Disruptive Solutions to Our Health Care Challenges with Chelsea Clinton

So, Chelsea, I really happy to have you on the doctor's pharmacy. Thanks for coming.

Happy to be here, Mark. Thanks for having me.

And I want to get into this rumor that I heard once that you wanted to be a doctor. Is that true?

Well, when I was very little, I wanted to build spaceships and satellites, and I went to space camp, which really was one of the great highlights of my childhood, partly because Sally Ride was my space camp graduation speaker.

Oh, wow. She was an astronaut.

She was an astronaut. She was the first American woman in space with NASA. She sadly is no longer with us, but remains one of my great heroines and someone I was so grateful to be able to write about in my children's book, She Persisted. To answer your question, I did for a while want to be a doctor, and I actually went to Stanford thinking that I was going to be pre-med. And then as much as I am grateful for my kind of grounding in biology, chemistry, physics, I realized in college I was more interested kind of in what today we'd call the social determinants of health and kind of public health, kind of more broadly and holistically. So that led me to get First a master's degree in international relations with a focus on global public health. Later a doctorate in the same area and to complement that with a master's in public health. So once I realized what I was interested in, I certainly didn't stop in pursuit of that and now teach at Columbia and I'm grateful to have the chance to engage with issues that I care about so deeply from both a kind of scholarly perspective, an academic perspective, and also more of a kind of pragmatic, practical perspective through our work at the Clinton Foundation.

Yeah, it's powerful. So many people don't know that you're so focused on health and health policy and health systems and, you know, the social drivers of disease, we know are actually a bigger determinant of your health outcomes than what you eat or your exercise or even smoking, that your zip code is a bigger determinant of your health than your genetic code. And I think that This is an amazing area of your work that I want to focus on today, which is how do we begin to think about these big issues that are facing us around chronic disease, around childhood obesity, around mental resilience issues and depression and kids' inability to focus and learn in school and starting behind in school, you're whole too small to fail initiative. I want to get into all that. In terms of the work you do, a lot of it's focused around the Clinton Foundation's health initiatives. And you're the vice chair of the Clinton Foundation. You're also very involved in their health matters initiative as well, and things called the Alliance for Healthy Generation, the Healthy Schools Program. I'd love you to share what you guys are doing there to make a difference, because it started as an idea and now it's massive in scope. You're in, I think, 23 million students are benefiting from some of your programs. 26 million now. 26, okay.

I'm behind the times. 40,000 schools, you know, it's impressive. Well, I don't deserve any credit for kind of the genesis of this program and certainly kind of the people who work for the Alliance deserve the lion's share of credit for the work kind of as it is today. The Alliance for Healthy Generation started really as a reaction to my father's heart scare. When he kind of had his quadruple bypass surgery to kind of stave off, as the doctors had said, what kind kind of would have been a catastrophic heart event for him. He thankfully reacted in the way that I would hope kind of anyone would react who'd had that type of scare where he said, you know, I have to radically change my life and the choices that I'm making. And to his credit, he's done a really good job on everything except for moderating his stress. I don't think he's done very well there, but he certainly has a very different diet than he had, you know, a dozen years ago. He drinks more water, he sleeps more, I mean, kind of on everything, he exercises more, kind of walks really kind of religiously. So he's not done a good job on the stress moderation, but everything else he's done well. And after he recovered, he thought, you know, I need to do kind of more in heart health. And up to that point, the Clinton Foundation had really been focused on challenges outside the United States.

AIDS TB.

AIDS TB, malaria. I mean, all work that kind of we're still doing today through the Clinton Health Access Initiative. So he called the American Heart Association. back in early 2006 and he said, you know, what can I do? And he really thought they were gonna say to him, we need you to kind of be the poster child for why men need to go to the doctor. Because as you know, Mark, they don't. Even though kind of more women have heart disease, we're also more likely to go to the doctor more quickly and more likely then to get the interventions that we need more quickly. Whereas men are less likely to go to the doctor, less likely to get the interventions they need, and then kind of more likely, sadly, to to die of heart problems. So the American Heart Association did say that. They said, yes, please talk as often as you can about why you need to call the doctor if you are short of breath, have chest pains. But what they said that surprised them was we really need help to tackle childhood obesity. It is a crisis in our country. It's not getting enough attention. We think you could help draw attention to it and help us really try to solve it in the same systems-based approach that we know you're taking to health challenges around the world. And so the Alliance for Healthier Generation started in 2006. is a partnership between the Foundation and the American Heart Association. And at its beginning, it was in 13 states and I think 231 schools. And now it's in every state and more than 40,000 schools touching the lives of more than 26 million kids. And what we do is really try to help the environments be healthier for everyone. So to help districts think about how to make healthier purchasing decisions for school lunches. help increase kind of wellness options, not only for students, but also for faculty, for teachers and staff. Try to figure out creative ways how to get physical activity back into kids' school days because fewer than 10% of elementary and middle school kids now have daily PE classes or gym classes. So developing things that might sound silly but can have a big impact.

Exercise is not silly.

Math aerobics for kids, right?

Yeah.

If you do one jumping jack and then you do one more jumping jacks you do to jumping jacks. Little things that can make a big difference because we know moving even 20 minutes a day for kids can have a profound impact on their physical health, their mental well-being, and also their ability to sit still in school, pay attention, and learn whatever they're there to learn, whether that's science or arithmetic. And one of the most important things.

I think you did was recognize that how do you create healthy schools when they're full of sugar-sweetened beverages? that these kids drink and affects their cognition and mood and makes them hyper. I mean, you get give sugar and they bounce off the walls.

So they're 90% fewer calories now in school vending machines than there were a dozen years ago because of the work of the Alliance. So you're far more likely now to see smart waters that have no calories in them versus kind of full calorie Coca-Cola. You're far more likely to see actual snack-sized chips than kind of the family size chips that had really taken over kind of these super size products that had taken over school vending machines a dozen years ago. So totally agree. It's not only about kind of what's served at lunch, it's about the other choices that not only kids, but also kind of like teachers and administrators have in schools. So anything that we can do to provide healthier choices we think is good for the schools and Good for the students.

Well, your approach is really unique because often the food industry is vilified and you took a different approach, which was to partner with them to encourage them to do the right thing in a way that worked for them and worked for the kids and everybody did the right thing.

For so many school districts, and clearly I should say, although it's probably obvious, I wish this weren't true. I wish that we fully funded public schools. I think it is terrific that LeBron James is getting all the credit that he deserves for the school that he opened this week in Akron, I wish that every child had every opportunity to go to a school like that everywhere across the country. Many school districts are dependent upon their share of the vending machine revenue. It actually goes to help maintain their facilities, sometimes to pay teacher salaries, to be able to enable the schools to have athletic activities. So for many school districts, getting rid of vending machines was not a viable choice. So we thought, well, how do we change what's in those vending machines so that there are healthier options for students, teachers, parents, everyone kind of who would be in a school on a given day, while also ensuring that kind of that vital revenue stream for schools wasn't disrupted.

Yeah, powerful. So the other thing you guys are working on is around mental resilience, mental health. You know, we're seeing increases in depression and kids and suicide's an epidemic. And, you know, you're kind of working on an interesting approach, which is the, the, too small to fail program, which basically says, you know, these little kids are starting kindergarten at a disadvantage. They're cognitively not at the level of their peers. They have trouble reading, learning. And you suggested they can, you know, encouraged them to start talking, talking as teaching. is one of the initiatives, which I think is fantastic. I also think that the food that these kids eat and they grow up on affects their brain development, cognitive function, their behavior. How do you see that playing a role?

Well, I think in some ways the answer is embedded in the question. We know that 60% of our American children show up to kindergarten underprepared. and that for many of those children who are not kind of intellectually or socially, emotionally kind of resilient and prepared for schools, it is kind of the compounding factor of often not having caregivers who understood or were comfortable with kind of reading singing and talking to their children throughout those kind of critical first years of life. Those parents are also less likely to have books at home to then be able to kind of make that kind of easy and kind of seem expected in kind of a child's daily life. They're also then more likely to not have access to, not have the ability to afford nutrient-dense rich food. They're also more likely to kind of fall into what's known as the diaper gap. You know, 10% of American families with small children struggle to be able to provide enough clean diapers for their infants and toddlers. So for these kids who show up unprepared for kindergarten, they have confronted so many kind of structural inequities and inequalities already in their very young lives. And so kind of through too small to fail, we think about, you know, how can we try to help change that? How do we help parents understand that even 15 minutes of reading, singing and talking to their kids can have a profound impact, you know, utilizing time that they're spending with their kids while kind of making a meal or in a grocery store. We've partnered with diaper banks across the country. You know, diaper time is talk time.

Right?

So we can talking to your child while you're changing a diaper, also packaging books with the diaper bundles. We've worked with food banks and food pantries around the country, so particularly here in New York City with City Harvest that does focus on trying to provide nutrient-rich food to families. That mealtime is talk time. Talk to your children about the different colors of of the fruit, the different textures of the vegetables. Every moment really can be a teaching moment. It's not only what happens in home, it's also what happens in the other places where children are. We now have dozens of playgrounds around the country. Playtime is talk time, playtime is teach time. We've worked with a number of faith communities around the country to encourage pastors, rabbis, imams, priests to help parents, grandparents, other caregivers understand why it's so important that they not only kind of maybe bring their children into those spaces, but then talk to their children about kind of what they're hearing. So really kind of anywhere where children are, young children are, is where we are trying to be to help support parents and grandparents kind of to be the best advocates for their children that they can be by making it kind of easy for them to do so. Because everybody wants to make the right choices for their kids. It's just that a lot of people don't know how to or don't have access to the resources to enable them to do so. And we don't think that should be the fate of any child in America.

And that's really focusing on the issue of the social drivers of health, well-being, cognitive function, school performance. And, you know, a number of years ago after the earthquake in Haiti, you came down. I was down in Haiti. We visited Paul Farmer's place up in the hills where he's- Yeah, and he's an extraordinary man who you know very well who's figured out that he didn't need better drugs or surgery to cure TB and AIDS in one of the worst places on the planet in terms of health outcomes, he needed the power of community, peer support. And after the earthquake, we came back-.

Well, he also needed access to the.

Drugs, but- He needed the drugs, for sure, but the drugs alone weren't enough. And it wasn't like there was new drugs that needed to be developed, we just need to be able to use the drugs we had. And so after the earthquake, we had coffee or tea, whatever it was, and you turned me onto a book called Turning the World Upside Down by the former head of the National Health Service.

Sir Nigel Crisp.

Nigel Crisp, yes. And he wrote a very fascinating book about how we need to put people and communities at the center of healthcare, not doctors and hospitals. And combined with my experience in Haiti and reading that book, I began to think about it in a much deeper way and realized that we were focusing on the wrong end of the stick in terms of getting people in the hospital. If you get someone who's a diabetic in the clinic, it's almost too late. You want to work on the social driver. So, I basically from that was inspired to work with Rick Warren and create something called the Daniel Plan, which is a faith-based wellness program using this model of peer support and social drivers. And I'm just wondering how you see taking this concept and building it into the structure of our health policy because right now we have episodic care we pay for. Our reimbursement is basically for disease management, not prevention. And also it's not even taking care of the main issue which is dealing with the social drivers of health and also the behavioral drivers. So how do you see us moving more towards that? Is there like a window of opportunity?

I think that there are lots of necessary answers to your question, right? I don't think there's one silver bullet. I think that the answers to your question range from how do we ensure that there aren't food deserts and there are kind of nutrient-rich foods available to anyone and everyone everywhere. We see our current approaches through SNAP are just woefully insufficient. Woefully insufficient in terms of total dollar amount, woefully insufficient in the different places where people can go to use stamps. Food stamps. Yeah. The Supplemental Nutrition Assistance Program. And so clearly we know what we're doing now is is not working. And we see that kind of in the heartbreaking stories of families who are not able to provide the food that they want to provide for their children themselves. We see that kind of in the statistics, right? I mean, it is a tragedy and infuriating that about a quarter of American kids have a chronic disease, right? a third are overweight or obese. We now have six-year-olds suffering heart disease. I mean, this is just unconscionable.

We used to call adult onset diabetes.

We have, yeah, exactly. So, kind of, there are alarm bells ringing and clearly our response is insufficient, right? It's how we need to think about everything from kind of infrastructure health literacy in schools to what we think of as health insurance in our country. I would argue we need to be having robust and also kind of data informed conversations in all these areas. Because I think one of our challenges too, Mark, in kind of these conversations is that sometimes there are debates around things. There shouldn't be debates around. We actually know a lot about kind of what children should be eating to maximize their chance to kind of be healthy today and to lead healthy lives into the future, right? Like we know that children should be vaccinated. We know there's no safe amount of lead, right? We know these things and yet somehow these things get debated. So no, we should be kind of listening to the experts and then figuring out how we respond to that from a public policy standpoint to support, like, every child everywhere to grow up and lead the healthiest lives possible. And we don't do that.

Well, you've been inside, obviously, the political world as well as the policy world from an academic point of view. And the challenges are that from my perspective is there's so much money in the political process that drives policy that is unfortunate and that actually subverts public good.

And I don't think there's any debate around that. I mean, it's like, how do we deal with that?

Because maybe we have to wait till Citizens United gets overturned or something. I don't know, 40 years till a new Supreme Court.

How do we begin to deal with that? I don't think we, I don't, I think two things have to happen simultaneously that of course are actually like lots of little things under those kind of two big things. One, of course, like, you know, we, need a constitutional amendment, ensuring that Citizens United is no longer a force in our country.

What is that? For people who don't know what that is.

Citizens United was the Supreme Court ruling in 2010 that effectively said that money is speech. So it opened the floodgates for unprecedented amounts of money to flow into politics. As one example, like the Koch brothers said they're going to spend $400 million in this midterm cycle alone. Unbelievable. And so that has distortive effects in two ways, Mark. One, of course, in kind of what they're pushing, which is largely like an anti-regulatory agenda. And this is not to say the Koch brothers are the only ones to do this. They're just sort of the ones who do it at the greatest level.

400 million level.

And so it's both kind of their anti-regulatory agenda which we know is bad for public health. It's not good that chemical companies will be able to release more effluent into our water sources. That is a bad thing. It's not good that more of our public lands are going to be open to more drilling, more fracking, more harvesting of old growth forests. I don't think any of this is good from a public health perspective, but it's also terrible because it then crowds out space for conversations that we should be having around how do we ensure that there's no lead paint on any walls any longer, including here in New York City where there's still lead paint in some of our public housing. So I think it's distorting in a couple ways. That being said, I don't think we can wait until Citizens United gets overturned to keep pushing for what we think the right answers are. And I do think at the local and state level, in some places we're seeing some really remarkable progress, kind of what's happening in some community health centers around the country, what's happening in some public school districts around the country where school districts are really positioning themselves kind of to be health advocates not only for their students but also kind of for their families, you know, keeping public parks open, kind of earlier and later. I think we're seeing lots of local efforts that deserve our attention and our support, and also should be pressure points for trying to move the national conversation forward too.

Yeah, it seems like a lot of things start in the periphery and end up in Washington after they've already been proven, tested and accepted. And I think the state and local governments are bigger advocates for some of these policies. I mean, Governor Brown created a parallel climate change conference and bringing people from all over the world, which is sort of almost saying, okay, well, we don't need the federal government. We're going to do what we want to do because it's right. And I think the food system is, to me, also a big issue. And the food policies we have in the country are often subverting public health, our subsidization of commodities that get turned into processed food, our funding of food stamps through or SNAP, which 80 plus percent is probably for junk food, $7 billion a year is for soda. And yet, you know, we know the data on this very clear that soda is linked to sugar.

I know, but I struggle. I don't think the government should be telling people what food they can buy candidly. I don't think we should not stigmatize poverty any more than we have. So I think we need to be making SNAP more generous, not restricting the choices that people can make with it.

So, maybe incentivizing good stuff.

Well, I mean, I just don't think I'm not a believer in regressive policies. And so I don't support, and there are people who do support restricting kind of what SNAP could be spent on. And I'm not in that camp. I do think, though, clearly, as we're seeing now, with President Trump responding to the consequences of the trade war that he started by now providing additional subsidies to the farmers who are being most hurt by that. That is an absurdity. But certainly we have to have a real conversation, I think, again, informed by data and evidence about kind of what farming is. I mean, there's a book that I'm really looking forward to reading written by an author whom I don't always agree with, but I always respect Sarah Smarsh, who writes for the Guardian called Heartland. That's the story of her family farm in Kansas, five generations, and then why they had to ultimately sell their farm. So the story, I think, of our food industry is also, how do we ensure that family farmers can still be family farmers if that's the choice they're making. And how do we continue to produce more diverse food staffs around our country and also ensure that more people can eat more local food? I mean, that's not only, I think, good for them, but it's also would be helpful in our fight against climate change, something else that is a debate that shouldn't be.

Yeah, right.

Yeah.

And I think most people don't recognize that a lot Climate change has to do with our food system. 40% of our food is wasted. A lot of it ends up in landfills and off gases and creating methane, which drives climate. Totally.

It's both about how do we recover, rescue food and then ensure that we don't need to recover and rescue it because we're using it in kind of smart and efficient and healthy ways and health enhancing ways. It's also about the transportation costs of food, right? So how do we ensure that we're kind of building vibrant local ecosystems that help really support kind of total health of everyone kind of living and working there.

It's fascinating. I talked to a guy the other day named Ben Simon who started a company called Imperfect because it turns out of the 40% of food wasted, 20% is basically ugly food that the farmers can't sell to the grocery store. They don't want it, whether it's a funny looking tomato or a carrot.

So, that's a huge part of the food that City Harvest rescues directly from farms is this. So like the tomato that's slightly misshapen or kind of the banana that's not as long as the rest of the bunch. And absolutely, I mean none of that food should be wasted. We also have a real challenge in this country and the conditions under which a lot of people work kind of on our industry.

Farm workers.

Farms. And so I don't think this conversation can happen without also thinking about, you know, What does it mean to ensure that, you know, our food system is enhancing the health of everyone, including the people who grow, harvest, you know, produce, manufacture food? Because we know that, you know, in certain kind of farm worker communities, they're higher cancer rates, probably tied to the pesticides that were used.

Parkinson's.

We know that, There are higher rates of occupational injury in some parts of the food industry and just none of that should be acceptable. So also thinking about the dignity and the health of farmers and farm workers and food workers in general, I think also has to be part of this conversation.

Absolutely. I mean, the price of our food is pressed low because of how we have foreign policies that are unfortunately taking advantage of workers and the conditions are poor. In fact, farming farmers are probably the highest risk for disease. It's one of the most dangerous occupations. People don't realize that.

Well, and July is one of the hottest months on record.

Ever.

And so again, as we think about global warming and climate change, that also has to be accounted for not only in kind of how that is affecting what can be grown when, but also how we think about protecting workers, right, who are working in these, you know, outrageously hot climates. And I don't think we're doing enough kind of thinking about any of this. And I wish that kind of these were the conversations that, you know, we were having more of, you know, in Washington and around the country. And I know they're happening in some places, but they really should be happening everywhere because as kind of trite as it sounds, like, you know, we all need food. Yeah.

I mean, we need it regularly. I mean, you know, I think about climate change, aside from our food system itself driving so much of climate change, whether it's how we grow food, how we deplete the soil, the lack of ability to hold water in soil that's tilled and farmed in traditional industrial ways. You know, we actually also know that climate change is causing health consequences and climate change refugees that are increasing burdens on societies all over. So how is the Clinton Foundation working on the climate change issues and what are you guys doing around that?

So our area of work kind of in the big kind of world of all that needs to be done to protect our world, kind of from the effects of global warming and climate change, we narrowed in and again kind of this this started with my father on small island nations in the Caribbean, but also really around the world. And how do we try to increase small island nations resiliency and also their ability to recover more quickly from the extreme weather events that we have seen kind of often hit small island nations the hardest and are unfortunately expected to continue to do so. And so that means a few things. One, so many small island nations are heavily dependent on imported diesel for their fuel. That is not good for the environment. It's also a huge tax effectively on people living in those countries. In St. Lucia, for one example, some families spend 20 to 25% of their income just on cooling their homes, turning on their lights, kind of filling up their cars to get to and from work. And so trying to figure out how to help small island nations literally harness their renewable sources, you know, the sun, the sun, but also for many wind, geothermal. And so we're working kind of with a number of small island nations kind of to help them, you know, really write their own renewable energy plans that will help them become ultimately independent of imported diesel, something that really should be able to happen in 20 or 25 years, so not that long, like a generation. Dramatically lower their own energy costs and also to help them think about resiliency from a broader infrastructure perspective so that they're kind of fighting climate change in their own way but also going to be more robust in dealing with, unfortunately, the consequences of climate change that we're seeing in increasing numbers of extreme weather events and in the increasing severity of those extreme weather events that are particularly affecting small island nations in the Caribbean and around the world.

So you have a unique perspective around global health because since you were a little girl, you've been traveling to pretty much every country on the planet and you've seen things change over time. And so from that perspective and your perspective of knowing a lot about public health and global health policy, what are the biggest challenges we're facing now around global health?

Well, I think- what can we do about it? Well, I think it's important to note how much progress we've made. In the last, let's say like 25 years, extreme poverty has been cut dramatically, extreme malnutrition has been cut dramatically, unprecedented progress. vaccinated numbers of children are vaccinated around the world, child mortality has declined dramatically, and yet a million children still die on their first day of life. A million more die in their first week of life. When they die of things they shouldn't die of, right? They die of blood loss, oxygen loss, and we know how to keep almost all of these children alive. We know how to also keep most of the women who die of childbirth consequences alive, and yet we don't have the kind of right resources in the right places to do that. So I think, you know, we have to continue to build on what we know works, right? You know, training community health care workers, paying community health care workers, you know, that's particularly important, not only because it kind of validates and values that vital work, but also because it's really important candidly for gender equality in so many places. Many community health care workers are women, so kind of paying them for their labor and also increases their own kind of agency and independence. Continuing to help support countries in building their own health care systems, not only community health workers, but One of the reasons that Ebola was such a tragedy in Sierra Leone, Liberia, and Guinea a few years ago was because it not only preyed upon the networks of care, wiping out whole families, killing the healthcare workers who were the first responders, but because there were so few doctors and nurses and healthcare workers in those countries to begin with. One of the things that we're doing through the Clinton Health Access Initiative in partnership with Partners in Health and Paul Farmer is trying to train an entire healthcare workforce for Rwanda. So that within now a little less than 10 years, hopefully Rwanda will need no kind of foreign assistance for health because there will be a real network of nurses, of technicians, of nurse practitioners, of doctors, of specialists, of kind of public health advocates, you know, really kind of just every part of the healthcare system. And so I think if we can keep doing more things like that, Mark, while also, of course, kind of pushing for more access to clean water and better sanitation, right? Two and a half billion people around the world don't have a good place to go to the bathroom.

Yeah.

Right. So there's some basic things we need to get right to.

Flush toilets.

But, We also need to recognize that some pretty seismic systemic changes are possible if we have a clear vision of what we want to happen and if we continue to put people and communities at the center.

A number of years ago I read an article in the Journal of the American Medical Association that woke me up because it said that while there's still 20 million people a year that die from infectious disease and malnutrition, diarrhea and so forth. There's over 50 million that are going to be dying of chronic lifestyle preventable disease. And I remember at an event I gave the paper to your dad. I was like, this is really a huge area we need to think about because it's not just in the developed world we're seeing these chronic obesity related diseases, but we're seeing it increasing in the developing world where 80% of the world's type 2 diabetics are in the developing world.

Heart disease is the number one killer in most countries around the world.

And they're not equipped to deal with it.

And they're not equipped to deal with it. Also one of the challenges though is that a majority of the poorest people on earth now live in middle income countries and all of our development and aid systems are structured to focus on country income levels. So the question is how do we continue to reach people with resources wherever they are and whether that's trying to save the 750,000 kids every year still die of diarrhea, which I think is unconscionable, something that we know how to prevent and treat, something no child should die of. Or the growing numbers of people who are suffering from heart disease and may well die from that. And how do we think about that work in countries of different resource levels while also recognizing that we have a lot of work still to do in our own country, because heart disease here you know, is more likely to be fatal in people of color, right? More likely to be fatal in women of color than white women. So, you know, we also have the same Health disparities, gross health disparities in this country and, and need to have a laser-like focus on, on our own challenges here at home while also trying to do what we can everywhere else as well.

Yeah. I mean, it's a huge burden, and I think, you from Paul Farmer's work around community health workers dealing with TB and AIDS and malaria. It struck me that that work also is effective for chronic disease. You might be aware of this, but there was a study done by Piers for Progress, which was from American Academy of Family Practice, where they went to Uganda, Cameroon, South Africa, and Thailand, and they took these diabetics who were really uneducated. They gave them a flip phone, which I think they could text with, and they got them working together in community to help each other and support each other. had a dramatically lower, I think 50% reduction in health care costs. They had improvement in health outcomes, their blood sugars, their blood pressure, their weight, better than actually doctors visits, 10 times as effective as doctors visits. So I wonder if in these communities, how do we begin to sort of think about building those structures that take Paul Farmer's work and build it in the chronic disease world?

Well, and ensuring that there is meaningful support to sustain that work, right? I am thrilled that the government's going to allow Medicare Advantage plans, although I would be significantly more thrilled if they did it for Medicare overall because two-thirds of Medicare enrollees are still in traditional Medicare to actually pay for things like transportation to and from your doctor so that you don't miss a doctor's visit because you can't afford to get there. possibly paying for subsidized healthy food so that if your heart disease patient and your doctor says you actually need to be changing your diet, Medicare may now pay for that. Something else that they may pay for are some of these community participatory programs that we've similarly seen, whether kind of PACE in San Francisco or otherwise, that our older Americans, men and women alike, are more likely to be healthy less likely to have depression, more likely to live longer if they're in supportive community environments. Yeah, that's true. And so we should be incentivizing that. We should be paying for it because we know that it works.

Yeah. I mean, you remind me of a recent project by Geisinger looking at diabetics with the food pharmacy.

I saw that, yeah.

I mean, the $2,400 a year in food for these food insecure, poorly controlled diabetics along with group support, basically health coach, nutritionist, helping them change their behavior. Very, very decentralized care. It didn't need a well-trained endocrinologist or doctor. And in one year, they saved an average of $192,000 per person. These were really high utilization of healthcare. And it's a scalable model. An ounce of prevention is worth a pound of cure, right?

I mean, we're doing this at Cleveland Clinic now.

We're creating an initiative where we're going to pilot this and we want to get Medicare to reimburse this so that we can actually- They should. They absolutely should. It makes sense for them, but right now we don't have evidence-based medicine. We know the evidence shows this works. We have reimbursement-based medicine, I joke, and that's unfortunate.

But I think those are the kinds of things that I think will move things forward if we can shift that. I'm a huge believer and we should be fighting for what we think the perfect answer is, but we can't let the perfect be the enemy of the good. So while we kind of fight for what we think the right Systemic answer is we also have to figure out how to make kind of the here and now work best for every person as much as possible. And I think what you're doing at Cleveland Clinic is very much in that vein while also hopefully helps put pressure on kind of what we think Medicare writ large should be doing as well as Medicaid and commercial insurers.

Yeah, I mean it's stunning to me that the way the system is set up now, they'll pay for $190,000 of care, but they won't pay for $2,500 of food that gets much better health outcomes and reduces costs. It's pretty stunning.

Well, also, not only physical health outcomes, but also mental health outcomes and just the sense of well-being that we know is similarly associated to more controlled diabetes and healthier food.

Yeah, it's powerful. All right, I'm going to take a look.

Preaching to the converted, Mark. Yes, true.

I just want to take a a little tack into women's health, women's rights and disparities in women. And I know you and your mother worked a lot on this. I think your mother was one of the first to say in Beijing and 90s, you know, women's rights are human rights and human rights are women's rights. And I think that was a powerful statement. I think it's true across the board for all humans, but certainly for women, it's been an issue. And I was struck by a book I read called Drawdown by Paul Hawken about climate change. And aside from the food system, if you combine, you know, educating women and actually managing fertility and reproductive health, that those two alone would be greater than almost any other thing we can do for climate change, solar energy, wind power, all of that. And I was struck by that because it sort of speaks to how powerful women are across the globe in determining health outcomes and determining the choices that their families make that have global impact. So what kind of work are you doing in that to sort of help elevate women out of that harmful situation?

Well, certainly kind of thinking about the Clinton Health Access Initiative, you know, ensuring that women are able to in the countries, kind of where we do deep work, access a full complement of prenatal and antenatal care, are able to access a complement of reproductive health choices for themselves, including injectable, long-lasting, reversible contraceptives, so that they're able to make those choices without kind of pressure from their husbands, I think is increasingly central to our work, ensuring that that Gartcel and other HPV vaccines are kind of more widely used and distributed because cervical cancer is a major killer of women in some of the countries where we do genital wart.

That actually causes cancer.

That actually causes cancer. So ensuring that we're continuing to kind of increase access there in our climate change work and we work to have real, not just gender representation, but wherever possible kind of gender equity in our local climate change commissions and resiliency and kind of energy planning commissions. So ensuring that women are not just kind of shoehorned in but are kind of central to these conversations because we know that representation really matters in our healthy schools work, ensuring that kind of the schools, particularly where we do the deepest work, are really mindful of how body image kind of plays a role in the food choices that often girls are making or are not making and how to be thoughtful in encouraging girls to make healthier choices. Because we know that obesity is more likely to occur in girls more quickly. It is also more likely to occur in girls of color more quickly. So this is a social justice issue, a women's issue, as well as clearly kind of a health issue.

Yeah, 80% of African-American women are overweight.

So we try to ensure that kind of women and girls are embedded kind of in a very kind of central way in all of our work and everything we do. Because I don't think that you can think of women's issues as separate from any of these questions. That being said, I think now, taking off my foundation hat and putting on my advocacy hat, we know that women's rights are under assault in this country. We know that it is not histrionic to worry about Roe v. Wade being overturned if Kavanaugh is confirmed for the Supreme Court. You mentioned the book that talked about women's reproductive agency around the world. Women from the 1970s through 2009, just an entrance to the US labor market alone, added more than $3.5 trillion to our GDP. You can't separate out that rather stunning statistic from the fact that Roe v. Wade was in 1973. Those two things are not unrelated. Unrelated. Deaths from botched abortions declined dramatically from 1973 onward, pretty drastically, within a decade. And so we know that this isn't just an issue around the world. We know it is an issue here at home. And the sustained assault on Planned Parenthood is troubling. because women should be able to make whatever choices we think are right for ourselves and our family and should be able to access those services in actually accessible ways. Like you shouldn't have to drive across the state border or across the state to do so, but also troubling because most of what Planned Parenthood does is not related to reproductive health services. significant amounts of breast cancer screenings, significant amounts of heart health screenings. And so the assault on Planned Parenthood isn't only an assault on women's reproductive health agency, it's really an assault on women's health in totality. And so, I think all of us who recognize that and know that have to stand up against the attacks on on Planned Parenthood, one, on the attacks on women's reproductive health, two, and just the attacks on women in general that sadly also seem to be gaining greater traction these days. Yeah.

All right, last question.

Okay.

Last question. You have a really deep, broad understanding of health issues and the health consequences here and globally. And you have thought deeply about what are the levers for change? And clearly, this may be a redundant question because you already are doing it with the Healthy Schools Initiative, Women's Work, Climate Change Work, Chronic Disease Globally, Infectious Disease Globally. These are all efforts that you're engaged in and clearly because you think those are some of the greatest levers. But if you were a queen for a day or president for a day, what would you do to try to have the biggest impact to change things that really matter?

Oh, wow. Well, yes, well, we don't live in a monarchy, despite our current president's clearly...

He's trying.

Yeah. Clear kind of wishes to the contrary. So I wouldn't be queen. But I guess if I had a magic wand, if I had a magic wand, I would ensure that everyone had access to clean water, right, everywhere, you know, from kind of flint to Fiji. One of the great tragedies is kind of Fijians don't actually have access to the water that we drink out of the Fiji bottles around the world, which is one of.

That's disturbing.

Many, many disturbing aspects of kind of what people confront across the globe. All right, so one, clean water, you have two access to safe sanitation. You have three access to full complement of vaccines, four access to good, safe, secure, supportive education, and five, ensuring that girls and women had every opportunity, every expectation, every support, kind of equal pay, equal rights, kind of equal agency to boys and men around the world. I think if we had one of those five things, I think people would be a lot, a lot healthier and a lot better off. And yes, then hopefully you can kind of do six through ten and solve our food system problems with your magic wand.

If I had a magic wand, yeah, I have somebody thinks I would do.

But this is great and stop the earth from warming expected more than two degrees over the next century.

That's what's fascinating. By fixing women's issues and food issues, we could actually draw down carbon and actually help reverse climate change.

And don't forget clean water and sanitation.

Yeah, I mean, I know people don't realize that water is a big issue. I remember being at the World Economic Forum a few years ago and Jim Kim, the head of the World Bank, said the wars of the future will be fought over water, not oil. Only 5% of our Earth's water is fresh water and 1% is in Russia, so I don't know what to do with that. And it's being depleted at incredible rates in large part because of our farming. A lot of it's used for irrigation across the country.

It's not being replenished in part because of climate change. So today, actually, August 1st here, we'll end on a sobering note. Today, August 1st, when we're recording this, is the day that we now have kind of crossed over into depleting of the Earth's resources. So that means that kind of we're using in seven months the amount of resources that it should take us a year to use. And kind of this day moves earlier every year.

Yeah.

So every year we more quickly kind of use our, like, estimated allocation.

We're borrowing from the future.

We are literally borrowing from the future.

Amazing. Well, thank you Chelsea Clinton for joining us on the Doctor's Pharmacy, a place for conversations that matter. If you like this podcast, please subscribe, leave a comment, review, and share with your friends and family on Facebook and Twitter. And we'll see you next time on the Doctor's Pharmacy.

Great.