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Speaker 1: Pushkin. I'm Maybe Higgins and this is Solvable Interviews with

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Speaker 1: the world's most innovative thinkers working to solve the world's

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Speaker 1: biggest problems. My name is Nevine Rao. I'm the senior

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Speaker 1: vice president for Health and Rockefeller Foundation, and I believe

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Speaker 1: the crisis of maternal mortality is solvable. This episode, we're

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Speaker 1: hearing from doctor Nevine Rau. You just heard him there.

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Speaker 1: He's from the Rockefeller Foundation and he is a renowned

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Speaker 1: expert in safe pregnancies and healthy deliveries around the world. Now,

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Speaker 1: if you had to guess how many babies would you

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Speaker 1: say are born every day, I'll give you a second.

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Speaker 1: Now I cheated. I looked it up and UNISF estimates

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Speaker 1: that an average of wait for it, three hundred and

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Speaker 1: fifty three thousand babies are born each day around the world.

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Speaker 1: Is not incredible. It's more than four births every second,

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Speaker 1: and most of those they're safe for both the mother

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Speaker 1: and the baby. But many of those births are not.

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Speaker 1: In fact, nearly eight hundred and thirty women die every

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Speaker 1: day due to complications during pregnancy and childbirth. Now, most

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Speaker 1: of these deaths can be prevented through skilled care at

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Speaker 1: childbirth and just having access to emergency obstretric care. But

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Speaker 1: in Sub Saharan Africa, where maternal mortality ratios are the highest,

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Speaker 1: fewer than half of women are attended to by a

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Speaker 1: trained midwife or a nurse or a doctor during childbirth.

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Speaker 1: So you can probably guess that maternal deaths mirror the

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Speaker 1: gap between the rich and the poor. Less than one

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Speaker 1: percent of maternal deaths happen in wealthy countries. But I

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Speaker 1: wonder if you knew that America has the highest maternal

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Speaker 1: mortality rate of all industrial countries, in fact, by several

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Speaker 1: times over. Maternal and tile survival are the hallmarks of

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Speaker 1: healthy communities, and doctor Rown knows that. But he also

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Speaker 1: understands that although major advances in digital technology and data

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Speaker 1: science are definitely improving health intervention effectiveness, the global health

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Speaker 1: divide persists. All of these wonderful innovations, well, they're just

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Speaker 1: not reaching the poorest and most vulnerable communities. Doctor Rao

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Speaker 1: envisions a world where the data gap, and therefore the

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Speaker 1: health gap, can be bridged, and we'll hear more about

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Speaker 1: how he reached this thinking and also his daily work

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Speaker 1: towards this much better future. Let's listen to him now

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Speaker 1: with an apple bound What in your background led you

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Speaker 1: to this problem? How did you identify this as a

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Speaker 1: concrete problem that can be solved? And how must have

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Speaker 1: been about twenty five part of my training as a

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Speaker 1: medical student in rural India, and I remember this sixteen

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Speaker 1: year old girl being brought in. She had twins, and

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Speaker 1: these were the days when we didn't know she had twins.

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Speaker 1: There was no echo cardiogram, and apparently she delivered one

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Speaker 1: of the twins at home. It was a prolonged labor.

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Speaker 1: And now they brought her in to the hospital because

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Speaker 1: she had a second baby that was also obstructed. And

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Speaker 1: I remember there and helping with that, and as part

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Speaker 1: of that second delivery, she started bleeding and then literally

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Speaker 1: bled out, and I remember trying to stem the blood

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Speaker 1: and it's so horrific when you see blood gushing out

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Speaker 1: of a woman's Wigiane's just and you could see that

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Speaker 1: she was dying, and she knew she was dying. But

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Speaker 1: I never forget that, but that stayed with me. And

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Speaker 1: that was almost forty five years ago. And when I

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Speaker 1: got to America and I finished my training and was

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Speaker 1: a practicing physician, I was horrified to hear that this

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Speaker 1: problem still exists and in fact is getting worse in

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Speaker 1: some countries, and that even today woman died during pregnancy

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Speaker 1: and childbirth. The tragedy is that we know how to

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Speaker 1: save them. Most of the drugs and most of the

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Speaker 1: procedures have been in place since the nineteen forties, and

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Speaker 1: in some countries there is no materal mortality so to

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Speaker 1: speak of, and so it is solvable. It has been

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Speaker 1: solved in this day and age. There's some Scandinavian countries

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Speaker 1: that have solved it. So it is truly solvable, and

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Speaker 1: it has been solved. The fact that we still have

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Speaker 1: eight hundred women dying every day. Literally that's two jumber

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Speaker 1: jets crashing every day. I realized that we as a

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Speaker 1: human race are not going to progress unless we say

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Speaker 1: no to these unnecessary debts. Walk me through the nature

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Speaker 1: of the problem. So you say, the medical profession has

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Speaker 1: come up with solutions, we have ways to prevent women

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Speaker 1: from dying in childbirth. What is stopping people from getting

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Speaker 1: the healthcare that they need. I'll break it down. It's

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Speaker 1: very traditionally broken down into three segments. They're called three delays.

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Speaker 1: And this is very well researched and written about The

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Speaker 1: first delay is delay in seeking care. So this is

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Speaker 1: a delay in the woman herself going to the hospital

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Speaker 1: getting prenatal checkups, understanding that this needs and should be

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Speaker 1: a medical care and take care of her body and

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Speaker 1: her health, or the family also understanding that this should

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Speaker 1: be a delivery in the facility and that usually the

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Speaker 1: feeling in these villagers is the mother in law saying, look,

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Speaker 1: I delivered your husband in that back room. You go

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Speaker 1: and do it. We're not going to spend money on

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Speaker 1: hospitals doctors, and by the way, you still have to

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Speaker 1: sweep the barn and make the cows. So the first

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Speaker 1: delay is in seeking care even is a huge delay.

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Speaker 1: And the second delay is getting to care. So they

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Speaker 1: have realized, okay, they have done that, they've gone and

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Speaker 1: seen and had some prenatal checkups, but they have not

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Speaker 1: planned for how they're going to get to care. Either

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Speaker 1: they have not don't have the money at the last

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Speaker 1: minute to pay for the automobile the taxi, or they're

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Speaker 1: no ambulances, or even in certain parts such as Zambia,

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Speaker 1: if the flash floods have come and the road is

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Speaker 1: washed out, there's no way to get to care. So

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Speaker 1: the second delay is in getting to care. And the

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Speaker 1: third delay is receiving care. So there sometimes they do

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Speaker 1: that and they come and at the hospital there is

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Speaker 1: either no alexity, there's no medication, there's no train doctor,

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Speaker 1: there's no anesthesia, there no facilities, And so the third

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Speaker 1: delay isn't receiving care. And so it's not just enough

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Speaker 1: for us to say, oh, okay, we'll make sure they're ambulances,

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Speaker 1: because if they don't get into the ambulance, it's meaningless.

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Speaker 1: And or if they say, we say, we'll just put

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Speaker 1: dication and we'll train doctors, but if you haven't done

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Speaker 1: the community outreach to make them want to come, it's meaningless.

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Speaker 1: So really all three delays need to be addressed together.

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Speaker 1: And usually most of these women die a combination of

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Speaker 1: the delays. Most often it's all three. So maybe can

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Speaker 1: you give me some idea of what we're talking about

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Speaker 1: in terms of numbers how many women die annually, but

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Speaker 1: also how have those numbers been reduced in recent years,

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Speaker 1: and how do you foresee them being reduced further in

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Speaker 1: the next ten or twenty or thirty years. The goal

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Speaker 1: is to reach preventable maternal mortality, to reduce it down

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Speaker 1: to seventy by twenty thirty. I mean, no death is acceptable,

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Speaker 1: but seventy is a number that the world has put

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Speaker 1: us taken the ground saying, if we can make sure

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Speaker 1: every country comes down to seventy, that would be achievable.

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Speaker 1: Some countries today that number is five and in some

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Speaker 1: countries that number five thousand, and so we have made

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Speaker 1: huge progress in the last ten years. We've halfd metal

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Speaker 1: mortality as a world, but we're still very far away

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Speaker 1: from the seventy number. And the business is usual as

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Speaker 1: the rates of reduction as we see it now will

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Speaker 1: not get us to that number of seventy metal mortality.

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Speaker 1: So there has been a huge progress, but the rate

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Speaker 1: of reduction is not enough to get us where we

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Speaker 1: want to go. Those are the numbers. And currently, as

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Speaker 1: I said, eight hundred women die every day in the world,

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Speaker 1: and by the way, seven hundred women die every year

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Speaker 1: here in the US. It's almost two deaths a day. Wow.

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Speaker 1: So how do you overcome this first barrier? How do

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Speaker 1: you convince people to come to appointments, to come to hospitals.

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Speaker 1: How do you get them used to the idea that

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Speaker 1: birth is not something that takes place at home. So

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Speaker 1: if you take India as an example. They have done

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Speaker 1: a huge outreach to including conditional cash transfers to community

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Speaker 1: health workers to bring these pregnant women into the facilities,

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Speaker 1: and there was a push and there's almost been an

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Speaker 1: eighty percent increase in facility birth rates in India, so

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Speaker 1: it can be done, and behavioral change communications they've been

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Speaker 1: they've used local storytelling, they've used the power of pure experience,

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Speaker 1: so all that has worked, and in fact there's been

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Speaker 1: a huge increase in facility births rather than birthing at home.

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Speaker 1: But unfortunately that eighty percent increase in facility births has

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Speaker 1: not resulted in an equalent eighty percent decrease in maternal mortality.

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Speaker 1: The facilities were not ready for this onslaught and the

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Speaker 1: quality of care they were receiving or the protocols that

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Speaker 1: they had in place were not suffice and so they

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Speaker 1: did initially see the eighty percent decrease. But the way

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Speaker 1: India went about it is first is raising the demand,

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Speaker 1: using the awareness and incentivizing women to give birth in facilities,

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Speaker 1: including making the whole experience free, including the transportation, and

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Speaker 1: now are very much focused on the quality that the

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Speaker 1: woman will receive during that childbirth process. If you add

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Speaker 1: to that data analysis and data predictability and predictive analytics

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Speaker 1: to see which woman is a high risk and once

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Speaker 1: they come into the hospital and to triage them, and

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Speaker 1: to be able to use the latest and the best

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Speaker 1: in data and technology is again leads us to believe

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Speaker 1: this is solvable and hence is something we should be doing.

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Speaker 1: Tell me a little bit more about data. You know,

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Speaker 1: we're talking about remote communities. What kind of difference can

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Speaker 1: data make? How does that help doctors in rural India.

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Speaker 1: I have been in communities and it's amazing how the

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Speaker 1: advent of mobile phone technology has so penetrated even the

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Speaker 1: rural areas in a lighter way. They say, they probably

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Speaker 1: more telephones than bathrooms in India, and so the people

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Speaker 1: who have access to a phone more easier than electricity

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Speaker 1: with that kind of penetration, I have seen, say in

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Speaker 1: that village, in these communities, in a house, the husband

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Speaker 1: who's usually the farmer, the male, the man has a

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Speaker 1: phone and today on his phone, the farmer has a

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Speaker 1: weather forecasting app that tells him went to plant and

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Speaker 1: went to harvest. He's got an app that tells him

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Speaker 1: the prices of his harvest and the produce in the

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Speaker 1: market that day, so he knows when to sell. He

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Speaker 1: also has on an app transportation like the equordent of

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Speaker 1: the ubers, to be able to move his produce and

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Speaker 1: his harvest to the cities for a better price. This

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Speaker 1: exists today, We've seen it. And in that same house

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Speaker 1: is the wife who's the community health worker, and she

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Speaker 1: carries around six registers, does not have access to the phone,

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Speaker 1: has twenty families that she's seeing, has no idea how

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Speaker 1: to optimize her day, which household is at risk, which

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Speaker 1: child in her community of who she's responsible is at

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Speaker 1: risk for my nutrition? Why couldn't she have similar predictive

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Speaker 1: analytic tools like weather forecasting that would help her do

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Speaker 1: her job better. So it is not just the doctors

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Speaker 1: having access to data, It is how can the community

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Speaker 1: health workers, the frontline healthcare workers have predictive analytics tools

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Speaker 1: that will optimize their work process but also in real

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Speaker 1: time can give them insights and inputs on how to

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Speaker 1: take care of these patients, of what tests to do,

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Speaker 1: which ones are the triage, which ones are the ones

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Speaker 1: at high risk. So this could be something as simple

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Speaker 1: as community health workers having a kind of app on

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Speaker 1: their phone that could help them give advice to pregnant

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Speaker 1: women or help them make decisions about who needs what

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Speaker 1: kind of care. That would be exactly the start. From there,

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Speaker 1: you can envision where she could have the story of

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Speaker 1: her village to know if there's a huge absence of

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Speaker 1: children in one school in her community, she should now

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Speaker 1: go there to see is there a diary outbreak, what's happening?

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Speaker 1: Why are the children are coming to school? There are

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Speaker 1: so many ways we can then build on it. What

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Speaker 1: about doctors in these communities, how can they access data

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Speaker 1: and how can that make a difference to what they do?

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Speaker 1: So take supply chain. Most doctors in these villages, if

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Speaker 1: there's a primary secondary health center, the doctor in charge

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Speaker 1: has never been trained on stock forecasting, has never been

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Speaker 1: trained on human resource distribution and how to supply and demand.

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Speaker 1: If these apps can actually in real time keep track

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Speaker 1: of stockouts demands, is there any way that the data

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Speaker 1: can give a better insight to these doctors to be

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Speaker 1: able to do a better supply management, better access to

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Speaker 1: where the crisis and they can they have an access

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Speaker 1: that tells them based on social media and other data inputs.

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Speaker 1: Where are the migrants coming from, what's happening across borders,

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Speaker 1: where is the water on area, what's happening, is there

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Speaker 1: another ebola brewing? Data can help identify hot spots and

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Speaker 1: cold spots. Cold spots could be a whole region where

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Speaker 1: children have not being immunized and nobody's kept tracked and

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Speaker 1: we don't know because they are in the blind spots.

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Speaker 1: Hot spots could be where this flash pandemics or something

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Speaker 1: brewing that we could get earlier warning. But what about

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Speaker 1: specifically to deal with the issue of maternal mortality. Is

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Speaker 1: there you know, are there particular kinds of programs or apps,

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Speaker 1: or is there a kind of data that doctors can

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Speaker 1: find particularly useful. So if the frontline healthcare worker can

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Speaker 1: find out if there is a region where women are

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Speaker 1: not coming to anti natal care for visits and could

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Speaker 1: be very easily tracked based on whether the woman has

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Speaker 1: made an anti natal visit and if she asn't, they

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Speaker 1: could even make home visits or they could encourage the

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Speaker 1: woman to come in and we know, for example, simple

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Speaker 1: antenatal visit to check for protein in the urine, blood pressure,

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Speaker 1: sugar levels make a huge difference. I've also seen an

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Speaker 1: app it's in formulation stage. It's actually the camera can

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Speaker 1: take a video. So I've seen where in India, the

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Speaker 1: healthcare worker waves this camera her cell phone over the

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Speaker 1: belly of the pregnant woman. An inside, there is an

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Speaker 1: algorithm that based on that image and that picture that's taken,

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Speaker 1: the woman's size of the pelvis is measured, and the

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Speaker 1: baby's head is measured, and an algorithm predicts whether this

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Speaker 1: will be an obstructed labor, whether the child's head is

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Speaker 1: too big for the woman's pelvis. Wow, And that can

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Speaker 1: be put in a cell phone. Yes, I've seen it.

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Speaker 1: It already exists. Inside obviously has to be finalized and commercialized,

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Speaker 1: but people are thinking that way. So if you think

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Speaker 1: about how data and applications are changing in our lives today,

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Speaker 1: there's so many people with the Apple Watch that has

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Speaker 1: the health monitor on it. What can we do if

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Speaker 1: we take that kind of mindset and those kind of

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Speaker 1: assets to the developing world to improve public health, community

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Speaker 1: health And to me, I'm using maternal mortality as a

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Speaker 1: sentinel indicator the Canadian the coal mine, so to speak,

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Speaker 1: where it tells me the status and the health of

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Speaker 1: the community, because the first ones to die, the most vulnerable,

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Speaker 1: are the pregnant woman, and if we can save them,

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Speaker 1: it means very likely we have a system in place

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Speaker 1: that is saving many people. And so these data, these

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Speaker 1: tools are needed, are needed today. They exist. Is just

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Speaker 1: that somebody has to put it together, and that's where

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Speaker 1: we are. Do you get any opposition to the use

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Speaker 1: of technology and data? Do you find that people distrusted?

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Speaker 1: Do you have people rejecting it? In the countries that

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Speaker 1: I am working on right now, I can presume it

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Speaker 1: will happen. India is putting in place draconian and much

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Speaker 1: needed and many aspects health data, privacy and security laws.

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Speaker 1: So it is coming. But right now, when we show

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Speaker 1: up and we talk about how we are helping women

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Speaker 1: survive childbirth, there is open arms and even in even

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Speaker 1: in communities. Here in the US, it's the only developed

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Speaker 1: country in the world where metal mortality is rising. And

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Speaker 1: that is really an absolute shame, considering that we spend

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Speaker 1: more than any other country on healthcare. And is that

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Speaker 1: is that for similar reasons you have these same kinds

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Speaker 1: of obstacles in the US that you have here. Yes,

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Speaker 1: they are the same three delays, but they have a

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Speaker 1: different connotation. So the second delay is not that there's

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Speaker 1: a flash fard and they can't get to The second

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Speaker 1: delays she's in a housing project and taxis won't come there.

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Speaker 1: She doesn't have money for a taxi, and she can

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Speaker 1: see the hospital, but she can't cross it because there's

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Speaker 1: a huge highway in between. So, yes, you can envision

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Speaker 1: the delays. The concepts are the same, the details are different.

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Speaker 1: Also here in this country we have slightly different causes.

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Speaker 1: In the developing world. That three big causes are woman bleeding,

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Speaker 1: which is postpartum hemorrhage, pre acclamps here, which is when

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Speaker 1: the blood pressure shoots up and you get seizures and

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Speaker 1: brain damage. The third is sepsis, which is infection. Here

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Speaker 1: in the US it is coiegulation disorders, it is how

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Speaker 1: do you askular disease, It's comordabilities, it's older woman, it's obesity.

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Speaker 1: It's also general lack of health and women not engaging

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Speaker 1: with the healthcare system. So there are similarities, there are

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Speaker 1: some nuance differences, but the bottom line is the same.

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Speaker 1: Women are dying from preventable causes, and to think that

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Speaker 1: the rate is going up in this country is just unacceptable.

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Speaker 1: I agree, it's very shocking. It's all very well talking

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Speaker 1: about technology and apps and cell phones, but how can

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Speaker 1: you use this technology parts of the world where power

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Speaker 1: is unreliable and internet connections are unreliable? Do you have

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Speaker 1: solutions for that as well? So any and all attempts

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Speaker 1: at improving health will also have to buy nature address

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Speaker 1: the data inequity gap. Yes, electricity, internet connectivity, all these

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Speaker 1: are current barriers, but these have been bridged. There are

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Speaker 1: solutions for this. They are off grade solutions. They are

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Speaker 1: offline solutions. And in fact, most of the apps that

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Speaker 1: exist in most of the ones that are working right

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Speaker 1: now in parts of Africa by large part work offline

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Speaker 1: and then when the internet connection is there, they do

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Speaker 1: the upgrading. So these are solvable by technology. But it's

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Speaker 1: that feeling that we can and should do it that

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Speaker 1: is the piece that we need to cross. And once

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Speaker 1: we've crossed that, I have a feeling we can get

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Speaker 1: to all these current barriers. Even if you would have

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Speaker 1: asked me twenty years ago if I was in charge

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Speaker 1: of all health for a coastal village that was that

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Speaker 1: was routinely hit by hurricanes, and they asked me, what

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Speaker 1: would I have to do to make to save people

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Speaker 1: when the hurricane comes. Based on what I knew then,

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Speaker 1: I would have said, Oh, we need to build more shelters,

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Speaker 1: we need to have more hospitals, we need to have

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Speaker 1: more collar of vaccines, we need to have more clean water.

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Speaker 1: How do I save the lives? Based on what I know?

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Speaker 1: But today probably the thing that saves more lives is

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Speaker 1: the weather predicting app forecast that tells me the storm

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Speaker 1: is coming and I can evacuate people. And I would

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Speaker 1: have never thought of that as saving more lives. Twenty

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Speaker 1: five years ago, I'd have built more hospitals, more shelters,

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Speaker 1: But today that single app is saving more lives than

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Speaker 1: all the things we could have done. Similarly, today, if

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Speaker 1: we were talking about how can we save these mothers

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Speaker 1: from dying, we're talking about internet connect community. We're talking

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Speaker 1: about more hospitals, better training, on and on and on.

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Speaker 1: Perhaps there's technology out there that will take us to

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Speaker 1: a completely different place. I just want to make sure

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Speaker 1: that the current barriers don't hold us back, and that

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Speaker 1: we do understand there's a data in equity and that

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Speaker 1: that is exacerbating health in equities, and what are the

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Speaker 1: obstacles to you, what's still standing in your way, what's

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Speaker 1: keeping you from bringing down the this mortality rate more quickly?

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Speaker 1: So I will I will start that by quoting doctor

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Speaker 1: Mohammad Mahmata was an obstitation is an obstacian who considered

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Speaker 1: the father of this whole concept. He very famously once said,

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Speaker 1: and I'm quoting him, women are dying not because we

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Speaker 1: don't know how to save them. They're dying because we

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Speaker 1: have yet to decide their worth saving and to live.

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Speaker 1: That it is very clear that for any of what

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Speaker 1: solutions we come up with to stick, sustain and scale

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Speaker 1: in country, first we need the country. We need a

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Speaker 1: political sustainability. We need political will. We need the policymakers,

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Speaker 1: the decision makers to decide that the woman are worth saving. Second,

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Speaker 1: we need social sustainability. We need the culture to be

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Speaker 1: where the woman is valued and where healthcare is considered

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Speaker 1: important for these women to get and to deliver in

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Speaker 1: a facility. And then we also need the commercials sustainability

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Speaker 1: that whatever systems are put in place have to benefit

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Speaker 1: society and that we do understand that these are not

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Speaker 1: just programs that we can go in and set up

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Speaker 1: as philanthropy and turn around and walk away, because we

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Speaker 1: need to teach them out of fish, and then we

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Speaker 1: need to make it commercially viable for them to fish

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Speaker 1: rather than just give them the fish. So we need

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Speaker 1: to set up systems where this is then sustained locally

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Speaker 1: within the community. So that is the barrier is how

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Speaker 1: do we sustain scale the solutions that we put in place.

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Speaker 1: But it also sounds like, you know, there are these

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Speaker 1: incredible pieces of technology available, but there's also a fundamental

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Speaker 1: emotional or psychological obstacle, which is that not everywhere do

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Speaker 1: people think that women's lives are important. Obviously that is

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Speaker 1: true here in the US too. They are countries that

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Speaker 1: have come together that have realized that saving the woman

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Speaker 1: is not just that I think to do, but it's

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Speaker 1: the smart thing to do. And there is equality and

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Speaker 1: there is no mental immortality so to speak of. So

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Speaker 1: it is just this that they are still communities and

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Speaker 1: their countries that wage political wars on women's bodies, and

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Speaker 1: even here in this country is no different. So we

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Speaker 1: need to be able to break those barriers. But just

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Speaker 1: breaking those barriers and not enough. We need to come

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Speaker 1: up with the medication technology training to then actually really

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Speaker 1: save them, because no amount of cultural training will help

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Speaker 1: the woman who needs associated section. A lot of people

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Speaker 1: listening to this might be inspired by some of the

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Speaker 1: things you've said and might like to want to try

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Speaker 1: and help solve this problem. Are there things that listeners

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Speaker 1: can do? Do you have any advice for people listening?

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Speaker 1: So the first thing, there are many organizations that are linked.

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Speaker 1: I would say, be aware, get to know it, and

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Speaker 1: if you depending on the sliding scale, whether you suggest

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Speaker 1: your pocket, whether you can give some money, whether you

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Speaker 1: can give time, whether you can give some volunteer hours work,

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Speaker 1: it's a sliding scale. I think it all depends on

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Speaker 1: where your heart is. But I think the journey should

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Speaker 1: start from educating oneself, finding out who are in this space,

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Speaker 1: and then reaching out. And obviously, the Rockefeller Foundation has

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Speaker 1: our website, and on that website there's a health section,

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Speaker 1: and then you can see how we are working towards

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Speaker 1: trying to solve this. Really powerful words from doctor Navine

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Speaker 1: Rao from the Rockefeller Foundation there about maternal mortality and

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Speaker 1: also talking about what it's really dealing with, which is

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Speaker 1: women and children's lives, and how things can change when

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Speaker 1: society decides that they are worth saving. Solvable is a

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Speaker 1: collaboration between Pushkin Industries and the Rockefella Foundation, with production

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Speaker 1: by Laura Hyde, Hester Kant, Laura Sheeter, and Ruth Barnes

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Speaker 1: from Chalk and Blade. Pushkin's executive producer is Neia LaBelle,

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Speaker 1: Research by Sheer, Vincent, engineering by Jason Gambrel and the

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Speaker 1: great folks at GSI Studios. Original music composed by Pascal

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Speaker 1: Wise and special thanks to Maggie Taylor, Heather Fine, Julia Barton,

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Speaker 1: Carly Mgliori, Jacob Weisberg, and Malcolm Gladwell. You can learn

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Speaker 1: more about solving today's biggest problems at Rockefella Foundation dot org,

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Speaker 1: slash Solvable. I'm Mave Higgins now got solvus then