I’ve spent my adult life in the field of
global health my work has taken me from
the shanty towns of urban Haiti to the
hills of post-genocide Rwanda and now to
the melting seas of the Arctic I’ve seen
the ways the poor live and die in a
world defined by inequity but today I
want to talk to you about the ways the
poor live and die here in the United
States and why I believe it’s time to
bring global health home I came home to
the US at an auspicious moment for
global health I had spent several years
working on health systems reconstruction
in Rwanda and everywhere there were
signs of progress my return coincided
with the final year of the Millennium
Development Goals an ambitious framework
to improve health and well-being
globally under the goals maternal and
child mortality were halved and Rwanda
registered some of the most dramatic
gains life expectancy increased
significantly in extreme poverty was
halved against the backdrop of this
global progress I encountered a very
different situation here in the United
States for the first time since the
height of the AIDS epidemic life
expectancy fell in 2015 and then in 2016
researchers looking at this alarming
trend found surging death rates in poor
uneducated white Americans even retinas
racial disparities and life expectancy
finally narrowed the causes of these
deaths are not those that you might
expect heart disease obesity diabetes
instead these are deaths of despair
caused by suicide alcohol and drug
related overdoses and alcohol-related
liver disease and these rising death
rates reflect declining overall health
with nearly 80% of low-income Americans
experiencing poor health today we speak
from the epicenter of this crisis in
2015
New Hampshire led the nation in fentanyl
related overdose deaths Vermont was 10th
I’ve spent a lot of time trying to
reconcile the converging patterns we see
globally with the divergent trends at
home what does global health
to say to these challenges what is a
movement that’s focused on closing gaps
in access to essential medicines in low
and middle income countries have to
offer a crisis of overuse of
prescription drugs in our own context as
I’ve contemplated this question I’ve
returned to my own roots in global
health I’ve had to re-examine my
response to a common question how did
you come to this field I usually
explained that I began as a young human
rights worker in Haiti there
I witnessed sir victims of human rights
violations survive physical violence
only to die from a lack of access to
health care I wanted to spend my life
fulfilling the right to health rather
than cataloging abuses against the right
to life but I came to TEDx today to have
a frank conversation with you and I’m
going to start by being honest with
myself I went to global health because
it was easier to fight for access to
health care globally bench engaged in
the struggle for equity at home early on
I saw the ways in which what Paul Farmer
has described as structural violence or
the violence that’s embedded in the
social and political arrangements of our
world is reenacted in other forms of
violence I saw claims for justice from
marginalized communities framed in
language that appeared incompatible with
the polite discourse of human rights
I saw survivors of human rights
violations perpetrate violence against
other survivors global health
represented an area of moral clarity in
a world blinded by injustice and if I’m
being honest with you today this work
didn’t begin in Haiti but started much
closer to home just over 15 years ago I
was a student at Dartmouth interning
with an organization providing legal
services to women in rural Vermont as I
drove westward into Central Vermont each
morning I would encounter the take-back
Vermont signs peppering Vermont’s
bucolic landscape if that summer Vermont
would become this first state to
legalize same-sex civil unions and
Vermonters or natives of the states had
painted barn walls in erected signs in
protest
as a native of the blue-collar mid
western suburbs homophobic sentiment was
not new to me
however these makeshift notes a protest
awakened me to a struggle extending far
beyond a contested piece of legislation
on the surface these signs were
rejoinder to a social policy anatomy to
Vermonters and to the Flatlanders or
urban liberals promoting them I know
know that I went to work in human rights
internationally because I wanted to join
a human rights movement at the vanguard
of social change rather than one
resisting efforts to reclaim the past
take back Vermont I now recognize though
was not an expression of nostalgia for a
fading pastoral era but rather a cry not
to be left behind in a rapidly
globalizing world beneath these signs
lay the pains of shrinking opportunities
and loss of rural identity in a changing
global economy when I returned to
Vermont’s I saw roots of the current
crisis in the take-back Vermont movement
opioids had moved into many of the
communities I had visited many years
earlier and make America great signs
stood on hills previously a queue PI by
those from take-back Vermont as someone
who’s worked for many years in to
improve health systems globally I’ve
been encouraged by calls to bring
practices from global health such as the
use of community health workers and
mobile health technologies to bear on
these person for these problems we see
in rural communities here I’m reminded
though of what I saw is the failure of
traditional women’s organizations to
make inroads in addressing the
prevalence of domestic violence in poor
rural communities rural geography and
poverty intensified the physical
cultural and social isolation of women
experiencing abuse more importantly
though many women expends partners and
extended family than with the
organizations led by Flatlanders indeed
so many women desperately seeking to is
seeking to escape violence identify
themselves with the take-back Vermont
movement certainly week
we can learn much from successes
elsewhere however I fear that our
persistent desire to import healthcare
innovations from abroad points to a
persistent desire to avoid grappling
with the underlying inequities that
produce both poor health and political
grievances that we see represented in
the take-back Vermont and now make
America great movements a growing body
of research now attributes the
plummeting health outcomes we see not to
a lack of access to health care but
rather to growing financial insecurity
financial strain and feelings of
exclusion stress related to economic
insecurity may have particularly great
effects on the health of the poor
particularly because it’s perceived by
as outside of their control and even as
economic well-being improves in many
communities these gains are weakest in
rural areas in this misplaced search for
solutions to a problem that’s become a
bellwether for the health of the
Republic I think we’ve forgotten that it
was never new technology or
interventions that propelled the
successes we see globally you see when I
came into the global health movement at
a moment when the dominant perspective
was still that some lives mattered and
were worth saving and others simply
weren’t aids threatened to decimate
entire countries even though this was
several years after highly effective
antiretroviral therapy had become
available here in the US and other
high-income settings vast parts of the
world were seen as too backward to
benefit from modern medical technologies
cultural practices and traditional
beliefs many reflecting a lack of access
to basic health care education and other
rights were advanced as a premise for
denying access to treatment marginalized
communities hardest hit by this epidemic
the gay community sex workers migrant
populations intravenous drug users were
seen as dispensable this pernicious
racism and discrimination resulted in a
lot of stupid deaths I see echoes of it
in our view of struggling communities
the global health movement emerged out
of rejection of this notion that we
inhabit three worlds not one at its core
this denote is a belief that health
constitutes an enviable human right
scientists activists civil servants
patients communities and college
students much like yourself came
together to battle for access to these
drugs and then for the systems needed to
deliver them those of us on the
frontline of rebuilding these systems
knew that the stakes went far beyond
stopping preventable deaths in our local
catchment areas we had to demonstrate
proof of concept and that concept was
that the health of the poor was worth
investing in today 18 million people are
alive thanks to HIV treatment and the
tide has turned from a discussion of
whether to treat HIV and poor settings
to how to address a broader range of
disease priorities to how to achieve the
once unthinkable goal of universal
health coverage
today’s ever-expanding global health
agenda now includes non communicable
diseases injuries and cancer our
concerns have shifted to from utter
neglect of the diseases of property too
cluttered landscapes equitable
partnerships and the appropriate use of
technology but let us recognize that
global health has always been a movement
to recognize our common humanity
certainly we need modern medicine to
realize health is a universal right over
this is merely how we operationalize
this right and it’s this affirmation of
dignity that is so urgently at stake and
communities dying from despair I’m here
at TEDx today because I believe it’s
time to bring this global health
movement home but as we turn the moral
compass at the heart of global health
homeward we need to shift the global
health paradigm from one focused on
access to one built on an impending
imperative of equity
today’s epidemic of despair has emerged
along the very fissures from which we
collectively averted our gazes and we
need a new agenda to transcend these
divides I’m sure you’re asking what does
it mean
to build a global health equity agenda
equity the idea that all humans have the
potential to realize their optimal
health requires us to look at the
broader conditions necessary for health
an agenda for access begins at the
healthcare system often at the point of
illness it asks what are the gaps in
health care services and oftens assumes
that we can fill them simply by an
exchange of commodities or knowledge
from higher to lower income settings an
agenda for equity equity begins in the
communities bearing the burden of poor
health
it asks a very different set of
questions what do you need to be healthy
what is your vision for your health how
can we work together to achieve this
vision more importantly though in a
Genda for access presumes that we have
at different spaces in time an agenda
for equity recognizes our interpretive
interdependence it requires us to think
about marginalization lack of social and
economic power and the institutional
arrangements that govern our world not
as a means to delivering a medical
intervention but rather as the basis for
a healthy life and this in turn gives us
something more important it creates the
basis for solidarity and begins to heal
the divides that drive despair but I
think the real question you’re asking is
why should we the most global generation
ever care about communities much closer
to home especially when their social
beliefs and voting patterns appear
antithetical to our own values and
vision here’s why it’s taken more than a
decade but I now see take back Vermont
make America great communities as
predictive of our global future rather
than backwards as we look across various
geographies a perilous theme emerges the
feelings of dislocation and exclusion
that are contributing to poor outcomes
health outcomes here are also fueling a
political agenda that threatens our
efforts abroad scholars examining the
apparent paradox of support for a from
rural voters in rural Louisiana and
Wisconsin for candidates who embrace
positions seemingly at odds with their
own health and economic interest reached
a common conclusion in each of these
places in in each of these places
feelings of economic security and loss
of status loss of status were
contributing to what one termed a
politics of resentment analysis of
polling data from the 2016 presidential
election finds support for a
presidential campaign that’s embodied
this very politics of resentment to be
especially great in areas with poor
health and declining economic mobility
in this discontent we can trace a
roading global support for the work for
the global cooperation that underpins
our work with vulnerable communities
abroad this point was driven home to me
personally when my work brought me to
Greenland last year as temperatures rise
it twice the global average in the
Arctic Greenlandic communities are
losing this earth East sea ice on which
their survival depends as a way of life
disappears with the melting ice
Greenlanders now confront an epidemic
despair manifests in the world’s highest
rates of suicide and widespread
substance abuse the familiar pattern of
devastation
I saw weighed heavily on my mind as we
went out to sea the last day of our trip
we were too far from where large
icebergs were calving off from the ice
sheet but I could still see the remnants
floating southward watching this I was
reminded of communities beyond the
Arctic that are increasingly feeling the
health effects of climate change even as
their access to health care improves but
then I recalled the ways in which
inequities here are undermining the
political support needed to counter this
climate change there are three weeks
earlier the US had announced its
intentions
to withdraw from the Paris climate
agreement an accord seen by many
scientists is our last great hope for
arresting these changes the imperative
for equity became clear our failure to
address inequities at home in dangers
our ability to confront global health
challenges that know no boundaries of
place or time global health in its focus
on dignity offers a way to transform the
social and economic anxieties that
threaten communities everywhere into an
agenda for change the mere act of coming
together to produce health just to see
each other as human to recognize we are
not forward or backwards urban or rural
deplorable Zoar Democrats local or
global instead it forces us to recognize
we are not only individuals and
communities with agency and aspirations
for better lives but also as citizens of
a shared planet with a common future and
this is precisely the movement we need
at a moment when what ails the body also
ails the body politic it’s time to
recognize that struggling American
communities are the future of global
health and I believe that you Dartmouth
have a unique opportunity to lead this
bold new bold health equity agenda
beginning here in New Hampshire because
we all know that what happens in New
Hampshire matters not just to this
country but to this world and I know
that your generation has the moral
courage and imagination to confront the
difficult questions that so many know so
many of us in global health have long
ignored so TEDx Dartmouth let us commit
today to bring global health home for a
healthier and more equitable future for
everyone thank you [Applause]
global health my work has taken me from
the shanty towns of urban Haiti to the
hills of post-genocide Rwanda and now to
the melting seas of the Arctic I’ve seen
the ways the poor live and die in a
world defined by inequity but today I
want to talk to you about the ways the
poor live and die here in the United
States and why I believe it’s time to
bring global health home I came home to
the US at an auspicious moment for
global health I had spent several years
working on health systems reconstruction
in Rwanda and everywhere there were
signs of progress my return coincided
with the final year of the Millennium
Development Goals an ambitious framework
to improve health and well-being
globally under the goals maternal and
child mortality were halved and Rwanda
registered some of the most dramatic
gains life expectancy increased
significantly in extreme poverty was
halved against the backdrop of this
global progress I encountered a very
different situation here in the United
States for the first time since the
height of the AIDS epidemic life
expectancy fell in 2015 and then in 2016
researchers looking at this alarming
trend found surging death rates in poor
uneducated white Americans even retinas
racial disparities and life expectancy
finally narrowed the causes of these
deaths are not those that you might
expect heart disease obesity diabetes
instead these are deaths of despair
caused by suicide alcohol and drug
related overdoses and alcohol-related
liver disease and these rising death
rates reflect declining overall health
with nearly 80% of low-income Americans
experiencing poor health today we speak
from the epicenter of this crisis in
2015
New Hampshire led the nation in fentanyl
related overdose deaths Vermont was 10th
I’ve spent a lot of time trying to
reconcile the converging patterns we see
globally with the divergent trends at
home what does global health
to say to these challenges what is a
movement that’s focused on closing gaps
in access to essential medicines in low
and middle income countries have to
offer a crisis of overuse of
prescription drugs in our own context as
I’ve contemplated this question I’ve
returned to my own roots in global
health I’ve had to re-examine my
response to a common question how did
you come to this field I usually
explained that I began as a young human
rights worker in Haiti there
I witnessed sir victims of human rights
violations survive physical violence
only to die from a lack of access to
health care I wanted to spend my life
fulfilling the right to health rather
than cataloging abuses against the right
to life but I came to TEDx today to have
a frank conversation with you and I’m
going to start by being honest with
myself I went to global health because
it was easier to fight for access to
health care globally bench engaged in
the struggle for equity at home early on
I saw the ways in which what Paul Farmer
has described as structural violence or
the violence that’s embedded in the
social and political arrangements of our
world is reenacted in other forms of
violence I saw claims for justice from
marginalized communities framed in
language that appeared incompatible with
the polite discourse of human rights
I saw survivors of human rights
violations perpetrate violence against
other survivors global health
represented an area of moral clarity in
a world blinded by injustice and if I’m
being honest with you today this work
didn’t begin in Haiti but started much
closer to home just over 15 years ago I
was a student at Dartmouth interning
with an organization providing legal
services to women in rural Vermont as I
drove westward into Central Vermont each
morning I would encounter the take-back
Vermont signs peppering Vermont’s
bucolic landscape if that summer Vermont
would become this first state to
legalize same-sex civil unions and
Vermonters or natives of the states had
painted barn walls in erected signs in
protest
as a native of the blue-collar mid
western suburbs homophobic sentiment was
not new to me
however these makeshift notes a protest
awakened me to a struggle extending far
beyond a contested piece of legislation
on the surface these signs were
rejoinder to a social policy anatomy to
Vermonters and to the Flatlanders or
urban liberals promoting them I know
know that I went to work in human rights
internationally because I wanted to join
a human rights movement at the vanguard
of social change rather than one
resisting efforts to reclaim the past
take back Vermont I now recognize though
was not an expression of nostalgia for a
fading pastoral era but rather a cry not
to be left behind in a rapidly
globalizing world beneath these signs
lay the pains of shrinking opportunities
and loss of rural identity in a changing
global economy when I returned to
Vermont’s I saw roots of the current
crisis in the take-back Vermont movement
opioids had moved into many of the
communities I had visited many years
earlier and make America great signs
stood on hills previously a queue PI by
those from take-back Vermont as someone
who’s worked for many years in to
improve health systems globally I’ve
been encouraged by calls to bring
practices from global health such as the
use of community health workers and
mobile health technologies to bear on
these person for these problems we see
in rural communities here I’m reminded
though of what I saw is the failure of
traditional women’s organizations to
make inroads in addressing the
prevalence of domestic violence in poor
rural communities rural geography and
poverty intensified the physical
cultural and social isolation of women
experiencing abuse more importantly
though many women expends partners and
extended family than with the
organizations led by Flatlanders indeed
so many women desperately seeking to is
seeking to escape violence identify
themselves with the take-back Vermont
movement certainly week
we can learn much from successes
elsewhere however I fear that our
persistent desire to import healthcare
innovations from abroad points to a
persistent desire to avoid grappling
with the underlying inequities that
produce both poor health and political
grievances that we see represented in
the take-back Vermont and now make
America great movements a growing body
of research now attributes the
plummeting health outcomes we see not to
a lack of access to health care but
rather to growing financial insecurity
financial strain and feelings of
exclusion stress related to economic
insecurity may have particularly great
effects on the health of the poor
particularly because it’s perceived by
as outside of their control and even as
economic well-being improves in many
communities these gains are weakest in
rural areas in this misplaced search for
solutions to a problem that’s become a
bellwether for the health of the
Republic I think we’ve forgotten that it
was never new technology or
interventions that propelled the
successes we see globally you see when I
came into the global health movement at
a moment when the dominant perspective
was still that some lives mattered and
were worth saving and others simply
weren’t aids threatened to decimate
entire countries even though this was
several years after highly effective
antiretroviral therapy had become
available here in the US and other
high-income settings vast parts of the
world were seen as too backward to
benefit from modern medical technologies
cultural practices and traditional
beliefs many reflecting a lack of access
to basic health care education and other
rights were advanced as a premise for
denying access to treatment marginalized
communities hardest hit by this epidemic
the gay community sex workers migrant
populations intravenous drug users were
seen as dispensable this pernicious
racism and discrimination resulted in a
lot of stupid deaths I see echoes of it
in our view of struggling communities
the global health movement emerged out
of rejection of this notion that we
inhabit three worlds not one at its core
this denote is a belief that health
constitutes an enviable human right
scientists activists civil servants
patients communities and college
students much like yourself came
together to battle for access to these
drugs and then for the systems needed to
deliver them those of us on the
frontline of rebuilding these systems
knew that the stakes went far beyond
stopping preventable deaths in our local
catchment areas we had to demonstrate
proof of concept and that concept was
that the health of the poor was worth
investing in today 18 million people are
alive thanks to HIV treatment and the
tide has turned from a discussion of
whether to treat HIV and poor settings
to how to address a broader range of
disease priorities to how to achieve the
once unthinkable goal of universal
health coverage
today’s ever-expanding global health
agenda now includes non communicable
diseases injuries and cancer our
concerns have shifted to from utter
neglect of the diseases of property too
cluttered landscapes equitable
partnerships and the appropriate use of
technology but let us recognize that
global health has always been a movement
to recognize our common humanity
certainly we need modern medicine to
realize health is a universal right over
this is merely how we operationalize
this right and it’s this affirmation of
dignity that is so urgently at stake and
communities dying from despair I’m here
at TEDx today because I believe it’s
time to bring this global health
movement home but as we turn the moral
compass at the heart of global health
homeward we need to shift the global
health paradigm from one focused on
access to one built on an impending
imperative of equity
today’s epidemic of despair has emerged
along the very fissures from which we
collectively averted our gazes and we
need a new agenda to transcend these
divides I’m sure you’re asking what does
it mean
to build a global health equity agenda
equity the idea that all humans have the
potential to realize their optimal
health requires us to look at the
broader conditions necessary for health
an agenda for access begins at the
healthcare system often at the point of
illness it asks what are the gaps in
health care services and oftens assumes
that we can fill them simply by an
exchange of commodities or knowledge
from higher to lower income settings an
agenda for equity equity begins in the
communities bearing the burden of poor
health
it asks a very different set of
questions what do you need to be healthy
what is your vision for your health how
can we work together to achieve this
vision more importantly though in a
Genda for access presumes that we have
at different spaces in time an agenda
for equity recognizes our interpretive
interdependence it requires us to think
about marginalization lack of social and
economic power and the institutional
arrangements that govern our world not
as a means to delivering a medical
intervention but rather as the basis for
a healthy life and this in turn gives us
something more important it creates the
basis for solidarity and begins to heal
the divides that drive despair but I
think the real question you’re asking is
why should we the most global generation
ever care about communities much closer
to home especially when their social
beliefs and voting patterns appear
antithetical to our own values and
vision here’s why it’s taken more than a
decade but I now see take back Vermont
make America great communities as
predictive of our global future rather
than backwards as we look across various
geographies a perilous theme emerges the
feelings of dislocation and exclusion
that are contributing to poor outcomes
health outcomes here are also fueling a
political agenda that threatens our
efforts abroad scholars examining the
apparent paradox of support for a from
rural voters in rural Louisiana and
Wisconsin for candidates who embrace
positions seemingly at odds with their
own health and economic interest reached
a common conclusion in each of these
places in in each of these places
feelings of economic security and loss
of status loss of status were
contributing to what one termed a
politics of resentment analysis of
polling data from the 2016 presidential
election finds support for a
presidential campaign that’s embodied
this very politics of resentment to be
especially great in areas with poor
health and declining economic mobility
in this discontent we can trace a
roading global support for the work for
the global cooperation that underpins
our work with vulnerable communities
abroad this point was driven home to me
personally when my work brought me to
Greenland last year as temperatures rise
it twice the global average in the
Arctic Greenlandic communities are
losing this earth East sea ice on which
their survival depends as a way of life
disappears with the melting ice
Greenlanders now confront an epidemic
despair manifests in the world’s highest
rates of suicide and widespread
substance abuse the familiar pattern of
devastation
I saw weighed heavily on my mind as we
went out to sea the last day of our trip
we were too far from where large
icebergs were calving off from the ice
sheet but I could still see the remnants
floating southward watching this I was
reminded of communities beyond the
Arctic that are increasingly feeling the
health effects of climate change even as
their access to health care improves but
then I recalled the ways in which
inequities here are undermining the
political support needed to counter this
climate change there are three weeks
earlier the US had announced its
intentions
to withdraw from the Paris climate
agreement an accord seen by many
scientists is our last great hope for
arresting these changes the imperative
for equity became clear our failure to
address inequities at home in dangers
our ability to confront global health
challenges that know no boundaries of
place or time global health in its focus
on dignity offers a way to transform the
social and economic anxieties that
threaten communities everywhere into an
agenda for change the mere act of coming
together to produce health just to see
each other as human to recognize we are
not forward or backwards urban or rural
deplorable Zoar Democrats local or
global instead it forces us to recognize
we are not only individuals and
communities with agency and aspirations
for better lives but also as citizens of
a shared planet with a common future and
this is precisely the movement we need
at a moment when what ails the body also
ails the body politic it’s time to
recognize that struggling American
communities are the future of global
health and I believe that you Dartmouth
have a unique opportunity to lead this
bold new bold health equity agenda
beginning here in New Hampshire because
we all know that what happens in New
Hampshire matters not just to this
country but to this world and I know
that your generation has the moral
courage and imagination to confront the
difficult questions that so many know so
many of us in global health have long
ignored so TEDx Dartmouth let us commit
today to bring global health home for a
healthier and more equitable future for
everyone thank you [Applause]
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