So have you ever wondered what it would be like to live in a place with no rules? That sounds pretty cool.
Algunha vez vos preguntastes como sería vivir nun lugar sen normas? Soa ben, non si?
(Laughter)
(Risas)
You wake up one morning, however, and you discover that the reason there are no rules is because there's no government, and there are no laws. In fact, all social institutions have disappeared. So there's no schools, there's no hospitals, there's no police, there's no banks, there's no athletic clubs, there's no utilities.
Mais unha mañá espertas e descobres que a razón pola que non hai normas é que non hai goberno e tampouco hai leis. De feito, todas as institucións sociais desapareceron, polo que non hai escolas, non hai hospitais, non hai policía, non hai bancos, non hai clubs deportivos, non hai servizos.
Well, I know a little bit about what this is like, because when I was a medical student in 1999, I worked in a refugee camp in the Balkans during the Kosovo War. When the war was over, I got permission -- unbelievably -- from my medical school to take some time off and follow some of the families that I had befriended in the camp back to their village in Kosovo, and understand how they navigated life in this postwar setting.
Pois ben, eu teño unha idea do que é iso porque, cando era estudante de medicina no 1999, traballei nun campo de refuxiados nos Balcáns durante a guerra de Kosovo. Cando rematou a guerra, incriblemente obtiven un permiso da facultade para coller uns días e acompañar a algunhas das familias coas que trabara amizade no campo na viaxe de volta ás súas vilas en Kosovo, para comprender como afrontaban a vida nun contexto de posguerra.
Postwar Kosovo was a very interesting place because NATO troops were there, mostly to make sure the war didn't break out again. But other than that, it was actually a lawless place, and almost every social institution, both public and private, had been destroyed. So I can tell you that when you go into one of these situations and settings, it is absolutely thrilling ... for about 30 minutes, because that's about how long it takes before you run into a situation where you realize how incredibly vulnerable you are.
O Kosovo da posguerra era un lugar moi interesante porque alí estaban as tropas da OTAN, máis que nada para garantir que non volvese estalar a guerra, mais, á parte diso, o certo é que era unha zona sen lei e case todas as institucións sociais, tanto públicas coma privadas, foran destruídas. Teño que dicir que cando te atopas nun escenario ou nunha situación coma esa é a cousa máis emocionante do mundo... durante uns 30 minutos, porque iso é, máis ou menos, o que tardas en bater cunha situación na que te decatas do incriblemente vulnerábel que es.
For me, that moment came when I had to cross the first checkpoint, and I realized as I drove up that I would be negotiating passage through this checkpoint with a heavily armed individual who, if he decided to shoot me right then and there, actually wouldn't be doing anything illegal. But the sense of vulnerability that I had was absolutely nothing in comparison to the vulnerability of the families that I got to know over that year.
No meu caso, ese momento chegou ao ter que cruzar o primeiro control e reparar, mentres me achegaba, en que ía ter que negociar o paso por este control cun individuo armado ata as orellas que, se decidía pegarme un tiro alí mesmo, en realidade non estaría a facer nada ilegal. Porén, a sensación de vulnerabilidade que eu sentín non era absolutamente nada comparada coa vulnerabilidade das familias que coñecín ao longo daquel ano.
You see, life in a society where there are no social institutions is riddled with danger and uncertainty, and simple questions like, "What are we going to eat tonight?" are very complicated to answer. Questions about security, when you don't have any security systems, are terrifying. Is that altercation I had with the neighbor down the block going to turn into a violent episode that will end my life or my family's life?
A vida nunha sociedade sen institucións sociais está chea de perigo e incerteza. Preguntas tan sinxelas como “que imos cear hoxe?” vólvense moi difíciles de responder. As cuestións sobre seguridade cando non hai sistema de seguridade ningún son terroríficas. Tornará aquel altercado que tiven co veciño de abaixo nun episodio violento que acabe coa miña vida ou coa da miña familia?
Health concerns when there is no health system are also terrifying. I listened as many families had to sort through questions like, "My infant has a fever. What am I going to do?" "My sister, who is pregnant, is bleeding. What should I do? Who should I turn to?" "Where are the doctors, where are the nurses? If I could find one, are they trustworthy? How will I pay them? In what currency will I pay them?" "If I need medications, where will I find them? If I take those medications, are they actually counterfeits?" And on and on. So for life in these settings, the dominant theme, the dominant feature of life, is the incredible vulnerability that people have to manage day in and day out, because of the lack of social systems.
Os problemas de saúde cando non hai sistema de saúde tamén son terroríficos. Escoitei a moitas familias facerse preguntas como “O meu neno ten febre. Que podo facer?” “A miña irmá, que está preñada, está a sangrar. Que fago? A quen acudo?” “Onde andan os doutores? U-los enfermeiros? Se atopo algún, será de fiar? Como lles hei pagar? En que moeda lles pago?” “Se preciso medicamentos, onde os atopo? E se tomo eses medicamentos, non serán falsificacións?” E así unha detrás da outra. Nestas circunstancias vitais, o tema predominante, o aspecto dominante da vida, é a incrible vulnerabilidade coa que teñen que lidar as persoas un día si e outro tamén por mor da falta de sistemas sociais.
And it actually turns out that this feature of life is incredibly difficult to explain and be understood by people who are living outside of it. I discovered this when I left Kosovo. I came back to Boston, I became a physician, I became a global public health policy researcher. I joined the Harvard Medical School and Brigham and Women's Hospital Division of Global Health. And I, as a researcher, really wanted to get started on this problem right away. I was like, "How do we reduce the crushing vulnerability of people living in these types of fragile settings? Is there any way we can start to think about how to protect and quickly recover the institutions that are critical to survival, like the health system?" And I have to say, I had amazing colleagues. But one interesting thing about it was, this was sort of an unusual question for them. They were kind of like, "Oh, if you work in war, doesn't that mean you work on refugee camps, and you work on documenting mass atrocities?" -- which is, by the way, very, very, very important.
E resulta que este aspecto da vida é incriblemente difícil de explicar e facérllelo entender ás persoas que viven alleas a el. Isto descubrino cando marchei de Kosovo. Volvín a Boston, fíxenme doutora, logo investigadora de políticas de saúde pública mundiais. Uninme á Escola de Medicina de Harvard e á División de Saúde Mundial do hospital Birgham and Women. Eu, como investigadora, devecía por pórme a traballar neste problema de contado. Eu dicía: “Como diminuímos a vulnerabilidade devastadora á que se enfrontan as persoas que viven neste tipo de situacións tan fráxiles? Hai algún xeito no que podamos comezar a pensar en como protexer e recuperar axiña as institucións fundamentais para a supervivencia, como o sistema de saúde?” Debo dicir que tiña uns colegas marabillosos e, no entanto, un detalle interesante era que, para eles, esa pregunta era algo estraña. Dicíanme cousas como: “Iso de traballar na guerra non significa traballar en campos de refuxiados e documentar atrocidades masivas?”, cousa que é moi moi importante, por certo.
So it took me a while to explain why I was so passionate about this issue, until about six years ago. That's when this landmark study that looked at and described the public health consequences of war was published. They came to an incredible, provocative conclusion. These researchers concluded that the vast majority of death and disability from war happens after the cessation of conflict. So the most dangerous time to be a person living in a conflict-affected state is after the cessation of hostilities; it's after the peace deal has been signed. It's when that political solution has been achieved. That seems so puzzling, but of course it's not, because war kills people by robbing them of their clinics, of their hospitals, of their supply chains. Their doctors are targeted, are killed; they're on the run. And more invisible and yet more deadly is the destruction of the health governance institutions and their finances.
Levoume un anaco explicarlles por que me apaixonaba tanto este asunto, ata haberá uns seis anos. Daquela publicouse un estudo sen precedentes que analizaba e describía as consecuencias da guerra na saúde pública. Chegaron a unha conclusión incrible e provocadora: os investigadores concluíron que a maior parte das mortes e discapacidades provocadas pola guerra ocorren cando xa rematou o conflito. O período máis perigoso para as persoas que viven nun estado en conflito é tras a fin das hostilidades, despois de asinar o acordo de paz, cando xa se acadou unha solución política. Semella desconcertante, mais abofé que non o é, porque as guerras matan as persoas roubándolles as súas clínicas, os seus hospitais, as súas cadeas de subministración. Os médicos tórnanse en obxectivos e asasínanos. Teñen que fuxir. E máis invisíbel e, con todo, aínda máis letal é a destrución das institucións de goberno sanitarias e os seus medios financeiros.
So this is really not surprising at all to me. But what is surprising and somewhat dismaying, is how little impact this insight has had, in terms of how we think about human suffering and war. Let me give you a couple examples.
Así que a min isto non me resulta nada sorprendente O que si é sorprendente e, dalgún xeito, desalentador é o escaso impacto que esta percepción tivo na nosa maneira de pensar no sufrimento humano e a guerra. Vouvos poñer un par de exemplos.
Last year, you may remember, Ebola hit the West African country of Liberia. There was a lot of reporting about this group, Doctors Without Borders, sounding the alarm and calling for aid and assistance. But not a lot of that reporting answered the question: Why is Doctors Without Borders even in Liberia? Doctors Without Borders is an amazing organization, dedicated and designed to provide emergency care in war zones. Liberia's civil war had ended in 2003 -- that was 11 years before Ebola even struck. When Ebola struck Liberia, there were less than 50 doctors in the entire country of 4.5 million people. Doctors Without Borders is in Liberia because Liberia still doesn't really have a functioning health system, 11 years later.
Se cadra lembrades que o ano pasado o ébola azoutou Liberia, o país de África occidental. Daquela déuselle moita cobertura a un grupo, Médicos Sen Fronteiras, que estaba a dar a alarma e a pedir axuda e medios. Non obstante, poucas desas reportaxes respondían á seguinte cuestión: Que fan en Liberia os de Médicos Sen Fronteiras? Médicos Sen Fronteiras é unha organización magnífica que se dedica a prestar coidados de emerxencia en zonas de guerra. A guerra civil de Liberia rematou no 2003, 11 anos antes de que chegase sequera o ébola. Cando o ébola atacou Liberia, había menos de 50 médicos para todo un país de 4,5 millóns de persoas. Médicos Sen Fronteiras está en Liberia porque Liberia aínda non conta cun sistema de saúde operativo 11 anos despois.
When the earthquake hit Haiti in 2010, the outpouring of international aid was phenomenal. But did you know that only two percent of that funding went to rebuild Haitian public institutions, including its health sector? From that perspective, Haitians continue to die from the earthquake even today.
Cando o terremoto sacudiu Haití no 2010, o fluxo de axuda internacional foi fantástico, mais sabiades que só un 2 por cento deses fondos se usaron para restaurar as institucións públicas haitianas, incluído o sector sanitario? Dende esa perspectiva, mesmo hoxe os haitianos seguen a morrer a causa do terremoto.
I recently met this gentleman. This is Dr. Nezar Ismet. He's the Minister of Health in the northern autonomous region of Iraq, in Kurdistan. Here he is announcing that in the last nine months, his country, his region, has increased from four million people to five million people. That's a 25 percent increase. Thousands of these new arrivals have experienced incredible trauma. His doctors are working 16-hour days without pay. His budget has not increased by 25 percent; it has decreased by 20 percent, as funding has flowed to security concerns and to short-term relief efforts. When his health sector fails -- and if history is any guide, it will -- how do you think that's going to influence the decision making of the five million people in his region as they think about whether they should flee that type of vulnerable living situation?
Hai pouco coñecín a este cabaleiro. É o doutor Nezar Ismet. É o ministro de Saúde da rexión autónoma do norte de Iraq, Kurdistán. Aquí está a anunciar que nos últimos nove meses a poboación do seu país, da súa rexión, aumentou de catro a cinco millóns de persoas, un aumento do 25 por cento. Milleiros destas persoas que chegaron experimentaron traumas incribles. Os seus médicos traballan xornadas de 16 horas sen cobrar. Os seu presuposto non aumentou un 25 por cento, senón que diminuíu un 20 por cento, xa que os fondos destináronse a seguridade e medidas de auxilio a curto prazo. Cando o seu sector sanitario caia —e se algo nos di a historia é que caerá— como pensades que vai afectar iso ás decisións dos cinco millóns de persoas da súa rexión cando consideren se deberían fuxir dese tipo de situación vital vulnerable?
So as you can see, this is a frustrating topic for me, and I really try to understand: Why the reluctance to protect and support indigenous health systems and security systems? I usually tier two concerns, two arguments. The first concern is about corruption, and the concern that people in these settings are corrupt and they are untrustworthy. And I will admit that I have met unsavory characters working in health sectors in these situations. But I will tell you that the opposite is absolutely true in every case I have worked on, from Afghanistan to Libya, to Kosovo, to Haiti, to Liberia -- I have met inspiring people, who, when the chips were down for their country, they risked everything to save their health institutions. The trick for the outsider who wants to help is identifying who those individuals are, and building a pathway for them to lead.
Como vedes, este é un tema frustrante para min. e xuro que intento comprender por que somos tan remisos a protexer e apoiar os sistemas de saúde e de seguridade autóctonos. Normalmente escoito dúas preocupacións, dous argumentos. O primeiro ten que ver coa corrupción. coa preocupación de que a xente que está nestas situacións é corrupta e pouco de fiar. Hei de admitir que teño batido con varios personaxes indesexables traballando no sector sanitario nestas situacións, pero podo dicirvos que o contrario tamén é completamente certo en todos os casos nos que traballei. Dende Afganistán até Libia, pasando por Kosovo, Haití, Liberia... teño coñecido xente inspiradora, que, cando o seu país se viu nunha encrucillada, o arriscaron todo para salvar as súas institucións sanitarias. O truco para as persoas alleas que queiran axudar está en identificar eses individuos e marcarlles o camiño no que farán de guías.
That is exactly what happened in Afghanistan. One of the unsung and untold success stories of our nation-building effort in Afghanistan involved the World Bank in 2002 investing heavily in identifying, training and promoting Afghani health sector leaders. These health sector leaders have pulled off an incredible feat in Afghanistan. They have aggressively increased access to health care for the majority of the population. They are rapidly improving the health status of the Afghan population, which used to be the worst in the world. In fact, the Afghan Ministry of Health does things that I wish we would do in America. They use things like data to make policy. It's incredible.
Iso mesmo foi o que aconteceu en Afganistán. Un dos casos de éxito esquecidos e descoñecidos das nosas iniciativas de consolidación nacional en Afganistán foi o grande investimento que realizou o Banco Mundial no 2002 para identificar, instruír e ascender os líderes do sector sanitario afgáns. Estes líderes do sector sanitario conseguiron toda unha fazaña en Afganistán. Aumentaron de xeito impresionante o acceso aos servizos sanitarios para a maior parte da poboación. Están a mellorar rápido a situación sanitaria da poboación afgá, que antes era a peor do mundo. De feito, o Ministerio de Saúde afgán fai cousas que oxalá fixeramos nos EE.UU. Usan datos para deseñar medidas políticas. Abraiante.
(Laughter)
(Risas)
The other concern I hear a lot about is: "We just can't afford it, we just don't have the money. It's just unsustainable." I would submit to you that the current situation and the current system we have is the most expensive, inefficient system we could possibly conceive of. The current situation is that when governments like the US -- or, let's say, the collection of governments that make up the European Commission -- every year, they spend 15 billion dollars on just humanitarian and emergency and disaster relief worldwide. That's nothing about foreign aid, that's just disaster relief. Ninety-five percent of it goes to international relief agencies, that then have to import resources into these areas, and knit together some type of temporary health system, let's say, which they then dismantle and send away when they run out of money.
A outra preocupación que oio moito é: “Non nolo podemos permitir, non hai cartos para iso. É insostíbel.” Gustaríame apuntar que a situación actual, o sistema que temos actualmente, é o sistema máis caro e ineficiente que poderiamos concibir. Na actualidade, os gobernos, como o dos EE.UU., ou, por exemplo, o conxunto de gobernos que forman a Comisión Europea, gastan 15 mil millóns de dólares todos os anos só en axuda humanitaria, de emerxencia e para catástrofes en todo o mundo. Iso non inclúe a axuda exterior, só a axuda para catástrofes. O 95 por cento deses cartos van ás axencias de axuda internacional, que logo teñen que importar recursos a esas zonas e montar unha especie de sistema sanitario temporal que logo desmantelan e mandan fóra cando se esgotan os cartos.
So our job, it turns out, is very clear.
A nosa misión, polo tanto, é moi clara.
We, as the global health community policy experts, our first job is to become experts in how to monitor the strengths and vulnerabilities of health systems in threatened situations. And that's when we see doctors fleeing, when we see health resources drying up, when we see institutions crumbling -- that's the emergency. That's when we need to sound the alarm and wave our arms. OK? Not now. Everyone can see that's an emergency, they don't need us to tell them that.
Como expertos en políticas da comunidade sanitaria mundial, a nosa primeira misión é facernos expertos en observar os puntos fortes e débiles dos sistemas sanitarios en situacións de ameaza. E esta dáse cando os médicos foxen, cando se esgotan os recursos sanitarios, cando se veñen abaixo as institucións. Esa é a emerxencia. É aí cando temos que dar a alarma e sacudir os brazos. Estamos? Non agora. Calquera ve que iso é unha emerxencia, non precisan que llelo digamos nós.
Number two: places like where I work at Harvard need to take their cue from the World Bank experience in Afghanistan, and we need to -- and we will -- build robust platforms to support health sector leaders like these. These people risk their lives. I think we can match their courage with some support.
Segundo: os lugares como no que eu traballo en Harvard deben seguir o exemplo da experiencia do Banco Mundial en Afganistán, e precisamos —e farémolo— establecer plataformas sólidas para apoiar estes líderes do sector sanitario. Esta xente xoga a súa vida. Coido que podemos corresponder ao seu valor con algo de apoio.
Number three: we need to reach out and make new partnerships. At our global health center, we have launched a new initiative with NATO and other security policy makers to explore with them what they can do to protect health system institutions during deployments. We want them to see that protecting health systems and other critical social institutions is an integral part of their mission. It's not just about avoiding collateral damage; it's about winning the peace.
Terceiro: temos que comunicarnos e formar novas alianzas. No noso centro sobre saúde mundial, sacamos unha nova iniciativa coa OTAN e máis creadores de política de seguridade para estudar con eles o que poden facer para protexer as institucións sanitarias durante os despregamentos. Queremos que se decaten de que protexer os sistemas sanitarios e outras institucións sociais fundamentais é unha parte indispensábel da súa misión. Non todo é evitar danos colaterais; hai que gañar a paz.
But the most important partner we need to engage is you, the American public, and indeed, the world public. Because unless you understand the value of social institutions, like health systems in these fragile settings, you won't support efforts to save them. You won't click on that article that talks about "Hey, all those doctors are on the run in country X. I wonder what that means. I wonder what that means for that health system's ability to, let's say, detect influenza." "Hmm, it's probably not good." That's what I'd tell you.
Agora ben, o socio máis importante ao que cómpre que impliquemos sodes vós, os cidadáns estadounidenses e, por suposto, os de todo o mundo, porque, a non ser que entendades o valor das institucións sociais, como o sistema sanitario, nestas situacións fráxiles, non apoiaredes as iniciativas para salvalos. Non ides picar nese artigo que di “Ei, todos os médicos do país X están fuxindo. Que significará? Pregúntome como vai afectar iso á capacidade dese sistema sanitario para, por exemplo, detectar a influenza”. “Mmm, non ha de ser boa cousa”. Iso é o que vos diría eu.
Up on the screen, I've put up my three favorite American institution defenders and builders. Over here is George C. Marshall, he was the guy that proposed the Marshall Plan to save all of Europe's economic institutions after World War II. And this Eleanor Roosevelt. Her work on human rights really serves as the foundation for all of our international human rights organizations. Then my big favorite is Ben Franklin, who did many things in terms of creating institutions, but was the midwife of our constitution.
Na pantalla, están tres dos meus defensores e creadores de institucións estadounidenses favoritos. Por aquí está George C. Marshall, o tipo que propuxo o Plan Marshall, que salvou as institucións económicas de Europa tras a Segunda Guerra Mundial. Logo temos a Eleanor Roosevelt. O seu traballo a prol dos dereitos humanos é a base das nosas organizacións internacionais de dereitos humanos. E logo está o meu favorito, Ben Franklin, que fixo moitas cousas no que se refire a crear institucións, mais foi o pai da nosa constitución.
And I would say to you that these are folks who, when our country was threatened, or our world was threatened, they didn't retreat. They didn't talk about building walls. They talked about building institutions to protect human security, for their generation and also for ours. And I think our generation should do the same.
E vouvos dicir que estes foron os tipos que, cando o noso país estaba ameazado, cando o noso mundo estaba ameazado, non se renderon. Non falaron de construír muros; falaron de construír institucións para garantir a seguridade humana, para a súa xeración e tamén para a nosa, e eu coido que a nosa xeración debería facer o mesmo.
Thank you.
Grazas.
(Applause)
(Aplausos)