Emmanuel Cot is a generalized internal or international approach for medical ethics. Another question. Some journalists have recently posited a direct link between the enhanced interrogation methods of Mitchell and Jessen right back to the MK Ultra Research of Evan Cameron. Yes. In Montreal. If true, does that make it one wonder if the US has maintained a standing capacity and lab for torture within the CIA? Do you have an opinion? I don't believe they have such a lab, although I did write a paper about the research designs at Guantanamo, which were based on the work of Charles Murray. And there was a specific randomized trial at Guantanamo involving rotating attitudes and information and coercion in three rotating combinations in order to try and then seeing what the output was. And this was a log of one experiments largely got out and it's pretty fascinating. And that is in the second edition of both betrayed, I put that literature in. And the dog, Vicki, you wanna know where the dog is? The dog is Lynn. She's a rescue shih tzu. She is adorable. She's really smart. And L.I.M, she's named for the founder of the women's suffrage movement in China in the 19th century, a journalist and writer who finally hit the glass ceiling, grabbed her husband's money, ran away to Thailand and established a business cartel and became very ruthless. You asked. Go ahead. Some of the intense. Yeah, let's even talk about Dan Sophie. Oh yeah. The question it has to do about psychological torture and physical torture. This actually has been studied by a terrific researcher and he's a servant researcher. Metin Bozeglu. And what he found was that the incidents of PTSD after psychological torture as opposed to physical torture was exactly the same. And psychological torture consists everything from neglect, degradation, things like sham executions and prolonged sleep deprivation, bright lights, loud sounds, playing absolutely pernicious pop music at loud volumes for extended periods of time. And, but it has exactly the same amount of PTSD. It has of course fewer of the specific physical sequelae of physical torture, but it can be lifelong disabling. But Dr. Maz, I wanna bring your attention to one of the last questions. What should the, and I have very strong opinions about this myself, but I'd love to hear your thoughts. What should the role of doctors who do not participate in torture but are aware of the role that doctors have played in torture be in ending this problem? What's the role of doctors in general who aren't participating in torture? Well, in India, for example, more than 50% of physicians have seen a tortured person. In a profound way, a physician is a human rights advocate because human rights advocacy is a form of beneficence. And that means that physicians have an obligation, not simply to the clinical wellbeing of a particular torture victim, but an obligation vis-a-vis the infrastructure or torture itself. That infrastructure includes the parts of the sociopolitical system that cause torture, as in the case of the upgrade thing, but it also includes the infrastructure of impunity, which is the failure, for example, of medical associations and criminal courts to take on these cases. This requires a tenacious participation in gathering data and in reporting and in insisting that national medical associations produce templates for holding docs accountable and then seeing that they do. And I suggest a bunch of these in the last part of the book. Along those lines, I saw there's a statistic that says, well over half of the people in the United States who are themselves being trafficked, see physicians within the year, within any given year. And so one of my feelings and thoughts is we need to keep focus on these kinds of human rights violations and issues so that we can all keep pressing for what's good and what's right. We don't teach how to recognize these people. You know, ultimately, torture survivors in the United States have roughly the same prevalence as people with Parkinson's disease. Every one of us in medical school and in practice sees people with Parkinson's disease and every medical school curriculum and board test says this is how you recognize it and we don't do that for torture. It's totally invisible. Harvard has a good center of course but the screening and the recognition of torture survivors as for domestic violence not people who are in situations of domestic violence or being trafficked or what have you is very, very low. And if we spent more energy on that than on lowering blood cholesterol we would have better public health outcomes. I fully agree and maybe this will be the last question. What are the one to three things that you hope people attending this session will think or do differently as a result of your great work? What will make the greatest difference? Well, I think everybody has to ask themselves how are they gonna solve the backbone problem? The second question I think the really important question is to learn how to recognize torture in their own clinical practice. There are higher risk people than other. For example, if you look at countries in East Africa approximately 20 to 30% of the population has been tortured there but of the people who come here around 50% have been tortured because tortured people are disproportionately likely to leave. And to say that you haven't seen a tortured person is simply to admit your own distancing from people. So number two or three I think we have to ask the question of how is medical ethics going to move without abandoning respect for autonomy move closer to social justice? I want to thank you from the bottom of my heart for being here this evening and giving us this wonderful presentation and thank you so much for all of the work you've done for decades and showing us what it means to have a real backbone. Thank you for your example.


Look at the 70% of global deaths are coming from non-communicable diseases. If we look at that and realize that nearly 100 million people per year are pushed into poverty because they have to pay for their healthcare out of pocket. If we recognize that nearly half of the world's population still does not get access to a basic package of healthcare services, it tells us that we still have a very long road ahead. And if we want to be delivering on the needs of populations, on the needs of individuals and families, we need to transform the healthcare system and we need to transform how we think overall about the care delivery. So likely we have to move from a hospital and curative system to a community and preventative system. We need to move from a silo vertical system to one that looks at multi-stakeholder and multi-sector cooperation. And we need to move from a fragmented and sometimes paper-based system to one that is fully integrated and has data interoperability and data-informed decision-making. And so what I hope is that our panel this morning helps us get to some of the how can we get through these transformations. And so without further ado, let me hand over to the moderator, Helen Clark, former Prime Minister of New Zealand, who will be the moderator for the session. Thank you, Helen. Thank you, Vanessa, and also a former Health Minister for my sins. But thank you for the leadership you and the way for giving on health issues. Now, we have clearly an audience in the room and it's going to be a little hard to see your questions. So please, if you want to speak, do speak up from behind. And we also have an audience online. And particularly for the benefit of the audience online, let's do the formal introductions of who is sitting at the table. We have Josh Shabana, who heads Apollo Hospitals Enterprise in India. We have sitting immediately here. We have Jeff Van Houten from Royal Philips. We have Prasanth Mangat, who is also a healthcare provider based in UAE. We have Nancy Brown from the American Heart Association. And we have Stephen Clasco from Jefferson Health, USA, who also doubles as a doctor. Just to frame a little bit further from what Vanessa has said, with my background in politics and looking at resource allocation, of course, health is always one of the most challenging areas because there's an infinite amount of what you could do, but the money is never infinite. So you're always looking at what's the best use of the health dollar and how do we minimize hospital admissions and length of stay? How do we support primary prevention? How do we support secondary prevention? How do we make our hospitals more effective? What's the role of technology? All the issues that we have a ton of expertise around the table on today. So in our discussion before, we thought we'd start with the people who have a background in health and in the advocacy around prevention and management of heart disease. Then we'll come to the providers and then we'll come to the technology people. So that's going to be our structure. So I'm going to start with you, Stephen, and you've kind of framed a question for us in the green room along the lines of what would our jobs look like in the future? So over to you. Yeah, I feel like a panel on future hospitals a little bit like asking folks what was the future of retail after Amazon started. And I had my wow moment when I was at Standard and Poor's and they downgraded the entire non-profit healthcare provider system because what they said is if you folks don't disrupt, you're going to become a commodity. And I think that it's really a math equation. 40 years ago, Bill Kissick from Morton wrote a book called Medicine's Dilemma's Infinite Needs Finite Resources. Sound familiar? And he was the first person to talk about the iron triangle of access, quality and cost. And he said, you're not going to break that triangle unless you're willing to disrupt the system. And the things are solvable. It gets down to healthcare becoming digital. It gets down to healthcare becoming global. It gets down to bringing population health and personalized medicine together. And it gets down to healthcare being consumer centric. Just a few examples. We can do all our shopping in our pajamas watching TV. But if we have a stomach ache in most places, you're going to get on the phone and get an appointment five days later. The technology is there. The data is there. We just haven't utilized it as providers. So how do we get care out to where patients are instead of expecting patients to come to us for care? I think part of it is getting away from just talking about the technology. We always talk about telehealth. We don't talk about telebanking. We don't get up in the morning and say, I think I'm going to telebank. It's just that banking went from 90% in the bank to 90% at home. We have to start to bring those technologies together. Second thing, we have to start to think about what the humans are in a new healthcare system. Because once we do have better augmented intelligence opportunities, we still accept physicians in most places in the world the same way we did before based on memorization, science, GPA, and medcats. And we're amazed that doctors are more empathetic, communicative, and creative. Jack Ma, last year at this forum, said, you know, when we created cars, we didn't try to get humans to run faster. Computers will always be smarter than doctors, but they'll never be as wise. So how do we start to choose physicians and nurses around empathy, et cetera? We also have to retrain our workforce. And finally, I think healthcare is the only sector in this entire forum that's not global, right? I go to the smart cities piece. You go to the finance piece. The head of finance in Shanghai is just as brilliant in the United States or Australia.  The things that are done for two-thirds of the world around things like acupuncture and area of adic medicine, in the United States are considered alternative health. That has kept us. So at the end of the day, I believe that we run an 18-hospital system. I believe that we will start to be paid based on how healthy our population is versus how many people come in to fill our beds. And I think that that's a revolution that has to start now. We have to align some of the payment models. The last thing I'll say is there's a great Upton Sinclair quote that said, it's hard to get somebody to do something when their salary depends upon them not doing it. And we have a lot of that in policies where we talk about population health, but we still pay people to have acute care in hospital beds. Yeah, there's kind of maybe an evolution of the capitation payment model for primary practitioners, which a number of countries have, but it's never really been taken to the whole health system, as it were. Nancy, bringing you in from American Heart Association. You know, it's really interesting. Steve mentioned the word, it's all about the person. And I think that the thing we have to remember as we think about the future is that individual people still need to make decisions about living healthier lives. And when you think about what's happened, I can use as an example in cardiovascular diseases in this downturn of death rates in the United States because of the onset of fantastic scientific discovery. Statins, other medications, procedures that have really reduced the rate of people dying earlier from cardiovascular diseases. But you look globally and in the U.S., the social determinants of health are really standing in the way of individuals living their longest life. You know, when you think about the fact that 80% of the world's cigarette smokers live in low and middle income countries or in the United States in communities that don't have the same privilege as other areas, we have a lot of work to do, not just in inspiring people to care about their health and well-being, but also to address things that are not traditionally connected to the health care system. Earlier this week we were, and we were talking earlier today, about the Smart Cities Initiative, urban planning, you know, the projections of how many people will be moving into urban centers. And as that work is happening, how are we designing cities so that people can get physical activity and access to nutrition? We see this alarming rate of individuals taking up e-cigarettes, vaping, jeweling that we are very concerned about will addict the next generation of smokers. And so many of the things that bring people to Steve's Hospital are things that can be prevented. And so we have to think about the holistic environment in which an individual lives. What is their education level? How do we use advocacy to make our cities smarter? How do we make sure that all people have access to high-quality health care? These issues will continue, unfortunately, to be front and center so that as fronds is creating state-of-the-art technology for our health care systems and for us as individuals to manage our own lives, you know, we at the American Heart Association worry a lot that in the U.S. and globally not all people will have access to this state-of-the-art technology. And so we really need to think about that when we think about the future. And Nancy, what you've done great is really going at that 80% of health that doesn't happen at the hospital. Right. Because that technology got better, and we did a better job of taking care of somebody who had a heart attack or a stroke. You said, I'm going to go right after that 80%, which, frankly, the doctors hadn't been concentrating. That's right. And, you know, going after the 80% makes a big difference. And that happens by inspiring people. It happens by helping to make sure all people have access. And it happens through advocacy and public policy. You know, if you can't help an individual change their behavior, if you change the system around them, look at just what's happened with clean indoor air acts in the U.S. You know, this avoidance of secondhand smoke has reduced drastically and has been proven scientifically to reduce recurrence of heart attacks. And Nancy, you've pointed to the whole environment around people, because if you're in an obesogenic environment, if you're in an environment where the advertising still suggests that tobacco smoking is a desirable thing to do, you as an individual are up against a lot of externalities, right, that are going to modify your behavior in ways which won't be so great for your health. Absolutely. And if you don't have access to fresh food, and the only thing you can have is processed and packaged food, which is high in sodium and high in added sugar, you know, why are we surprised that there's an epidemic of obesity and type 2 diabetes? Yeah. So let's come to the providers. And in our discussion before, Shabana, you were talking about the investments that you're in process that I was making beyond the hospital, as it were. So I hear everything you were saying, and I think that people are not different. It's just that in the scale of how you have to provide it becomes very different when you come to a country like India and some of the others when you say that there are 1.3 billion people and all of a sudden the highest that a person wants to pay for a heart surgery is probably $5,000, but the government wants you to do it at, you know, a tenth of the cost. And then you start talking to see where do hospitals fit in and how, so your solutioning becomes so different. So then you think about how can we keep them out of a hospital? What is it that we need to do to create facilities around it? So, you know, we're all coming from the same place. You want to keep them out for other reasons. We need to keep them out because we just can't treat them. Nobody can build the infrastructure of hospitals in India. When we started 38 years ago, we had to change regulations that hospitals were not have been considered as something that, you know, banks would fund. So we had to change things around to build it. And then you start and understand and all of us, it still is there that when you talk about the future of hospitals, when you start designing a hospital, by the time it's built, it's probably obsolete. So you have that big challenge in terms of a facility and then we say, what can we do differently? So I'd like to actually talk about a couple of things that India does differently and some things that will probably be tomorrow's scaled models.  So we started a project with Philips to do an EICU. So who does EICUs? And this is something that we're actually putting in rural hospitals because you can, you know, you can train doctors, but how many of them want to move out of the city and live in a village? But there are people there, you want to keep them well. So it's not just in countries like India, but it's China, it's rural America, rural Canada. All these people have the challenges. So I think that the telemedicine part of it, so you can come into a very high solution. That is an EICU. We do tele radiology for around the world. And you do this at scale. And telemedicine is something that, you know, we have a track record of actually doing two million consults. And that's a large number. But we do think that that's obsolete today. As you said, you know, that nobody thinks about banking. So what we've done is actually put it there on a phone, on an app that you can ask people. And two months ago, I was in Israel. And they have the coolest of technologies, and everybody knows that. So what they did is that you can start monitoring your blood sugars, your blood pressure, and so many more parameters. All this can come, and they said the reason, so they have an autoscope and everything, and they said your mobile phone has the highest computing and the best imaging. So why do we have to reinvent that? So I think that is the disruptive technology. Our mobile phone is the disruptor and could be very well where the future of hospitals will move us in that direction. And a recent study that, you know, they said what would be your biggest disruptor, and like you said, they said Amazon. And Amazon hasn't even gotten to the act. Apple at least has, you know, they have the phone that is doing so many things. And in that, they said technology will disrupt hospitals by 30%, insurance by another 32%, and all the others. So you know, this is what we're looking at. We're looking at finding solutions, A for population, for scarcity, and also for the wonderful technology we have in disruption. So we truly live in exciting times. So maybe for Vanessa, this would be a good topic for next year's forum. Instead of going self-driving cars, we're going to have self-healing humans. Right. That could happen. As long as you can make it affordable. Prasad, how does this resonate with your provision? Yes. Thank you. Definitely, I go with Sundita's view. We are an organization who are active for the last 45 years in various economies. We are a decently large player in developed markets, including UK, Spain, and Italy. And we also have been, you know, concentrated on GCC, where we control one third of the market of the GCC, which is having higher possessing power. And we also have been recently very active in markets like South Africa. So to me, when I look at the entire health care problem, I divide that health care problem into three set of problems, which you know, which sometimes we discuss with Phillips on this particular subject. There is not an order of importance, but if you look at, there is this percentage of population in the world who pay from their pocket, who are effluent, who have the money to pay, who want the best of the best. So this, if you look at it, providers like Sundita or me in that market, to a certain extent, they are subsidizers for a larger platform for us. Then for them, the problem is different. From their perspective, whether I'm getting value for money, from a health care provider like us who are working in that environment, most of our health care resources are sucked by these high-value-paying customers. So how will you balance your health care resources to the other set of people? Then you also have a second set of problems that comes out from maybe around 25, 30 percent globally, but some economies like you may be in the US or maybe in the UAE, where we have 90 percent, which is sovereign, directly, indirectly supported insurance programs, where the sustenance of health care is primarily focused on how government can continue to fund this premium of insurance companies. There, the entire sustenance comes into the fact that we need to make sure that government should be able to pay for that for a longer period of time. If government system fails, none of us, the private health care providers, won't be able to work. The investments go completely futile. So we need to identify that problem, and how can you do that?  We also started the telepathology, whereby, you know, the resources. So if you look at it from a health care perspective, there are two cost elements which comes in. One is your consumable risks, and one side, two is your human resources. How can you optimize or maximize your entire, these two expenditure definitely is a key in the success of the second set of problems. Then we have a majority of the problem, which is 50 to 60 percent of the world, which is around 3 billion plus population, who are paying from their pocket the health care, which, as Nancy said, people who are entered into poverty because they spend money, or like people who are not able to enter into health care because they don't have money to go for health care, and the entire system is spent on to that. So there the problem, that problem, I think I completely go with your view that telemedicine, how the disruptive technologies should be used in order to find a solution for those set of people. We work today, today we work globally around 8.5 million patients who walks into NMC's facility across the world in different strata. So we started recently with a telemedicine program to reach into 3 million odd students in Kenya as a country who are on the puberty age of 11 and 16 where they enter into communicable diseases. So we started that as a pilot project and we are working on it. We currently started working on the, for the refugees under the UNSCR in Jordan using the telemedicine program. So telemedicine definitely has got big value in that strata of population, which definitely all the three problems has to be seen to be going in hand in hand. Otherwise providers like private providers who are multi-countries will find difficult to give, you know, there's no one solution that fits into every country and every demography. You remind us too of the global agenda for universal health coverage and how to make it possible. Right. And it's the sort of top priority for health and the sustainable development goals. But we keep coming back to technology as having a lot of answers. Yeah, that's a good thing. There's something to do for us. And just for everybody to know, so Philips, we focus on health and health care. And when we pivoted our strategy some years ago, we said consciously we are not only going to focus on hospitals, we are going to focus on the entire continuum of care from healthy living, consumers, how do you keep them healthy to early diagnosis screening and then the acute and episodic care and then the chronic care. So I laid that out as a continuum and in your introduction you already mentioned what can you do on preventative care and how can you make health care more efficient and how can you work on secondary prevention. And here in value-based care we often talk about access, product cost and outcomes. And so we need to tackle all three. Access is about the social distance of people. Will they get care at all? Productivity, I mean as I serve customers all over the world I see huge differences in efficiency. I mean I would say we can probably make hospitals 30% more efficient without huge interventions. And then you could redirect some of those resources to your primary and secondary prevention. And then of course outcomes I think science and technology will still advance further to make precision health work even better so that we can tailor it to who needs it.  That you could say is the consumer but actually the consumer has not always the knowledge when they're healthy they don't care and when they're unhealthy they need specialized knowledge. So if you talk about the future of the provider I see the role of the provider as the care orchestrator. And second notion that I would put on the table here is that we need to work towards networked care. So now we have a concept where we bring care into the community linked to specialized centers and somewhere we have an air traffic control which should focus on coaching people to stay healthy but should help to direct the right specialist care to fix people and if they have a chronic care how neat how do we support them to live at home in the community with a chronic issue without all the time having to go back to the hospital. So that care coordination can be greatly facilitated by technology. We already heard how access to specialist care in remote areas can be done via telehealth, tele radiology, telepathology, EICU which brings doctors into contact with patients in remote areas. But we need to take this a whole lot further where we get longitudinal information about patients which means we need to slide all the silos of information which is a horrendous issue today where we don't get a holistic view of patients when they come. So there is an informatics opportunity and challenge because once you have data both on population view but also on individual view you can become proactive. Now I can say you are trending in the wrong way or the right way if there is a digital twin kind of a picture of how people are doing with their health especially that is very realistic for chronic patients then we can exercise that role of the care orchestrator much better. We can be proactive rather than reactive and I think that will enhance the quality of life but it will also avoid unnecessary cost. So we envisage that through the cloud we are connecting patients and providers. Technology can make hospitals a lot more efficient and then I would hope that we would redirect that money both to primary and secondary prevention because all together we burn enough cost in the world and I think we could do more with that effectiveness and I think examples in India also demonstrate that you can do interventions at a fraction of the cost. Now that is not always popular and we all of course like to charge big bills but when we want to reinvent healthcare and healthcare we need to look at it much more holistically and some disruption will have to happen. It seems like a common theme among all of us is getting away from Phillips just looking at itself as a technology piece for us so when somebody comes into our hospital or we were talking even in the heart you are looking at how that interacts with the brain. What we have come to call it is healthcare with no address that the definition of Jefferson five years from now will be the care and caring we give wherever it is. I personally believe that most of the non-surgical healthcare that we provide in hospitals now will be done at home with a new level of provider that will go out to the home and do most of those things probably with better food and nicer TVs at home than they will have here. The other thing is that the whole equity piece a lot of those things are solvable and we talk about global equity but even within Philadelphia 6.2 miles away there's a 21-year life expectancy difference and we have six academic medical centers in Philadelphia so that gets to the 80% of education and housing and food the example I gave Nancy is we looked at readmissions for congestive heart failure and we always think it's what happens in the hospital and these patients allowed us to do digital footprinting of what they were doing. It turns out that we could predict who is going to come back by how many pizzas they ordered the first week because we put them on a low-salt diet and if they ordered two Domino's pizzas that week chances were they weren't on the low-salt diet. Because they don't realize that bread is the biggest source of sodium in a person's diet. Of course into the whole privacy issue which is a whole other. We have run with a health system in North America a program for congestive heart failure patients who very often have also other comorbidities and they're elderly and through a telehealth program that included behavioral coaching and daily measurements all that data was collected into our command center for care coordination and these thousands of patients this was a large scale trial we demonstrated that we could reduce re-hospitalization by 50% their enjoyment of life went up they felt better cared for. We're doing this at scale in India for condition management and diabetes for instance which is the big killer in India we're trying to get patients onboarded just for compliance and we've seen that we're able to reduce hospital bills we're able to actually insure them better and I think insurance is important that if you can get them and so now we've actually using data we're able to say that if you have this test and in this compliance we can actually cut down your insurance cost and these are models that are being used across the world saying that we're connected to the smart devices so we should think that that's another part of keeping people involved I was just going to say that you look at some of the great frontiers in heart disease management look at the new Apple Watch and the ability to detect heart rate variability and how that might ultimately interact with the kinds of systems Franz is building we can do that today we need the science to be able to help and we've got to train doctors on the other hand that's another point that data can actually bring it down to the so the future is close our biggest investment this year has been on wearables so let's just picture this technology exists it's all got to come together you'll go to sleep in your pajamas monitor your heart rate monitor your respiratory rates if you have asthma when you wake up you're Alexa or your home pot instead of just playing the daily podcast we'll say your respirations were little labored the AQI out there is X maybe you should take an extra inhaler today literally that will be where where healthcare starts at home that's on the secondary prevention level what I'm interested in is from the point of view of the person who sees themselves as healthy they're not used to the doctor you're ringing up and saying oh by the way I had an alert from your Fitbit so it's kind of also got to change the way people are thinking about their own good health and I want to bring you back in on that Nancy because you're so powerful and advocate around this I think it all comes back to what does it take to inspire people to realize the most important thing they have in life is their health you said this at a meeting we were at dinner we were at the other night friends health is wealth we're affluent that can afford the wearable devices very focused on getting their steps we were talking about how much we're standing up because our watches are being us to to stand up more but you know I think this idea of helping people protect the health that they have most people are born we often say most people are born in ideal cardiovascular health and it's their lifestyle or the environment around them that makes that deteriorate over time there is no magic bullet it's helping to inspire people to want to eat right to make sure they're not smoking cigarettes and to get exercise and to manage their health with their health care provider but it's also this changing communities and environments let's give people the best chance possible to not be exposed to cigarette smoke to make sure that there are healthful foods available those things are all important in prevention you might have noticed we have a very articulate panel but we also have a lot of expertise in the audience so if anyone would like to come in at this point yes over here please I would like to raise some partnerships working in hospitals this is very important because we built with the sign and we also operate but what is the future because the governments don't have money so there is a big need of hospitals over the world what are your thoughts of doing this if you have any experience in private public partnerships in hospitals we did the first one in India and it's it actually turned into a quaternary hospital in New Delhi with the government and then we went through 20 years of expertise about how so the first fundamental thing in a PPP is we have to assume that something will go wrong and what have you done to be able to address it as the government changes so you have to put that together and having said that there is no moving away from it because if the government is planning like in India for instance and I don't know about Mexico but in India the government today spends only 1.5% of its GDP on health and that's nowhere near enough they need to spend like other countries maybe 5-6% more they have committed another 3% still not enough when they want to look after 1.3 billion so now they are calling in to the government sector and saying that why can't you come in and find solutions take over our existing hospitals which we recently did a week ago that were managing the services and this is going to be the model that you can go state by state and in India it's a state it's a federal health is federally run so I do think that the future glad you brought it up hospitals cannot but there's a lot of context in this isn't it in my country if you even mentioned putting a public hospital over to private provider to be a public revolt but other countries are starting in different positions I'm saying that as a neighbour but in my country it would be seen as very difficult but there's different context where there's not provision and where there's a role to come in as you say I have a few examples I thought you were only cricket frenemies you could say of course what is I mean personally I believe it should be policy setting and the guardrails and the direction I've seen many countries where government run hospitals are not the best run hospitals right so countries also where they are well okay there are exceptions but so whether it's Brazil Turkey, Saudi Arabia many other countries they start now PPPs to actually move public old public poorly run hospitals into PPPs which are in the cases where we are involved special purpose vehicles where we all invest technology companies hospital operators and we go at risk and we basically work on excess productivity and outcomes what I talked about earlier and then the governments can supervise that and hold us honest and it is a model that works and I think this is a way to modernise healthcare in all those countries that and also free up then resources to actually do more on the population. So in this particular case you know exactly I go with exactly what Francis is saying we have a business model where we run PPP models in multiple countries for the government of UAE and other governments we run in countries which are rich economies like UAE we also run highly war shattered economy like Yemen we run in sessions we run in Morocco where exactly what Francis said where there is a risk is distributed in multiple players and we as a provider comes and works to improve the patient experience and clinical outcomes patient experience and clinical outcomes definitely have an impact on the total cost of money that has been spent by the government and the infrastructure so infrastructure is a committed infrastructure so the technology comes in from the provider the technology provider and healthcare provider works to improve the KPIs which are the ambition is countries like UAE to take it to the US gold standards but other economies to go into the better results of the world we have seen results in UAE this is we are working Yemen this is the third year that we are working and over the period of time we were able to really take it to the global standards which effectively is reducing the spend of healthcare of the government I'm so glad you asked that because I think we're about to enter a golden age of public-private partnerships I think more and more there's an understanding that it's not a vendor-vendee relationship anymore it's a little bit more France that it's let's go into this together we're working with a company called Color Genomics so we took our 30,000 employees and offered them with Color Genomics free genomic testing with subtyping there's five different disorders that make a difference and literally they were willing to go at risk with us because we're self-insured to say look we think that the care the outcomes of cost and the access will be better because of that and we'll share in that I think the thing that has to happen though we have to start to mix both worlds together of technology and provider I think the EMR is a good cautionary tale the EMRs were developed given to us and I've told other people the only technology in the history of the world that because you've paid for that technology you have to hire more humans so it doesn't get confused so what we're starting to do with our friends at Silicon Valley is we're embedding faculty and medical students out in these companies and they're taking their engineers and they're on my cabinet they're sitting with me at Jefferson so they actually understand what our problems are and it's actually changed some of the business models that they're going to say we're solving a problem that doesn't exist so this is the problem they have so I think as you start to do that and get patients and providers and social agencies and all that money that's being spent to disrupt healthcare in Silicon Valley and around the world together and actually talking to each other it makes a difference. Let's come in again from the audience right behind me, Robert Garrett. I agree with all of our panelists that more and more healthcare is going to be delivered outside of the four walls of the hospital and I do agree that our smartphones will actually deliver a lot of healthcare into the future but being that this panel is about the future of hospitals what do you actually see more walls of the hospital still doing in the future there's no doubt more medical care is being delivered already outside the hospital Steve you suggested also more surgery being done outside the hospital so are hospitals essentially going to be intensive care units or do you see with the aging population and the onset of more chronic diseases a more broad role for hospitals of the future? I think that's been one of the big controversies as I've talked to the provider pieces of the forum you know this eight years ago people were saying with the baby boomers aging etc we're going to need so many more hospitals then of course you know with the value based stuff and keeping out of the hospital so I think this is what I think I think that hospitals that provide acute care surgical care obviously intensive care will actually boom I think what you'll see is in communities like the areas around Philadelphia have 43 community hospitals some owned by different for-profits that really have a low acuity index I think those hospitals will be at risk I think we'll probably have less hospitals and the hospitals that we have that are providing good cost access and quality I'd like to see literally if things are failing we have hospitals with leapfrog these in our place that are doing secondary care those hospitals need to frankly fail and other hospitals are running 60% census rates so I think we'll see less hospitals I think we'll see some retraining of some of those nurses and other healthcare providers our number one college at Thomas Jefferson University is the college of emerging health professions what jobs can we start to give certificates for don't exist today home nurses community health ambassadors etc but you know in a great system like yours I think what will happen is we'll get a continuum of care across your hospitals so that they're doing the right procedure for the right patients at the right time in that context also technology will start playing a role I call it the air traffic control of healthcare right where you will have your clinical and operations planning and if we can predict that patients will come in rather than they show up at the emergency room they need to go should this patient go to your tech care center or should we rather have them in the community in a cheaper bed while you can still through telehealth give specialized care to that secondary location but that means that the whole network becomes a networked care organization unscheduled care can happen today we are now moving almost 70% of our non trauma non ambulance patients are in an efficient ED in fact we actually built an urgent care center literally like a block away from my hospital because we might say we ought to see you but we don't need to see where all those trauma and ambulance patients are coming in we can see you a block away and by the way if you need to come in the hospital we can still see you but that's a conscious management of traffic but that's very by medicaid patients and everybody but I think that I can't agree with you more that hospitals will happen but the rate at which it will happen is very different based on countries with this so it might happen faster for you all it will definitely happen in India but the rate of what we need first you have to serve that and then we can move on to that because you didn't have the hospital so the future I think has to be tiered context exactly if you look at it one is availability of hospital you know America may be an exception or the UK not just maybe an exception but an economy is where we work you know we have seen that one is availability of money exactly what Sunita said about India a few years back India today has availability of funds for healthcare but there are a lot of markets across the world in markets like for example we are looking at Mexico as one economy where we find in certain markets either availability of capital is scarce or the cash is available expensive so once you enter into 15% plus you know financing cost models this healthcare will definitely will not flourish in those economies so again the number of people who are coming out of the medical schools you know if you look at it we went to Nigeria we have operation now in Nigeria so even if you look at Nigeria as an economy Nigeria has been producing medical professionals now in the US or UK a lot they are not ready to come back because of the social system that exists in those economies so a nation who spends not money in medical schools and if there is a brain brain happening in this will be again a second impact third extremely simple but lack of clear water good drinking water in those economies whatever we try we talk about genetics screening globally we talk about preventive mechanism for the effluent rich of the 1 billion the 3 billion suffers because of lack of drinking water which can have a big impact so exactly I resonate what Sundita say that the future will be different to 3 different set of people in the world you know somebody like in US it may be in a different manner but those developing economies like in Saudi Arabia or like India will have a different issue but those coming from certain other parts of Middle East some in North Africa from the West Africa or some part of Latin America definitely will have a completely different problem that has to be so the future of healthcare has to be seen in 3 different manner but I think those 3 sets of people exist in every one of our countries we brought one solution which on this particular subject we started working with Cincinnati Children's Hospital or Boston Children's Hospital which also we start working with a big NHS system where there's definitely a cash trap in the system you know either the government has to pay academic institution doesn't have money to like exactly what you said the NGO funding is coming down nobody is ready to put on money on those activities how will those institution going forward continue to be flourishing if we don't have such institutions globally or academically inclined institution doesn't flourish the global healthcare and to really go into a really doomed state Steve come back in on the medical professional education because you have a lot very interesting things to say on that so look I think that we have not changed either our curriculum or the way we select physicians for 50 years and I think so the simple fact is we're talking about all this predictive analytics augmented intelligence that's hardly in the medical school curriculum by the way there's almost no population health in most medical school curriculum at least in the United States and in the UK in fact I gave this talk to one of the top 10 medical schools in the country and I was talking about quality and population health and food and the Dean was upset that I said they don't do enough and said you know we have a whole day the third year population health think about how ridiculous this is think about how ridiculous this is that most of these folks that apply to schools major in chemistry or biology take four years of just learning chemistry or biology then the first two years of medical school is sitting in a classroom chemistry and biology doing multiple choice tests we merged our 192 year old health science university with a design university and we have this thing with Princeton where we're taking kids after their first year at Princeton and we're saying you have to major in something cool you know not chemistry not biology could be anthropology could be French art just become a good person take the minimum amount of science courses you have to take and then you'll get into Jefferson after your four years and they get an MD master's in design because we merged with a design school the second thing real quickly is that we have to retrain our workforce because we think in departments we're here for any of this stuff to happen and we're going to bring care to patients patients don't think in departments if you have a headache you don't think do I have a normal surgical headache a neurologic headache a psychiatric headache or a family practice headache but in most places around the world you have to go to four different doctors we got an ALS center of excellence for one simple reason and this sounds so simple we actually brought everybody when the ALS patients came in down to where they were and the place that had the center of excellence in Philadelphia made them go to each different four because the neurosurgeons wouldn't be caught dead on the floor where the neurologists were because they didn't like to mix those things so I think we need a fundamental retraining of the humans because we're going to have robots next to us and we've trained doctors to be really good robots it doesn't make any sense Nancy I want to bring you back in because you know the population health perspective the life of the work that you do come back in on me I think the whole issue of what is the role of hospitals I'll just bring it from the patient point of view and to the point Steve was just saying you know it the thing that's most important when people are receiving care is that they're in the state of mind where they can accept the care and their family under knows and understands what's going on and I think we believe really strongly that all of the new technologies for people to be able to be at home instead of being in a hospital that will make a huge difference in terms of outcomes for patients and for their families having people in a hospital where they're being shuffled around and nobody understands and things aren't clear that really is not good for outcomes the other thing I want to mention is the organization that writes guidelines in the United States for cardiovascular disease for stroke and for all of the risk factors you know blood pressure cholesterol you think about how positive this new healthcare system that we're envisioning today can be for the implementation of guidelines which ultimately are being put in place so that patients can live long and healthy lives last year we published as an example new guidelines for blood pressure that drastically in the U.S. changed the criteria for what is considered a person with high blood pressure the day after the guidelines were written 110 million people woke up in the U.S. that having high blood pressure that didn't have it the day before those guidelines would say you know first line therapy is you know exercise and nutrition but you know how do you get the healthcare system and doctors to understand what these new guidelines are and how to help patients understand the lifestyle things not just let's give them more drugs and so these new healthcare systems that we're hearing about in the technologies that Franz is talking about can fix that problem because in the U.S. it takes on average this is a horrifying number 16 years from the data guideline is written until it's fully implemented in practice and patients are receiving the benefits so all of these changes in the healthcare system and in technology will make lives better for patients we now actually take our applicants and take them to an art museum and say tell us the story so that they can start to put stories together and bring that together because I've delivered 2,000 babies and you know it's easy to deliver from baby to a normal oh it's easy for me to say but it's it's incredibly difficult delivering an unscheduled down syndrome baby every single time that that would happen doctor what does this mean and there will be a robot next to me pretty soon there will be much better taking pictures of the baby and saying what's genetically wrong but it will never get to what does it mean means what does it mean in my image of a perfect baby and I want future doctors to be able to talk about the impact and the fact that this is a beautiful baby that we can help you take care of one thing I should have said the most important thing in the future of hospitals is not forgetting the human touch and you know nothing is more important to a patient than having a nurse or a healthcare provider sit next to them and hold their hand and describe what is going on and helping people through that experience we should never forget that the walls and the technology matter and I think the future of hospitals if we had to say it would be using all the technology to allow the humans to spend more time with the patients because right now it's so that's possible it's not enough let's say some of the faults with the current EMRs are that they are claim systems and they take time away from the patient right whereas if we have much more context specific technology with AI we can automate a lot of jobs and make time available for the patients and you don't want to miss things that's what technology is about not to be able to diagnose fast that's the most frustrating for a patient and in India when they're paying for it out of their own pocket and you send these people for a test so they say oh the doctors are going to get something out of it so they're sending us for an MRI or you're asking us about these extra tests and we said well we're not solving for you know we're not solving for the 100% we're solving for even that 1% if we miss it and they go into an event that for them is 100% so I think that hospitals of the future should be way more caring and clever and accurate about diagnosis and the serriums of care also between practitioners within a hospital is huge and get more complex if I compare that to an industrial system coming out of the industry you would weed that out through process automation through checklists through best practice adoption across the board and technology can help do that I would advocate that I would also free up money to do other things in the one hope I would hope to get the whole healthcare world economic forum and we talk about the future of hospitals that we don't get too caught up in what's going to happen 10 years from now what we can do today because at the end of the day things haven't changed enough globally there's a quote I like to use from the NBA where Jason Kitt went to Dallas Mavericks and he said I'm going to turn this team around 360 degrees we do a lot of turning things around 360 degrees we have this technology we have the human touch we have great leaders we have an outcome change because we haven't concentrated on the social determinants of health exactly the same exact point from this when you look at it I run more than 30-35 hospitals across the world the last few years we have been really working on using something like LEAN and things like that to standardize your procedures today some of the most procedures are highly standardized like how you work in industries, in manufacturing sectors and then maybe over time if I claim myself to be successful as a health care CEO I'll say that all the procedures are standardized but that only solves a portion of the global problem the practitioners in my 30 hospitals who runs health care in cardiology or in diabetology completely are different in the same in the same set of NMC network itself I see 20 diabetologists working in 20 different forms in one place I see endocrinologists saying that diabetes should be with me and when somebody say that endocrinology say that diabetes should not be with me to that extent so the future of health care I'm not talking about hospital should be to standardize at least 5 or 6 or like the top 6 or 7 health care problems to be standardized for example in AHA is doing it on the patient so specific areas where we can have a standardized form and that be given to the doctor today we run a team of peer review of doctors and every time it comes to a situation that it comes to my office where the doctors start having problems among them and that is a big challenge in the health care system the protocols and procedures that you follow administratively or non-clinically is not coming on the clinical phase and clinical phase if it is done maybe to a great extent the time spent on EMR can be more standardized time can be spent more on patient and the result also will be standard and unified across the world we can learn from aviation right there are certain things that still require you to be human but the checklist is not if you are a Delta pilot you don't go to Delta if you are doing a blood test 200 or 180 you know whatever it is but I said we are not going to have any trouble with this panel talking and we have just about talked ourselves right out with one minute and nine seconds to go so really to kind of bring it to a head I completely agree with what Steve said about the future of the hospital certainly for a society like mine and like yours and it is going to be the acute it is going to be the intensive, it is going to be the emergency and then we are going to depend on a whole spectrum of other things happening to support the home care perhaps the less intensive community-based facility the training for the people who are going to be doing that the role of technology but then we also have the other context where countries actually don't have enough hospitals yet at all or services and that has got to be built perhaps informed by the trajectory that the hospital system has gone in other societies absolutely and technology regardless of the context rich country or poor is going to have such influence in diagnosis prescription support of the patient and so on so thank you fantastic panel please give them all a big hand thank you thank you


The all-progressive Congress APC Presidential Campaign Council on Tuesday dismissed insinuation on the health status of the party's presidential candidate, Bola Ahmad Tunibu. The council was reacting to a statement credited to the Labour Party presidential candidate, Peter Obi, who casts his passions on the integrity and physical condition of the former Lagos state governor. Obi who addresses supporters of the Labour Party's retreat and mandate in Abuja said, Tunibu was medically unfit to rule Nigeria, warning against voting for a candidate who sees a presidency as a form of entitlement. However, in a statement issued by its director of media and publicity, the council described Tunibu as a horse who walks assiduously for 20 hours on a daily basis.