Making Big Bets: How To Completely Change Your Life & The World In 2024 | Rajiv Shah

These things matter and they actually ripple and they affect things.

It is shocking to me how often people don't believe something is possible and that's the first step. Why are so many people in America subject to chronic disease? Why are our rates of chronic disease so much higher than every other country on the planet?

And we spend twice as much on healthcare.

And we spend- Way more than twice as much on healthcare. And when you actually start with a blank sheet of paper, the answers are what you have talked about very eloquently in your books and on the podcast, which is it's what we eat and it's how we live. And it's not actually because our healthcare.

System- no, it's not a healthcare problem.

Lacks technical skill or technology to address chronic disease. And in fact, if you go back even farther and look in the 1970s, as part of a grain war with Russia. Basically, we reshaped American food policy and agricultural policy and went towards a policy that encouraged farmers to just grow- Go bigger. Go fence row to fence row, right? And ever since then, you've seen American productivity in agriculture go way up and price per calorie go way down and calories consumed go up almost in equivalence with pricing go down.

An extra 500 calories a day per person. And when you add that up over a year, that's like 50 pounds a week.

Exactly. And it's extraordinary. And that's why Americans were so vulnerable to COVID and COVID related mortality and morbidity. And it's a shame and it's inexcusable. And so when you and other thought leaders constructed a vision around how food itself could be the medicine that avoids that chronic disease pandemic, we were excited to learn from you guys and women and to construct a big partnership with, in this case, the American Heart Association and the White House, the Biden White House, through their Hunger and Nutrition Summit to say, let's make this a discipline in the United States. Let's really learn how to make sure people can get access to food in a way that dramatically changes real medical indicators of chronic disease like hemoglobin A1C levels. And then let's get insurers and public sector insurers like Medicare and Medicaid to pay for it. so that we can make fresh and healthy meals available to people who are otherwise either food insecure or vulnerable to chronic illness and chronic disease. And I think if we can do that together, it may take decades, hopefully not, hopefully we can move faster, but if we can bring public sector and.

Private sector together- that's why I'm working on longevity so I can be around when it happens.

We can change the nature of health in this country at scale, and that would be a big bet worthy of really committing ourselves.

It seems like one of the most important bets, because it's not just here globally, there's twice as many deaths from chronic disease globally, even in the developing world, than there are from infectious disease. It's the number one killer is food, 11 million deaths a year. I think that's conservatively from the Global Burden of Disease Study. And looking at 195 countries, and it's a solvable problem, just like vaccines could solve preventable childhood deaths, this is not something we need to have new scientific advances in or new discoveries or anything really that sexy, except getting people access to the right food and helping them support those changes they need in their behavior to implement that. And I think it's almost kind of not thought about as a solvable problem because when I'm meeting in Washington, we're here in Washington, DC today at the Rockefeller Foundation headquarters, but I'm also, I've been going around meeting with congressmen and senators and their staffs. And part of the problem is it's just kind of a lack of understanding about how to think about this problem differently. You know, Einstein said, we can't solve our current problems with the same thinking that created them, right? We have to have different thinking. And that's what you really talk about in Big Bet, which is how do you think differently to get the results? And you've had big results, sometimes with small efforts, right? You talk about you and Mitch Landrieu when you went down to New Orleans after Katrina. I know Mitch, he's an amazing guy. And they were in all these Confederate statues and he was trying to solve for addressing this as a problem because why we have monuments to people who were really celebrating slavery? And it was very political, very controversial. The workers had to wear bulletproof vests and have masks and no one could see their faces. It was quite a thing. But you decided to make a bet on Mitch. And it seemed like a small thing, take down a few statues in one town, but it had a huge ripple effect, right? Can you talk about that?

Well, it did. This episode happened right when I started at the Rockefeller Foundation. I had visited New Orleans to really look at a lot of the work we did to rebuild different communities in New Orleans after Hurricane Katrina. And Mitch and I were walking through town and the first thing you realize walking through New Orleans with Mitch Landrieu is he knows everybody in town.

And their first and last names.

And their first and last name and their kids and their stories and what an amazingly well connected you know, community leader and mayor, extraordinary mayor. And he had worked for years to build consensus around the community, around taking these statues down. And, you know, he felt as he talked to kids, especially young black kids in that city, that there was just no reason to be staring up at a 60-foot statue of Robert E. Lee who had never visited New Orleans as part of a military campaign. And all those statues were put up. in the 1890s and turn of the century as part of an effort to intimidate and terrify the black community. And in fact, one of the statues actually celebrated an attack on the integrated police force of New Orleans, which was an extraordinary act of terrorism, and it was sort of celebrated as one of the statues.

Was that during Reconstruction?

Yeah, yeah. And so Mitch did all this work. When they started to take the statues down, the contractor who was leading that effort, had his sports car firebombed in his driveway near his home and basically pulled out of the exercise for personal safety. And it became a much riskier, much more costly thing. It also became much more political. So the state government was intervening and threatening to prevent them from doing things. So they had to move fast and Mitch sort of asked me to pay for the cost difference between what they had and what they needed now that the costs had gone up to get an out-of-state contractor.

You basically had to have mercenaries protecting them.

Exactly, yeah. And to take this down. And I was just fairly new to this Rockefeller job, and I was like, well, I don't think this is how we make decisions. We have program officers who know their subjects for years and years, but I made some calls and realized, you know, realized that it was just worth making a bet on Mitch. You know, he had a vision for what he wanted to do. He had community support and we had hours to days to act. So I said yes. We went ahead and provided those resources. He took the statues down and that led to, and who knew it would have led to this, but it led to a movement across the country to ask ourselves the question, should these public monuments often put up to intimidate should we have a reconciliation around that. And then that blew up even further during that violent episode in Charlottesville, Virginia, where people lost lives and where it really became a flashpoint in American political life. So, you know, sometimes making big bets is about betting on others who have worked tirelessly to create a vision of what's possible. And I was fortunate to have the opportunity to bet on Mitch and what a great leader to learn from.

What it kind of inspires me about that story is that, you know, it kind of reminds me of what Margaret Mead said, right? That, you know, never doubt that a small group of highly committed people can change the world. In fact, it's the only thing that ever has. And, you know, you bet on Mitch and, you know, his crew down there. And that led to this cascade effect. And, you know, So some ways making big bets might not be, you know, I'm gonna end world hunger. It might be, I'm gonna start in my community, but that has a potential effect down the road. And I think we see that happening. And, you know, and I'm sort of inspired by your vision of how we think about things. And for me, I've been trying to think about as a doctor in the trenches, seeing in my lifetime the explosion of chronic disease and obesity. I mean, I'm older than you, but when I graduated medical school, there wasn't a single state that had an obesity rate over 20%. Now most have 35% and I think 42% is the average in the country. So, you know, this is just in a few, literally a few years, I still remember, you know, when it was not like that. And I think the costs are escalating and it just, it seemed like such an overwhelming problem. And I think, you know, members of Congress and people even in the administration, are not, you know, kind of thinking about this as a central problem that's affecting so many things we care about. And to me, food is the nexus where it all comes together, right? Chronic illness and its burden on, you know, human capital, its effect on social capital because of the effect of this on our children and their academic performance, on our military readiness, because kids are unfit to fight. 70% get rejected because of its effect on social injustice and health inequities, its effect on climate and the environment. from how we grow our food. And so I begin to sort of see that and the economic burden, which is staggering, right? I mean, think about if we had the extra trillions of dollars that we spend unnecessarily on this problem because we're like mopping up the floor while the sink's still overflowing, what else could we do? Could we have, you know, universal education for people? Or could we have universal health care? I mean, what could we do as a society, uplevel our people, public health? And so, you know, it's such a daunting, intersecting set of problems. How do you think about this? Because you're in such a leadership position, you're so respected, Everybody knows who you are, listens to you and sees the big things you've done. And now you're focused on this issue, which to me is like, makes me dance the jig, really, honestly, when I go home. And that not only that you're thinking about it, but you're actually doing things. You created a report on, for example, the true cost of food, which means we spend $3 for every $1 we spend on food. We spend $3 in collateral damage on health and social human natural capital. all of it. And you know, I'm putting 250 million into food is medicine. You're trying to create the periodic table of phytochemicals with Dari, which is 200 million dollar effort. I mean, these are big bets. So how do you see your role and in kind of being a catalyst, an agent? You were talking earlier, we were chatting about a meeting you brought together like 20 plus congressmen and senators and Republicans and Democrats in Italy to kind of have a think tank about how to solve this. And you were sort of inspired by what you were hearing. So what on the ground, when you're in the trenches, how are you seeing us making the bet on this? And what are the things we need to think about?

Well, I write in the book about a methodology for making big bets that I think is very applicable here. It starts with saying we're not going to let this be a couple of great pilot projects that excite us, but don't go anywhere. We're going to actually set a big goal, like eliminating 50 or 80 or 100% of chronic disease in the United States as an example.

Amen.

And then the question is, do we really know enough about the innovations and solutions to get us there. And I think this is where the community of scientists that you've helped lead and build over time have a ton of data that shows that in a targeted, efficient way, improving dietary intake can reduce medical endpoints of chronic disease in certain populations, certain settings, and where we're investing the 250 million with a set of partners to expand that data set. So the solutions are clear. the next step is really saying, do we have the right partners around the table to take this to scale? And this is the part I'm most excited about because in our emerging partnership, we have Kaiser Permanente, we have a group of insurance companies that are saying, look, we're not sure how, but if you guys generate the right data, we should start considering reimbursing for this. If you think about it, it's somewhat insane to be paying for Wegovy and Ozempic and not just healthy food. I'm not against those medical interventions, they can be extremely helpful. But at scale, do we want to have dietary practices that make us unhealthy and then take $1,000 a month medical intervention? Or do we want to just- Or.

Is it $2,400, $2,700 a month?

Yeah, exactly. Or is it better and more scalable to just use food as medicine in a targeted and effective way? And so getting those partners, Public private is a big theme through the book. And I think having public sector insurers like Medicaid and Medicare have a clear pathway to reimbursement is mission critical to making this work at scale. And so we'll keep sitting with, as you and I have, with Republican and Democratic senators, right, at those dinners. And they come and they, and people, why are they doing it? They're not doing it because they read a report somewhere. Frankly, they show up at these things because somebody had a heart attack. Yeah. And they learned about how their diet can help prevent the next one. And then they want their brother or their sister or their father to benefit from that knowledge, right? And I have a whole chapter in the book called Make It Personal about basically crossing the political divide. Nothing is more personal than a person's personal health story. And I think we can build extraordinary relationships and consensus across the aisle in this country to do something as big as this. Disease is not red or blue. And you and I have been sitting there and we're like, oh my gosh, these folks are having the same experience whether they are a liberal mayor of a big American city or a conservative Republican senator from another farm state. And then it really is about measuring results and communicating what is known and what we're doing at scale. I find that basic methodology, focus on fresh innovative solutions, identify the partners you need to go to scale and do anything it takes to build kind of consensus and collaboration and then keep measuring results. It's just mission critical. And I think a huge part of this effort will have to change American policy on the agriculture side and on the health reimbursement side. I look forward to a day when, you know, kids going to med school learn something about nutrition.

My daughter's in med school now.

I wasn't the world's best medical student.

But I did not learn.

Yeah, you were busy getting economics degree. I didn't learn much. I was a little distracted. But even if I wasn't so distracted, I wouldn't have been taught a whole lot about food as medicine and about.

The primacy of nutrition and American chronic diseases. Yeah, this is important. The moment it seemed like things really changed for you was when you saw Nelson Mandela. He recently got out of Robben Island. He was released from prison. He came to America. He came to Detroit. at Tiger Stadium, where you'd watch many games, and he gave a speech that you watched in your living room with your family. Can you talk about that moment for you and what actually went through your body and your mind and your soul that actually made you inspired to become the man you are?

I grew up in a pretty normal family, in my view, in a middle class community in suburban Detroit. My dad, as you pointed out, my parents are both Indian immigrants. They came here with educational scholarships, but no actual resources. And as you noted, my grandfather famously emptied his, well, famously in our family, I guess, emptied his rupee-based retirement account to buy a one-way ticket for my dad to come here.

And think about that. I mean, what it was his nest egg was basically the price of a plane ticket.

Yeah, but they just thought if you could get to America and you were smart and hardworking and you played by the rules, your family would be great. You know, that was their unyielding belief. And for our family, it largely turned out that way. And my dad worked at Ford for 30 plus years. And while everyone in my Community growing up was somehow connected to the auto industry, it was Detroit in the 70s and 80s.

Yeah. And.

And one day, I must have been a junior, a senior. I think I was a senior in high school. Nelson Mandela was released from prison, as you point out, and came to Detroit, of all places, largely to say thank you. And he walked on the floor of the River Rouge Auto Plant, a place where Henry Ford kind of invented the assembly line and vertical integration in American manufacturing. And he told a group of UAW auto workers, Thank you. for your support. And then he went to Tiger Stadium and this huge event. It was all Motown. It was Stevie Wonder was open for him. And then he gave the speech. And he closed all his speeches in Detroit with this extraordinary phrase where he would say, To the people of Detroit from the people of South Africa, I want to tell you that we respect you, we admire you, but above all, We love you. And I just thought, amazing. Someone in a jail cell for decades comes out with such warmth and openness and optimism and love. And I just, I sat there and get goosebumps now. I sat in, I was just watching on TV thinking, I want to do something with my life that helps other people.

Yeah.

But honestly, I didn't have any clue how, you know, I grew up in an Indian American family. I was either going to be an engineer or a doctor. kind of took my shot at both. And I just didn't know how do you become, if you're not going to be Nelson Mandela, which none of us are, how do you have a path that allows you to imagine changing the world at scale? And it wasn't until a few years after all of that that I started to see how that could be the case. And I wrote the book, Big Bet, so that other people who have that yearning and desire to make a difference but might not exactly know the path or the way to do so can feel confident that there's an opportunity out there for you.

Yeah, it's a powerful story. I think, you know, we first, I don't know if you remember this, but I actually first talked to you when I was in Haiti right after the earthquake. And I went down there on the first plane. It was actually a friend of Hillary Clinton's that had become a patient and he had a jet. He's like, let's go to Haiti. And I'm like, okay. And we put together a crew of, you know, two ICU docs, a nurse anesthetist, two orthopedic surgeons. We literally filled his Gulf Stream up from floor to ceiling with medical supplies. I ran around the hospitals begging, and I got there, and it was just a disaster, literally a disaster. It was, I think, unimaginable. Like, I think two, three hundred thousand people dead, two, three hundred thousand people injured. The hospital in Porter Prince was through the epicenter, and, and people were just abandoned there. I mean, the patients were abandoned. It was a medical director and the nursing director, and everybody else was gone. And, you know, he called, I called Hillary to ask for help, and then she can put me in touch with you. And, you know, we kind of coordinated on some things. But, yeah, you probably don't remember me back then, but it was, you probably were doing it so much, but you basically were, like, appointed by Obama. And six days or something after you got the job as the head of USAID, you basically had to deal with this Haiti crisis. and what was that like for you?

Well, so- and they're like, by the.

Way, I love the story where you walk into the Oval Office and Biden's saying to Obama, I don't know about this kid, he's 36 years old. Is he up to the job? What are you thinking, Barack?

It was amazing. The day the earthquake, I was about a week into my job. And it was the first time I visited the US Aid Operations Center and I went up there and then they're like, you, got to get back to your office. I think the president's gonna call you. So I get back to my office. I had, I just started, I didn't have any of my appointees in place. And the Senate was sitting on a bunch of confirmations. So it was just me.

You were the USA.

I was the Obama administration in USA. So I had my Blackberry and I was like holding it near the window, hoping I got enough bars so that when I got a call from the White House, I didn't kind of screw that up. And they call and they're like, president would like to speak to you. I was like, great. And of course, he comes through and he's like, Raj, this is the largest humanitarian catastrophe we've ever seen. It's less than two hours from our shores. As you noted, hundreds of thousands of people are gonna perish. We have to do everything we can to show America's power can be used for our moral purpose. And he was so clear about what he wanted. And it was funny because I actually had a notepad and I thought, I didn't know it was my first phone call from the president as your boss, calling. So I had a notepad out. It was a little intimidating. Exactly. I was going to take notes because I thought he'd be like, now you do this, this, this, this. He was going to give you a roadmap.

And I said, absolutely, sir.

And he said, make us proud. Here you go. Waiting for my roadmap.

And the phone line goes dead.

So I look at my BlackBerry and I was like, did I just drop the phone call with the president? Thankfully, I didn't because we had CNN in the office and he went straight to the the press room at the White House and got behind the podium and he says to the American public, he's like, I just spoke to Administrator Rod Shah, I'm putting him in charge of a whole of government response. And I've directed this, this, and it was like everything. It was like I've directed the Coast Guard, I've directed the US military to.

Be at his disposal.

Like all the things- so those are your bullet points. Those were my bullet points they just transmitted on television. And I thought, okay, this is my roadmap. And then the next morning, we were in the Oval Office to brief the president. And that's when I got there a little early and he and the vice president were having a chat about it. And I will say Vice President Biden and now President Biden, of course, has been an incredible mentor and supporter of mine. And I'm very grateful for his leadership, too. But that's when they were having that conversation when I walked in.

Yeah.

So, yeah, I try to try to write in the book about both. the challenges of doing this work and also kind of how it feels to be involved in some of these settings. Because as you've had this experience many times, it's also you're not always super certain of yourself in every moment, right? We just learn and do the best we can along the way.

Yeah, it's true. And I think this moment is particularly challenging. It's sort of the best of times, worst of times moment in history. I mean, I guess every time is challenging throughout history, but it feels like we're facing more existential crisis like climate change, massive rates of chronic disease, massive rates of hunger at the same time, huge inequities across the globe economically. And the list goes on and on. And it's kind of enough to make you want to just binge on Netflix and forget about it all, right?

Well, it is, but at the same time, And this is really why I wrote the book, is I feel super optimistic about our future. And I feel like I've been exposed to people who have been able to do some extraordinary things in immunizing children around the world and saving tens of millions of lives or coming together across bipartisan divides and holding hands and helping 100 million people be protected from hunger and deep malnutrition. Or even now, some of the work we get to imagine and do together to build a consensus around using food as medicine to deal with the overwhelming challenge of chronic illness in this country that, by the way, as you know, made America the country that experienced the highest excess mortality from COVID And it's because of the way we eat, it's because of the way we live, and it's because of the preconditions we carry around and accept as normal. And all of these things are changeable. So the book is really about finding those fresh, innovative solutions that can be the basis of big bets, and then having an aspiration that's big. If you're going to if you really believe food is medicine that can address chronic disease, that is an insight that should not just be available to your patients, but it should be baked into public policy, insurance companies, and how they reimburse the American medical system, and it should benefit all 300 million. Americans who might otherwise be vulnerable. And that's what the book is about, the bets that lift up everybody.

Yeah, I mean, one of the big bets we've been talking about and working on is just this incredible burden of chronic disease and the problems with our food system from field to fork. And six out of 10 Americans have a chronic disease, four out of 10 have more than one, 93% are metabolically unhealthy, 75% are overweight, 42% obese, depression and mental illness. It was an article in JAMA came out last week about the role of ultra-processed food in mental health and the 50% increase in depression in those who eat more processed food. So these are big problems. And unfortunately, a lot of actors aren't focused on this. They're looking at kind of like blind men in the alley panel. Let's tweak this or let's tweak that. And you're like, no, let's step back and let's analyze the problem differently. You start with the book, like ask a simple question. How do you get people excited? Oh, do you want to vaccinate like three kids in Africa? I don't know. but do you want to eliminate polio from the face of the planet? Okay, let's talk. And I think you kind of talk about how do we reframe these problems to capture people's imagination and ask the right questions and then be data driven around it, be building alliances and partnerships based on these big visions that actually allow things to happen. And so one of the things that excites me most about the RockefellEr Foundation is that in your leadership, you're actually putting your money where your mouth is. You are funding a $250 million initiative to study food as medicine. I've been working with the AHA and your team to help move that forward. And at Cleveland Clinic, we're submitting a part of your RFP for doing research to do that. But how do you see us tackling this? Because I think our audience is very interested in this area of health and the chronic disease epidemic and obesity and the problems with our food system. Yeah.

Well, I'm glad you made reference to ask a simple question because I learned that from Bill Gates. Yeah. And I found myself, in my 20s, sort of after the Gore campaign and after I thought we won, but it turns out we actually didn't. Unemployed and not quite sure what to do and somehow landed in Bill and Melinda's offices.

So, just for people listening, he went on from riding around in Jalopy, helping campaign workers get to the different sites, to ending up in Bill Gates' office, helping him head up a new initiative at the Gates Foundation to solve big problems like the problems of avoidable preventable childhood deaths from vaccine preventable illness.

Exactly. And Bill and Melinda had read an article about rotavirus, the disease, and rotavirus vaccines. And we were all perplexed by their observation that when the vaccines are available, they're going to be available in countries where kids don't actually die of rotavirus. And the 400,000 kids dying in America. In America, in Europe. And the 400,000 kids dying in India and Africa. and parts of Latin America are not going to have access to these vaccines. And that just felt wrong. And so they asked themselves, you know, how could we vaccinate every child on the planet with the full range of vaccines that would prevent child death?

And rotavirus causes diarrhea, and it's essentially a diarrheal disease. And kids who are malnourished tend to die from this, whereas kids who are American and pretty well nourished tend not to.

Exactly. And in medical school, I think most medical students have had whether you know it or not. So you're quite acquainted with it. And so Bill would gather us regularly and just ask the same question. He'd say, what would it take to vaccinate every child on the planet? Let's start by saying, what does it cost to vaccinate one kid? What are all the elements of that cost? And what was shocking was if you asked that question to experts around the world who dedicated their lives to public health, most people couldn't answer the question. They said, oh, that's too complex. That's too challenging. It's the wrong way to think about it. It's like, you know, we can answer the question for a community, but not for the planet. And, but, but Bill was and Melinda were persistent. And ultimately we answered the question and did a lot of work, multiplied the answer by the 104 million children born every year and came up with a rough order of magnitude of how much resourcing we would need to vaccinate every child on the planet. It was like $84. It was $84 per life year saved in our modeling. And then we went on to invent an innovative financial solution, an immunization bond that we designed with a group of European heads of state and foreign finance ministers like Gordon Brown, the UK Chancellor of the Exchequer. And that ultimately reshaped the global vaccine industry at scale. And the result over 20 years has been 980 million kids vaccinated and 15 million kids lives saved. So that's really where I learned- that's.

A lot of kids.

And if you're, you know, the difference between asking yourself, what can we do with what we have? Which kind of bounds your thinking compared to how would you accomplish this extraordinary, unimaginably big goal?

Well, that's a problem people have, right? Is that they basically don't think differently about problems. They kind of carry these old assumptions and beliefs. And Patty, who was your boss at the Gates Foundation, had this whole idea of this white paper. Like we start with a blank sheet of paper. Forget everything you knew, toss it away. Let's reimagine what's possible, right?

Yeah, so that's Patty Stonesifer, the first CEO of the Gates Foundation. Today, she's the CEO of the Washington Post, an extraordinary leader, and I would love to point out also a trustee of the Rockefeller Foundation. And she did.

She said, let's, we start with a blank sheet of paper, just ask these basic questions. You know, I think about the big problems you solved and helped solve, vaccinations, you know, to save children from preventable deaths, bringing trying to bring an end to hunger in places that really rampant hunger, bringing energy security and energy to places where they don't have electricity. You tried this in Congo with the dam. It was not exactly worked out like he wanted. But, you know, you've done things that nobody really is against. Nobody's like, oh, we should not vaccinate kids to prevent disease, or we should not end hunger, or we should not give people electricity. Like, there's nobody really on the other side going, no. In this instance, There's a whole industry. I mean, this is the biggest industry on the planet. It's $16 trillion, employs more people than any other industry, and is responsible for more deaths than any other thing, including war, smoking, and everything else together. So how do you navigate that? You're creating alliances, partnerships, because I've spoken to CEOs of many big food companies and they're like, Look, we gotta get it, but we can't really change because if we make our products healthier, people won't eat it, or our competitors will still make the same stuff and they'll go over to them. So we have kind of a problem where there's a fair bit of opposition. We were even talking about SNAP, for example, which is over $100 billion program that provides food security, not nutrition security, but food security, getting enough calories to people, not just nutrients, to people who can't afford to eat well or eat enough. And we're just trying to get a bill passed It just provides reporting on what SNAP dollars are used for. So American taxpayers should have a right to know, what is this money being used for? What are they buying? There's such resistance in Congress and from the food industry, it's acting through Congress, to even just get reporting. Let's not take any action. Let's not change anything. Let's just get the facts, get the data, right? Measure it. So how do we start to deal with that level of challenge?

Well, you're right to point out that that's a huge challenge. I mean, I started my public service career in the Obama administration in the Department of Agriculture. And actually, before Michelle Obama's campaign to improve the quality of school feeding, a lot of the basic procurement structures in American school lunch programs rely on taking, you know, I would say old, because I think outdated is technically not the right term. oversalted old food product and agricultural production excesses and dumping them into the school feeding program at scale. And it's because a lot of American nutrition programs come from a history of dealing with commodity surplus. In fact, all of American food aid around the world, America's most generous country, comes from a 1950s era bill called the Surplus Commodities Act.

Right?

So feeding programs were not about health as much, they were about calories, and they were about absorbing excess. And we just have to be cognizant of that and know what we're up against. And while it's true that a lot of these other efforts may not have had as organized an opposition, it is shocking to me how often people just simply don't believe something is possible. And that's the first step.

Failure of imagination.

Failure of imagination. So, you know, I think You are a critical voice to get more Americans to believe and decision making.

You give me too much credit, right?

Well, no, but to believe that food is medicine can make a huge dent in the chronic illness that exposed America to so much COVID mortality, period.

And- By the way, it's just we're 4% of the world's population, but 16% of the deaths. 16.

16, yeah.

Cases and deaths. So fourfold more than we should have been. And we should have been fourfold less because of our healthcare system.

And by the way, we were going into COVID in a global ranking that we helped create called the Global Health Security Index. We were the number one country in terms of preparedness to handle a pandemic. Any generic pandemic. And it turned out to be totally inaccurate for this reason.

Well, it was inaccurate because we were all so sick and pre-inflamed in the the COVID virus just activated that.

Just activated that and gasoline on a fire. Exactly. But to go to your question, I just think you gotta use both the public and private sector levers of change together. And I've been struck by when we take on this work, a lot of times people think of it as, oh, this is a charitable exercise and therefore it's just going to be doing a little bit of good in some places. And doing good enough is really not going to achieve the vision you and I share of transforming how America handles its chronic disease pandemic. And at the same time, I'm struck in the public sector how often people just say, well, that's too hard.

You call that the aspiration track?

Yeah, it's just too hard. It's too complex. It's not gonna work. Or, I can't, you know, we can't build the right coalition. And what I found is if you really put effort into it, you can actually build the right coalition to make progress. I mean, I walked on farms with Senator Jim Inhofe in Ethiopia, talking about climate change, but in words that were more aligned with what was in his head and heart. And he became an extraordinary champion for building climate resilient crops across Africa and the rest of the world. And he was someone who held up a snowball on the Senate floor to contest climate change, right? But in his heart, like a deeply thoughtful, caring person who on the issue of hunger would do everything anyone could to help protect, especially African communities that were starving. And that's where you just got to go that extra mile and understand how to get people to act on what's in their heart.

And wondering, you know, I was thinking, you know, out loud here, but, you know, with the gravitas of the Rockefeller Foundation, with its capacity for convening. Have you ever thought about bringing all the people who are at the top of the food industry, all policymakers together in like a secret meeting where people, you know, there was no reporters, there was no transcripts and people could just roll up their sleeves and okay, like we're facing a tsunami here. How are we going to deal with this? Because, you know, you obviously don't want to lose your, you know, profit margins and your shareholders would be upset for sure, but how do we work together to solve this? Have you thought of that?

Well, we should do it. We've done it in smaller scale than what you just described. And we are holding hands with some pretty significant both food companies and retail enterprises like Kroger, for example.

Right, that's true.

We're trying to push this all forward. But that is the path we need to go on. And a big bet that was not one of the ones I helped originate, but really George W. Bush's big bet and Tony Fauci's around fighting HIV/AIDS around the world, was grounded in getting the pharmaceutical industry over time to make lower-cost ARVs available broadly. And that happened and that changed everything. But it took years and years and years of engagement and partnership development.

That's PEPFAR, right?

Yeah, and that's PEPFAR, the President's Emergency Program for AIDS Relief that saved tens of millions of lives. And I've literally visited communities where you drive down the road in rural western Kenya and the number one product being sold were coffins. because the AIDS pandemic was so dramatically affecting able-bodied people in those communities. And then 10 years later, it's a manageable disease because of American leadership. But it's not just American leadership, it's public-private, and it's getting industry to appreciate that it can be part of the solution in a way that doesn't destroy its bottom line. And I think that's what we're going to have to do with the food industry, on the health of the American population and frankly the global population, because the global food industry is right now actively copying the model of what happened in America over the last 50 years.

That's frightening.

And it will effectively poison much of the world if we go down that same exact path.

I just got back from India and I was in some small town. I went to the local mall area. It was just like every fast food junk in the world that was there. like, wow, you know, like, you know, I remember years ago, I was, I was, Hillary Clinton was a senator. We were working on, you know, healthcare reform together and trying to get lifestyle change. And she bought me around to meet different people and send her a hark in. And we're just chatting. She's like, you know, I went to India and met with the, you know, my counterpart. I'm like, we want to help, what can we do to help with, you know, infectious disease? And so the health challenges you're having is like, what do you mean? We have problem with diabetes. This is the problem here in India. and it's just, you know, we basically created the worst diet on the planet and are exporting it everywhere.

And yeah, and we have to understand why, right? Which you of course do, but it's low cost, super convenient, tons of added sugar, fat, salt, make it largely addictive, and then you pour billions of dollars of super sexy marketing around the whole thing and it becomes fun as well. And so as you point out, but what we're trying to change is not just one or two communities or one or two insurance programs, but actually the culture of food and the industry and the food industry at scale. And that's a big bet worth making and it'll take a while to happen, but we're going to pursue it together. And some of those drug solutions make me laugh.

Last night, someone was talking about a drug that they were on called contrave. I don't know if you know this drug.

I don't.

What is it? But it's basically Naltrexone or Narcan. and bupropion, which is an anxiety drug. So, it's basically like what you give to people who are having a heroin overdose to block them from the opium or the opioid basically from killing them. And, you give that to someone who's overweight, it blocks the effect of sugar to hit that opioid receptor in the brain, which is what it's doing. And, that sort of almost is this implicit acknowledgement that these are addictive foods.

Well, but that's also the path to answering your question, which is how do we scale this up? If more, I was with a group of CEOs of large-scale companies that are largely self-insured. And one of the topics that came up was paying for the semiglutide medicines.

Yeah.

As they start to deal with those costs in the structure of their businesses, is the next logical question is going to be, is there a better way to achieve this outcome? And that's where we want to be prepared with our data and our partnerships and our results so we can help large insurers kind of pivot to say, okay, if you're going to pay for that, you should also cover this and cover this intervention in a way that affects your entire patient population or your employee pool.

I think it's such a key point because what you're talking about is finding people who have aligned interests, right? Who, and often that's aligned financial interests. So self-insured large corporations like the Fortune 100, 500 companies, they're paying a lot. I mean, in general, a motor spends more on healthcare than they do on steel, Starbucks spends more on healthcare than they do on coffee beans. Like, that's untenable, right? And it's making us less competitive globally, and it's also, you know, just unsustainable as costs escalate. and I think those are really powerful allies because they're actually getting insured, sort of it's complicated way it works, but they're not actually providing health care, but they contract with insurance companies to actually cover that. But they pay for it. They pay for it.

Exactly.

And so they can actually influence what's covered and what's not covered, right? And so there was a friend of mine who started a company to address diabetes using a very low carbohydrate diet, or even in ketogenic diets. And it was very, very effective. And they sold it to United Healthcare. And they were like, well, how come the ADA isn't saying this? And they were like, well, maybe, I don't know, but their program isn't working and they also get a lot of their funding from pharma and from the food industry. So, there's all these conflicted relationships.

And what I love about that story is I write in the book in a number of examples about building alliances and finding the right partners. And often find the right partners means finding the right corporate partners. Our efforts to fight energy insecurity and energy poverty rely on collaborations with big energy companies, not oil and gas to expand solar and distributed solar, but it's still working with big companies. And I have found, and this is, I think, is true in food as medicine, we will find big companies that have an economic interest in getting this right. You know, there's always someone on the other side of the trade. And building those alliances and partnerships and the skills to do so is as much of what the book is about as anything else. And I hope when it's something true at Rockefeller, when we look for partners to join us, or even when we look to hire and grow our teams, we want people who are good at building alliances because that's what it's going to take to solve some of these hairy challenges.

Yeah. It kind of reminds me of this picture I saw of this Chinese man, like, you know, Tai Chi kind of guy, walking around the outside of like a wicker basket, like without falling over and like keeping it perfectly in balance. And the quote, I'm going to muck it up, but it was something like, those who say it can't be done should not be kind of trying to tell people who are doing it that it can't be done. Yeah.

Right.

And I think that's what's so inspiring about you is you're like, you're tackling problems problems where people say, this can't be fixed. It's too big, it's too complicated, it's too difficult. And, and yet you're, you're, you're diving right in, you know? And I think there, there's a lesson for all of us in that, which is not to turn away from what's hard, but to turn toward it and to actually think about what in our world we can impact and what we can do, because all of us can make a difference. All of us can, whether it's, you know, a small level in our own kitchens, these things matter, and and they actually ripple and they affect things. And I think, you know, it's kind of like the dominoes. When you're working on these big problems and you get a couple of key alliances and partners and you show that it can be done, then the people who say it can't be done go, oh, well, actually it can be done.

Well, I'll tell you, that's why I wrote the book, because I hope people, especially young people, but really anybody reads it and says, hey, I can be part of the solution. And, yeah, I can apply this mindset and this way of thinking to to the issues I care about in my community or on my planet. And the more people we can attract to the mission, you know, the more successful we are with that. And you've probably found this too. One of the most gratifying things about doing this work, you don't, at the end of the day, become a billionaire in the way that you opened. But it does change you as much or maybe more than you'll change the communities you're in. You just walk around with more optimism and less cynicism. And if you, and we need that because there's so much cynicism out there already. If I want to be cynical, I'll just pick up the paper and read about everybody fighting with each other and not much happening. This is a path to be more optimistic about what we can achieve together.

Well, you know, Raj, it's quite amazing to hear you talk about this because you haven't been sitting in your office at the Gates Foundation or the USAID office or even at the Rockefeller New York and just kind of behind a computer screen dictating what's going on. You've been in the places in the world where there is unimaginable suffering, where there's hunger and poverty and lack. I mean, you share a story about being in the BK Hells in India where you're scraping people would see if they have leprosy and living in a crappy little hut with mosquitoes biting you. And you've seen it up front and you still got this big smile on your face and you still have a positive view of the world. and you're not disheartened. And I think it sounds really paradoxical, but when you kind of are in that process of thinking about others, when you're in that process of serving a greater good, and it takes you out of your own little life and ego and makes you understand something different about the world, and also provides a weirdly a level of satisfaction, happiness, and gratification that it seems paradoxical. Like when I was in Haiti, it was, I mean, the 82nd Airborne was there because the hospital, it was a nightmare. I don't know if you know the story, but we were there and somebody said there's jobs. And so the whole campus of the hospital got mobbed and we couldn't like do our work and it was a nightmare. And slowly other agencies started coming in. but I was like, called Hillary. I'm like, hey, we need, we need the military in here. So she sent the 80 second airborne, and we hadn't eaten in, like, three days. So I'm like, can I have one of those MREs?

Because I'm sorry.

And it was like, it was like, 400. You want one of those? It was 475 ingredients. It was chicken and dumplings. And I looked for, while I was heating up, I looked for the chicken on the label. I said, no chicken. It was like a chicken-like substance, you know? And anyway, so the story is like that. That basically they said they had never seen a worse disaster in their life, even in Afghanistan, Iraq. And I remember was working 20 hours a day and it was horrible with so much grief. But also, I felt really high and happy and like it was weird. I had this weird sense of like, I wasn't thinking about myself. I wasn't thinking about problems. I was just in the trenches serving. Right?

Well, I know exactly how you feel. And I'll tell you, I'm so proud of the folks who worked with USAID at the time. There was a huge snowstorm here in DC that winter.

Oh, yeah.

And people said, you know what?

I was sweating bullets in Haiti.

I don't remember. Well, they said, I'm not gonna go home. I'm gonna sleep across the street in a hotel and just keep working 'cause this crisis demands it. And I remember years later, I had a chance to take my son, who was a little kid then, through to visit Paul Farmer's hospital. And Paul walked us through the neonatal infant care unit and introduced us kids he had kept alive through that extraordinary facility. And we were pointing out that coming out of the world's greatest humanitarian tragedy, there was a lot of good and a lot of impact and a lot of service. And in fact, six months after the earthquake, the level of diarrheal illness in Port-au-Prince was lower than it was the day before the earthquake. The level of childhood malnutrition had collapsed by 50% and more kids were getting fed and were improving their nutritional outcomes after that six-month window. And it was in part because the world had mounted a passionate and effective humanitarian response in the light of an absolute tragedy and disaster. And people don't, you know, the news cameras are all there the first couple of weeks. No one goes back six months later and says, hey, this is an orphanage where kids used to be you know, malnourished and now they're not because Care International is running this innovative feeding program that is both supporting local farmers and feeding these kids. Those stories rarely get told, but when you do this work, you get to be a part of those stories. And it does make you hopeful and content and excited about what's possible.

That's true. Yeah, and I think part of, you know, I think, you know, Paul Farmer's example, he was also a friend. I got to meet him in the middle of all that. He made big bets. He was a young medical student like you with big ideals and decided to go against the entire global public health establishment that said, We can't deal with TB and A's in Haiti because it's too complicated, it's too difficult. The drugs have to be taken on schedule. They don't have watches. They don't have clean water. And he's like, no, this is a solvable problem. And he started asking simple questions. He did the white sheet of paper, and he's like, It's really about people helping people. And he created this whole model of accompaniment. How do we accompany ourselves and our neighbors to health? And I think that's really partly what I think is a solution to our crisis in America. I read a number of books after that. It was so inspired. And one of the books, he's like, we need to deal with this chronic disease in a similar way. We need a million community health workers in America. And that doesn't sound sexy. It doesn't sound exciting. but it's actually so powerful. And, you know, we think, you know, if we have to sort of create big scale change, but maybe it's a lot of little things that make a difference, you know? And I think I've seen this happen. You know, I went to part of this movie Fed Up was on childhood obesity and then went down to South Carolina and easily one of the worst food deserts in America. And it was a family of five living in a trailer, food stamps and disability. The father's 42 on dialysis from diabetes already. The mother's, you know, 100 pounds overweight. The son's 100 plus pounds overweight, almost diabetic at 16. And all I did was, rather than give him a lecture on what to do, I said, let's, let's go shopping and get some simple food. Let's cook a simple meal together from simple ingredients. They never cooked anything in their life. Yeah. And long story short, basically, I left and I gave him a guide on how to eat well for less and how to do this. They lost 200 pounds as a family. The father lost 45, got a new kidney. The son lost 50, went to work at Bojangles, gained it back. But then he reached out to me and we worked together. He lost 132 pounds. He was the first guy in his family to go to college, asked me for a letter of recommendation for medical school. And now he's a doctor. And I was like, wow. I was like, wow. Maybe this problem is not like some new technology or some new drug. It's just people helping people, neighbors helping neighbors. It's like just simple skills. And, you know, it doesn't sound sexy or exciting, but maybe that's part of our solution, food and community. And when you look at places where they have health and longevity, that's what they got. I wrote a book, Young Forever, and I went to the Blue Zones, and that's what they got. Good food and lots of community and support. So that's kind of, I think, how we think differently about these problems.

Absolutely. And by the way, the basic point that people want to help themselves, that's as true in that story here in the United States as it is when you go to, I mean, we went the heat of the famine in 2011 into Somalia, in communities that were blockaded by al-Shabaab terrorists and overwhelmed by a massive drought. And mothers want to help feed their kids.

Yeah.

And will do extraordinary things to access food, support their families, and create a better life for their children. And they'll do all the work and they often have most of the knowledge needed to get there and just need a little bit of nudging, supporting, standing with in order to help unlock that ability to be better. And that's a great story that way. Yeah, I mean, it's just, you know.

Honestly, Raj, knowing you and knowing your work. And, you probably don't remember this, but during that Haiti time, I came to Washington, and it's a long story, I won't go into it, but basically I met a long lost cousin who was actually in charge of the Red Cross International Relief. And, I didn't know it. Oh, wow. Even, he was like my, my grandmother's great nephew or something. And I never met him. And it turned out he ended up giving $10 million to help the hospital and fund the staff and so forth. But I came down on that trip and I was in a restaurant and I turned around and you were sitting there. And I was like, Hey Raj, you probably don't remember me.

Well, can I tell you one of the things about, since we've talked about that Haiti episode, more American families gave in some way, whatever way they could. Sometimes it was through text, thing we had set up and sometimes it was to the Red Cross and sometimes it was in your case where you actually get on a plane and go do more American families gave to the Haiti earthquake relief than watched the Super Bowl that year.

Unbelievable.

And, you know, just made me, it was a reminder that people want to be on the side of right if you give them a chance. And a lot of what this book is about is learning how to give people a chance.

So this is exactly what your life's about, right? is giving people a chance to have a better life. It's just this beautiful humanitarian vision. As now president of the Rockefeller Foundation, what are your next big bets? We talked about food is medicine, which is important, about rethinking agriculture and regenerative agriculture, addressing chronic disease. What's on your hit list actually to solve?

Well, we have an extraordinarily exciting list of big bets. The the biggest one is we just announced last week is a billion dollar commitment to accelerate the climate transition and fight climate change around the world. It just turns out that we are as a globe, we are off path to achieve a sustainable future. We're going to blow past the Paris targets. We're on our way to two and a half to three degrees warming, and we're blowing past every ecological tipping point that the scientists evaluate and predict. So the consequences of even a little bit of warming are worse than we thought. The most vulnerable 2 billion people on Earth are the ones that are gonna suffer the most. Hunger will double. Displaced populations on coastal cities will lead to 200 million climate migrants.

Fisheries will- the UN said a billion, I think, when I looked- Is that right?

Yeah. Fisheries will be destroyed. I mean, it just, so we, and we believe that the technology exists or can exist to help those communities both be part of the solution and protect themselves against those catastrophic outcomes. So as part of that, we're helping to reach a billion people with renewable electrification.

Yeah, I told you you want to be a billionaire.

Yeah, that's what we, and I'm excited because it's happening, you know, because we're able to make it happen and we're able to bring partners to the table. Another big bet's around school feeding. I think, you know, a lot of times school feeding is where kids develop habits around their diet and their understanding of nutrition. It's also, especially in developing countries, It's a way to provide some feeding and some food to families because they'll take extra food if it's part of the allotment back to their families. And I was at a school feeding site in Kenya where thanks to our collaboration with the government in Kenya and introducing school feeding, school attendance went up 150% and girls in particular were going to school. So we think there are about 720 million kids around the world that are school feeding eligible about about 460 million or so get some form of intervention, but most of it is very low quality diet. We think we can dramatically improve the dietary quality they're reaching and target another 100 million kids relatively quickly. So a group of heads of state are heading to Paris, I think, in about three weeks time, and we hope to build a global school feeding effort that brings public and private partners together to change the nutrition path for kids. in 80 plus countries around the world.

And it's so important because malnourished kids die from simple infections.

And malnourished kids are the most vulnerable.

That actually would not kill Western kids, right?

Yeah, and in practice, it's a way to kind of jumpstart local agricultural economies and get local agriculture both focus on nutrition outcomes and have a- Farm to school. Farm to school, yeah, which is part of our story here in the US, but could be a bigger part globally. So that's another big bet we're excited about. And food is medicine. I mean, we've talked a lot about it, but we're going to create together over the next few years the database that will show with definitive rigor and quality that food interventions can directly reduce the burden of chronic disease and the cost related to that burden. And that will, I think, change the economic incentives and allow us to build the alliances you mentioned earlier that could actually change health outcomes for 40-50% of the American population.

That's quite a list.

That's an amazing list. It's fun to get to come in every day, work on these things, work with leaders and visionaries like you and our team is so exciting and so pumped up to make a difference on these things.

That's really, really exciting, Raj. I think those seem like big problems, but I think what's exciting is that actually, have solutions. And I think the food is medicine thing is both an opportunity and it is also fraught a little bit with some danger. And I'll just share my thoughts if I can. Yeah, please. It's a podcast with you, but I just so passionately... I'm learning. But I think it's kind of a failure of imagination in the healthcare system and also in policymakers. They don't understand the power of food to transform biology and how fast it can work, particularly around chronic illness, whether it's diabetes or or heart disease or other issues. And I think, you know, if I, if I was going to do a study looking at whether, let's say, a statin prevented a heart disease, if I used a milligram of a statin, I would find it didn't work. If I used a milligram of aspirin to treat a headache, I'd find it didn't work. Or if I use it, an antibiotic to treat depression, it wouldn't work. Right. So you have to have the right drug at the right dose for the right person at the right time. And, and food is pharmacology is not really well understood by traditional medicine. It's not just like, oh, eat better. It's very specific. And so I think that's where I've spent the last 30 years focusing is how do we take care of my own patients in my clinic doing this? And have had profound insights by just, and honestly been shocked as a doctor because it's not anything I learned in medical school, right? Oh, you can't reverse diabetes. Well, yeah, you can. Or you can't reverse heart failure. Well, yeah, you can. Like, I have so many patients with that. And it's, it's stuff that if you say to a regular doctor, they're like, I don't know, it's not true. It doesn't really work. Or policymakers, they don't get it. And I fight this all the time when I'm talking to policymakers. Oh, prevention. I'm like, no, no, no, not prevention. This is treatment. This is treatment. And I think that conversation needs to shift. If you love that last video, you're gonna love the next one. Check it out here.

When we started seeing these changes taking place in people that had their own personal remissions, I thought, thought, well, is that teachable? And what is the science behind teaching it? Can we teach people how to begin.