Chelsea Clinton

Addressing Challenging Global and Domestic Health Problems- April 9, 2015

Chelsea Clinton
April 09, 2015— Boston, Massachusetts
Harvard Voices in Leadership Series
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Well, thank you, Atul [Gawande], thank you, Dean, for welcoming me. Thank you to Betty Johnson for all of her stewardship of this event and ensuring that we all got here on time and in the right places. Thank you to everyone at the School of Public Health and the broader Harvard community who has made this event possible today. I also would like to thank Dr. Nall for all of her work on behalf of cancer survivors here and around the world and we were just talking about hopefully more work we can do together through the Clinton Global Initiative this year and in years ahead.

I am particularly grateful to be in conversation with Atul, because he is something of a hero in my family. As he may not be aware, I think my father deserve some credit for his tremendous book sales that the dean talked about. Although I know you have a more recent book out, my father continues to hawk shamelessly “The Checklist Manifesto.” It's certainly required reading in my house and I wouldn't be surprised if here as well, and all the chuckles I think validate why it is so important that all of us think more about the systems that we too often take for granted.

I want to spend most of the time that we have today in conversation with Atul, based on the questions that he would ask and those that you have submitted. But before we move to that conversation, I do want to talk a little bit about the work of the Clinton Health Access Initiative and the Clinton Foundation in global health and in health here at home in the United States.

In 2002, when my father left the White House he knew that he-- or in 2001, when he left by 2002, he knew that he wanted to do something around HIV/AIDS, but he didn't know what that something would be. He didn't know how he would be uniquely positioned, given the work that he had done as president, given the people that he knew, given his, I think, his remarkable ability to distill a challenge, to understand when a system needs to be fixed or when the system needs to be better defined and created, how to apply all of that to the challenge of AIDS.

2002 seems like many eons ago now. The Global Fund to just open its doors. PEPFAR wasn't even yet a twinkle in President Bush's eyes. There were only 200,000 people in the developing world on ARV treatment. The vast majority of those lived in Thailand and Brazil, countries that could afford to have their own generic manufacturers of ARVs and in which the countries had sufficient resources to either subsidize or outright purchase ARVs for their HIV positive citizens. And so this was the environment in which my father traveled with Nelson Mandela to the Barcelona International AIDS Conference in 2002.

He was determined to do something. He didn't quite know what would be most impactful. The world was starting to pay attention. More resources were being marshaled. But not yet to real effect in too many people’s lives around the world.

And while at the AIDS conference, he was approach by Dr. Denzil Douglas, who then was the Prime Minister of St. Kitts and Nevis in the Caribbean. As Dr. Douglas explained to my father, St. Kitts and Nevis didn't have a real challenge that was an impediment to accessing treatment and care for so many people around the world. It didn't have a stigma problem. But it did have a significant money problem and a systems problem.

And so we ask for my father's help to better negotiate with the generic drug manufacturers, at least in Brazil just over the Caribbean to the south, for not only St. Kitts and Nevis, but for the Caribbean writ large. Because even the Bahamas, the wealthiest nation relatively speaking, in the Caribbean, was unable to provide drugs for its HIV positive population. And my father thought, yes, I can figure out how to do this.

And so that was the genesis for the Clinton Health Access Initiative and really for the market-shaping work that has driven much of the Clinton Foundation's work around the world, not only in health, but in agriculture, in combating climate change, and fighting childhood obesity here at home. So in 2002, when the average ARV price was upwards of $10,000, the Clinton Health Access Initiative as a nascent entity, began to negotiate with multiple parts of the system. And for the first time really defining a system, recognizing that the challenge of what had been characterized as a high price, low volume market shouldn't have to persist as such, given the resources coming online from the Global Fund, the tragedy of the increasingly recognized AIDS challenge around the world.

And so today, as I know many of you are aware, the average cost of antiretroviral treatment per person per year is between $1 and $200. In some countries it's even less. And of the more than 10 million people that are on treatment in the developing world, 8.2 million of them access treatment through more than 70 agreements that the Clinton Foundation and the Clinton Health Access Initiative helped negotiate. Now more than 4 million of those acquire treatment through PEPFAR dollars.

So that makes me proud, not just as a daughter, but also as an American taxpayer. You laugh, but I mean that quite sincerely. I think it says something about our values as a country that we continue to make access to treatment a national priority. That market-shaping work, CHAI then translated into helping negotiate a more than 50% decrease in the price of the pentavalent vaccine, massively expanding the purchasing power of GAVI, UNICEF, and others, a more than 40% price reduction in injectable, long-lasting, reversible contraceptives, ensuring that more women have more agency over the choices that we make for ourselves and our families around the world.

And that paradigm then got translated through the Alliance for Healthier Generation, which Atul mentioned, the partnership between the Clinton Foundation and the American Heart Association, the genesis of which was my father's own heart scare. That's the euphemism that we use in my family for his almost cataclysmic, likely to have been fatal, heart attack that thankfully was prevented when he did the right thing, had chest pains, called his doctor, and had a quadruple bypass surgery at the end of 2004. At the beginning of 2005, he called the American Heart Association and he said, well, what can I do?

He said we've been doing this work around AIDS across the world. Do you think any of that would have utility here? We thought about kind of heart health. Can we help drive down the price for treatment? Could I be the poster boy for prevention? Like, what can I do? And the American Heart Association said, sure all that would be great. But what we really need your help on is combating childhood obesity.

And while there's a lot of awareness now that childhood obesity is a significant challenge in our country, that wasn't as well syndicated or socialized at the beginning of 2005 when my father began working on childhood obesity. And he took the same principles that had helped to animate CHAI's work and applied them to the Alliance's work, working to build consortiums of school districts to better effectively purchase healthier options for school lunches, working with beverage manufacturers to ensure that they could still ship the same quantity at the same price of beverages to schools to sell in vending machines, but moving away from full calorie sodas to waters and to flavored waters.

Doing things that individually, may not have such an impact, but collectively coalescing, again thinking about the food system in which kids live and work and play and go to school as a way in which to really combat and ameliorate the childhood obesity challenge. And increasingly, this is recognized as not just a challenge for those of us who care about public health, but for Americans who care about any concern that's facing our country. In 2013, the Joint Chiefs of Staff declared childhood obesity a national security crisis.

In 2014, the New York City Fire Department and Police Department acknowledged that they were unable to recruit sufficient numbers of new officers because too many were failing the physical fitness exams. The National Council of Economic Advisers has said the childhood obesity poses the risk of an economic tsunami almost irregardless of what nets out in the various concerns around our health care system reform.

And so thankfully, that's given real momentum and agency to this work, because ultimately, and I think Atul and I will talk about kind of how we assess success at the foundation or in our family. We're always trying to work ourselves out of a job. And so because increasingly, childhood obesity is recognized as not just a moral imperative that we need to correct, but a security and economic imperative, school districts increasingly are able to find their own funds to better purchase food. Increasingly, the Defense Department is giving resources to schools that are on or near military bases so that they can do the same. Increasingly, other foundations locally, whether it's in Miami or Little Rock or Northern California are helping to support school districts to do similar work.

And so that means that we're able to take that work and do it elsewhere. That to us is ultimately what success looks like, when the governments that we help negotiate with the generic drug manufacturers no longer need us to help negotiate the next generation of drug agreements. Of the more than 70 countries that we helped originate their negotiations, more than 40 have now done the second and third negotiations on their own. That to us is real success. And there's a transfer of skills wherewithal and systematic understanding such that, in the best sense, we're no longer needed.

And so I hope that we can talk more about our work in public health around the world or our work with school districts and more broadly here in the United States, including the newest unlikely partner with the Alliance for Healthier Generation, McDonald's. You laugh, but a majority of American kids-- this is true, eat at least one meal a month in a McDonald's. So if we're going to solve the childhood obesity challenge in our country, we truly have to continue to go to where kids eat.

And McDonald's committed to, at the Clinton Global Initiative Meeting in 2014, to move away from French fries in Happy Meals towards fruit or vegetables, to no longer include sodas in Happy Meals, but instead include milk or water or in some markets, fruit juices. They've almost entirely made good on that commitment here in the United States. And it's one that they're working on achieving around the world, because sadly childhood obesity is no longer just an American challenge.

So hopefully we can talk a little bit about how we think of success, how we think of needing to engage often unlikely, but necessary partners, in tackling any public health challenge or other challenge where we believe we are uniquely positioned to make a difference and also how we think about saying no. Because for those of us that care so much about public health, I think so often we think we have to say yes. But sometimes the smartest thing we can do is to say no to the first option, so that we better can say yes to the second option where we're more well-positioned and equipped to make a difference.

So thank you for welcoming me. Thank you for being interested in the work of the Clinton Health Access Initiative and the Clinton Foundation. And I look forward to talking to Atul I guess about whatever he wants to talk about although I've kind of put a few mental markers in that I hope he will permit. So thank you all very much.

[Applause]

GAWANDE: That was great. And I think what was great about it is it gives a picture for people of just how deeply embedded you are in leadership in global health and public health in the United States. You have-- well, I read a profile of you, a bunch of profiles. And I think the most interesting thing that was said was that of the three Clintons, you are the one who is most hands-on at the foundation. And it described your direction as more data and outcome driven, arising from some of what you were hinting at, the desire to try to prioritize and to have clarity about metrics and outcomes, very comforting for a public health community here that likes to think about the cost effectiveness of what we're doing and push in that direction.

So if the key struggle is prioritization, do you want to influence that at the foundation? How? What are the levers that a young leader has walking into a big foundation?

CLINTON: Well, thank you, Atul. I think there were lots of questions there and I'll try to answer them in a way that makes sense in an overall arc. And I'll do that in a couple ways. I think that the fact that the foundation has been successful in some of the ways that I outlined, actually increases the burden on us to continue to prove the validity of our model, but also to syndicate the validity of our model. I think that it is now terrific that we take for granted that there are lots of market discontinuities that remain low hanging fruit in various health commodities around the world.

There's lots of work that's happening for example now on various testing economics, trying to change not only kind of HIV or rapid infant diagnostic testing economics but increasingly to change the economics around malaria and tuberculosis testing and otherwise. We are engaged in some of that work, but most of that work we are not engaged in. And I think that that is terrific.

And so part of what I've done at the foundation is to try to help us be more open source, to try to be more transparent with our partners, whether our funding partners or our programmatic partners, kind of whether that's through the Clinton Health Access Initiative or through the Alliance for a Healthier Generation or otherwise, with what we've done that we really think has worked, kind of at a very granular and practical level so that others can learn more quickly from our successes and also our stumbles.

And then I think we have an obligation to think about logical extensions of our work that may not be immediately apparent. So again, thinking about the Alliance, I'm deeply passionate and I talked about this actually when I was here in 2013, the juvenile justice system. There are 53 some odd thousand young men and women who, every night, sleep in a juvenile justice facility in the United States. Disproportionately, they are young men of color. Disproportionately, they have significant health challenges.

They are, depending on the state, at least as likely, if not more likely, to be struggling with obesity than the non-juvenile population. And because we've seen real success in the districts where we do a lot of deep work on childhood obesity, where at least the childhood obesity rates have plateaued, if they aren't yet declining. But again, to data, we have to sort of stop the upward trajectory before we can reverse it. I really believe that we had a moral imperative to try to translate the work of the alliance into the juvenile justice system.

And so a couple of years ago we started working with California and Arkansas. Similarly through a sort of hands-on technical assistance paradigm, helping the facilities and the systems be smarter purchasers of food, helping figure out ways to get physical activity back into the juvenile justice systems in a way that the systems would feel comfortable, but would really be authentically useful for the young men and women living in those facilities. And we partnered with Emory as our evaluative partner.

And the pilots of those programs showed what we hoped it would show, an increase in health literacy, an increase in the kind of confidence of the young men and women in the facilities to feel like they knew how to make healthier choices for themselves, at least in terms of diet and exercise. And then one hopes that those healthier choices help ladder up to other healthier choices in their lives. And we're looking to extend those programs across the country. So that's a little bit how we think of success in sort of a macro sense, and also how we think of what our next step responsibilities are to extend the programs that we believe are working.

GAWANDE: Well, so I hear embedded in what you're saying, the Clinton Foundation, the Clinton Global Initiative in particular is kind of famous for its pledges. And I hear you saying also, we want to be famous for our outcomes and the successful outcomes. And you're describing some pretty sharp metrics, not easy to hit, that are going into that, it sounds like you're pushing towards.

As you prioritize what the foundation tackles and what it does not tackle, how do you use either data or is it your gut as a family about what you want to go towards? Prison work or heart disease, in the personal case of the president, what drives that set of decisions about what you will do and what you won't do?

CLINTON: It's a great question. It's one that I think about obsessively. I do. I think about it obsessively. And we always try to start from kind of where are we disproportionately least likely to be able to have a positive impact, either because of market-shaping work that we've done already or because of our school-based network or because of work that my father and mother may have done historically. And if someone asks us to do something, because I think another important point to make is that we only work at the invitation of national or local governments or whatever the pre-existing institution is.

So for example, for CHAI, we only work at the invitation of national governments. For the Alliance for a Healthier Generation, we only work through the school districts. So we're now in hundreds of school districts across the country. We work with more than 16 and 1/2 million kids' lives every day through the 27,832 last checked, schools. But all of those school districts have asked us to help enhance their health and wellness position.

And so when we think about what more we can do what we say yes to, we start with sort of where we are. And so, an example thinking about a doctrinal, is we were asked a few years ago, through the Clinton Health Access Initiative to help a country where we've done a lot of work on AIDS and tuberculosis in particular, to help design their cervical cancer program. But we didn't know anything about cervical cancer.

And we didn't know anything about the sort of kind of primary, secondary, and tertiary care systems that were in place around cancer already in that country or would need to be in place and how to get from A to B. And so we said no. We made suggestions of other partners that we thought were more well-equipped to help that country kind of transition to the vision that it was just starting to define. And I think that was the right choice for us.

So having a disproportionate likelihood to say yes or even to affirmatively go out and do things that are kind of extensions from a technical standpoint or a programmatic standpoint from work we're doing already or where we have previous experience, and to be very judicious about saying no, even when partners that we have deep and productive working relationships with ask us to do something that we don't think we're the best to do.

GAWANDE: One of the questions came from the students. Of the knowledge you gained from your master’s in public health, what was the most important for your future career?

CLINTON: Statistics.

GAWANDE: Because?

CLINTON: Well I think it cycles back to my obsession with data. I'd done a lot of work in economics and I was really comfortable with economics. You're still laughing. But I think that means that a lot of you agree with me secretly, even if you are not comfortable being as obviously nerd-like.

GAWANDE: You can program in Stata?

CLINTON: Yeah, I love Stata. And Access and all sorts of other programs. And I think that's actually been really useful for me. Because it enables me to do absorb information more quickly, from kind of more sources. It enables me to kind of mentally sift through it and catalog it. And I think that in a world in which there are so many demands on all of our times.

And now that I'm a mother and I'm always trying to be even more efficient in my work to maximize my time with our daughter, Charlotte, I just am so grateful to all of my kind of bio stats and the additional statistics that I took at Mailman.

GAWANDE: Your PhD and now your course at Mailman that you're teaching on global health is about global health and governance. So what I'm wondering is, what do you think is a key thing people don't understand about the link between global health and governance, and especially what does it mean that governance connects to global health and global health outcomes to you?

CLINTON: Goodness. Well again, I think lots of questions. I think one of the challenges is that so often we focus only on what's in front of us. I think that's inevitable for all of us. And so understanding the ways in which the world works, sort of that, I would argue what has happened over the last year with Ebola was not inevitable, kind of in a philosophical or theoretical sense. But it almost was inevitable, given the system in which it happened.

Given the current state of global health governance as it is currently constituted from the WHO at a global and regional and national level, and given the fact that we continue to be more responsive than prescriptive and how we think about fragile state health environments. And so for me when I think about or teach about global governance, it's understanding the cascade of events in which any one narrative occurs. Whether it's Ebola or the case of AIDS and trying to not take for granted how important inertia is in those narratives. Given the state of the institutions from a formal multilateral standpoint, but also from a donor standpoint, from a developing country standpoint, a foundation standpoint. And yet then thinking, what is the ideal and how do we get from here to there, in a practical, political sense?

GAWANDE: Well, I'll give you an example that I feel like I struggle with all the time. We have a number of teams here at the school who are involved in trying to improve maternal and child health. And a recent study showing that when you measure what matters, its things like do they have enough access to the facilities for delivery? Do you have the right medications? Do you have the right personnel? All those kinds of things. But then the strongest predictor that you would have any of those things is corruption.

And how to tackle and what to even do about places where there's deep corruption and your choices are, well, we don't work in those-- should we not work in those environments? If we're going to work in those environments, how do you engage in corrupt governments? So have you started to have some sense of what you do and don't do to even move the ball forward in a space like that?

CLINTON: And also recognizing how what happens here in the United States also impacts the ways in which organizations or even individuals are able to work in areas across the world. So as a practical example, the Foreign Corrupt Practices Act here in the United States historically has not been applied to foundations, to NGOs, to even kind of domestic funding of UN agencies that work in often imperfect environments. But there are various states attorney generals, there have been people who advocated for still serving Attorney General Holder, that the Foreign Corrupt Practices Act be extended to NGOs, foundations, to not only those of us that engage in sort of direct service work, but also theoretically the Gates Foundation, which is the behemoth funder in global health around the world. Which would completely change this argument.

Because right now, the values-based conversation is, am I comfortable being in a situation where I might be perpetuating kind of a long term dysfunction to facilitate short-term gains that you can justify, thinking, well, if they're healthier people, they'll grow up hopefully to be healthier voters. And maybe in the next generation they're going to vote out those who've been engaged in the endemic corruption. That entirely shifts, if the legal burden on whether it's the Clinton Health Access Initiative or the Gates Foundation or smaller NGOs just dedicated to helping protect and advance maternal health, whether it's in Cambodia or Costa Rica, are going to be examined through the lens of the Foreign Corrupt Practices Act, in which, if you have any knowledge of any corruption in any place that you were doing business, your assets are frozen and you're unable to do your work.

That is that it's a fundamental governance question. And I would argue it's one for those of us that care about global health, we should be engaged in those debates at the state and national level. Because often I think those of us that think about public health don't realize how political or legal conversations happening that ostensibly are quite disconnected from what we do can have real implications, for if we're even able to do the work that so many of us feel called to do.

GAWANDE: That's not an idea I'd heard. It would be really radical, even to use the convening power of the Clinton Foundation to bring people in NGOs around. What are we really doing about corruption? It's, I think, a fascinating indication of where you're potentially able to push things in your leadership role.

One area that you have really embraced recently is about the role of girls and women and their status around the world. And you're applying this very outcome-driven notion to it. Can you tell us a little bit more about this campaign you're launching?

CLINTON: So I'm deeply passionate about everything around girls and women. And I didn't know that I could be more passionate about this until it became a mother and until I had a daughter. I guess I think that also something that clearly has resonance. And in 1995, when my mom went to the Fourth World Conference on Women in Beijing and declared that women's rights are human rights and human rights are women's rights, something they shouldn't have been incendiary. But at the time, it was actually censored on Chinese television.

So clearly it was deeply threatening, at least in the place where she was speaking. And was certainly not taken for granted as a principal, much less as kind of motivating kind of design for us in how we think about development programming and aid. She really began her advocacy on behalf of women and girls, whether in maternal health or enabling women to equally participate in the workforce around the world and kind of that thread of her life. Again, thinking about were we disproportionately able to make a difference, for whatever reason, led my mother and me when she decided to join the Clinton Foundation, to really think about, well, what can we do to continue to advance, what at times can feel a Sisyphean task. But one that we believe is not only morally the right thing to do, but strategically and economically the smart thing for us to do to ensure the full and equal participation for women and girls.

We realized again, to Atul's point around convening power, that we could likely convene unlikely partners. And so we believe the No Ceilings Report that we launched a few weeks ago is the most comprehensive data set ever, around the status for rights and participation for women and girls around the world, partly because we worked with traditional data partners, I'm sure data sets that many of you are familiar with, kind of from the World Bank, various UN agencies, but also less traditional data partners like Facebook. Because Facebook has the largest female population in the world. There are more than 700 million active female users on Facebook.

So trying to understand the ways in which women are using technology to sometimes circumvent or ameliorate the ceilings that they still face in their own lives. And then putting all of it online in an open source, searchable kind of easily usable, downloadable. You can download it into Stata. As well as Excel and other kind of formats. Because we hope that it will have validity and utility to people sitting in this room, but also to young people around the world, to try to help better articulate what they want to see and to better make the case to see that for women and girls.

And I think that's true here in the United States. One thing that I kind of, again, just say to belabor to some extent, because it continues to surprise every meeting I'm in or every fora in which I'm speaking, is that the United States is one of only nine countries in the world to not have paid maternity leave for mothers of infants. It's surprising, I think, to many of you.

And if it's surprising to many of you, who clearly have a public health bias or otherwise we would not be in this room together, imagine how surprising it is to people who don't have a public health bias or vocational calling. And the company that the United States is in, is Suranum and then largely South Pacific small island nation states, countries that have significantly fewer resources than we have here. And to me, that's a real value judgment that we continue to make as a country. That we continue to not invest in ensuring that mothers have this crucial kind of early moments and even months to feed and to bond with their children.

And so for my mother and for me, the No Ceilings work hopefully helps not only kind of assess where we are, but eliminate where we need to go, because of what progress has been made. In 1995, the United States wasn't one of nine. It was one of literally dozens. So the world has moved beyond us. And I think that we need to make the right choice for our future to catch up.

GAWANDE: Do you do have another example of a measure that you feel is moving or that is movable that brings a concrete sense of what status improvement really means?

CLINTON: Well, I think another one that I think generally people find surprising where we haven't improved on a global level is workforce participation. So in 1995, 55% of women over the age of 16 where either in school or working. In 2013, 55% of women around the world 16 or older were either in school or working.

And in the United States, it's not much better. It's just shy of 58%. And this is actually fundamentally a systems question. I mean, how do we ensure that we shift expectations around what is acceptable for women? How do we ensure that policies in the United States where a lack of paid maternity leave is one of the last barriers and kind of is overcome.

But also there are more than 100 countries around the world where there still is legalized discrimination against women in the workforce, where women can be denied jobs or it's legal to pay women less. There are a number of countries where there are still restrictions on women's movement, a number of countries where there's restrictions on whether a woman can open a bank account or get a loan without having a male family member cosign.

So we have a pretty clear sense now in way that we didn't 20 years ago of what the barriers are. And we have a lot of data about what happens when those barriers are removed. But we are so far from being where we need to go.

And so at the Clinton Foundation and particularly through CGI, using our convening power, trying to convene real conversations that hopefully have a lot of attendant peer pressure to help, whether it's governments move to where it's clearly in their best interest to move or kind of getting foundations and others to continue to dedicate resources to often sort of unsexy subjects or sometimes politically sensitive subjects to help amplify the public pressure within countries to help ensure that every girl can grow up and be whatever she wants to be.

GAWANDE: The students had a lot of questions directed towards the idea of how a young person can lead. And you have been trying to do that. How do you think a young person leads an older generation where they may not want to go, especially when a couple of them might be your parents? How do you exert leadership within a foundation that has been so defined by your parents? And what do you think the lessons are for young people about being able to do that, because in some way we're all defined by the older generation?

CLINTON: Yeah, completely. I think, well, I'll answer the question first about my family and then answer the broader question about the Foundation because I think they're different. But you asked them both and I'm happy to talk about each. Within my family, I'm really grateful that we have had kind of a conversation about what we think the challenges, the opportunities, the solutions are, whether today or in the future, literally my whole life. The first thing I learned to read was the newspaper.

One of my earliest memories, truly, is during the 1986 gubernatorial election, in which my father was running against a man named Frank White, who represented the darkest part of Arkansas's past. He was an unapologetic segregationist. He was just determined to drag Arkansas back to the dark days. And he was my father's Republican opponent for reelection when my father was running in 1986.

And I guess the benefit of having three family members is that you have kind of two candidates and a moderator built in to the breakfast table or the dinner table. And so we would have these kind of fierce debates, in which my parents would kind of force or empower me, depending on your perspective, to play my father, to play Frank White and to play the moderator. And I think that was hugely useful training, not only for my debating skills later in life, but also for being comfortable talking to my parents on an equal level. And that they always treated me with the expectation of having my own opinion.

And I think that was a gift they gave me that I didn't quite understand how profound that was until I became a mother, sort of realizing that they didn't only listen to me, they expected me to have a point of view. They expected me to have the data and the evidence to defend that point of view. And they expected me to be able to do that in under 60 seconds in the debate format.

So I think that that has enabled me to be comfortable when I've historically, and has been in the public domain, disagreed with my parents my big issues, like gay marriage, a number of years ago, until they kind of came to a place where they support equal marriage rights in our country. And to things even kind of within the Foundation, which are often questions of prioritization, not so much of what we should be doing, but maybe what we should be doing first or kind of how we should be organizing ourselves to do something. So that sort of the family-based answer. So I guess the takeaway is that I will be kind of forcing Charlotte to have lots of debates as soon as she's able to talk.

And then at the Foundation, I think it's a few things. I have a great amount of respect for all that my father has done that had nothing to do with my mother and me. But he really kind of was the genesis of and kind of continues to be the driving force for, and have lots of humility and respect for the people who've helped him do that work and continue to help him do that work. And there are parts of the Foundation and the Clinton Access Initiative that still very much are his bailiwick, where my mother and I are much more in a supportive posture.

In the same way there are parts of the foundation that my mother and I lead or that I have more kind of leadership in and she has more leadership in respectively. And so I think that is a healthy ecosystem. We talk about everything. We kind of develop priorities at a macro level. But there's also very clear areas where one of us is more of not just the public face but really kind of the driving day-to-day animation of the work.

GAWANDE: As she's contemplating running for president, it's bringing a lot more scrutiny to the Clinton Foundation. How do you keep the foundation and yourself effective going into this chaotic future that is coming?

CLINTON: Well, you're presuming a chaotic future, Atul. I don't know. I can't comment on the future or the chaos part. I can certainly kind of hope that it will be less chaotic, but expect that it will be quite chaotic.

I think we just continue to do our work. I realize that may sound like a Girl Scout answer, but I really believe that. I mean I believe if we continue to do our work, if we continue to have real results, we will continue to be able to work with the partners that we have had such productive impact with so far, whether on the kind of government side, whether on the local community school district side, whether on the funding side, whether on the evaluative partner side, I think we can continue to our work and we can continue to prove our results, we'll be able to continue to our work.

GAWANDE: Well, you've been incredibly impressive and forthright about what you think and what you're doing. I think I'll ask my last question, which is we've had a chance to talk about a wide variety of things. What do you think for the students are the two to three key takeaways is you might mention about leadership?

CLINTON: I think one, it's important to have a really honest assessment about what each of us are good at and not good at. I think it's important to have a real, honest assessment about what we are most passionate about or most angry about. I think kind of anger in interpersonal relationships is not very useful. I think anger is a motivating force about injustice in the world is incredibly useful to help us figure out what each of us want to focus on.

And I think being comfortable asking for feedback from those around us who we really respect, in terms of kind of what they've already done, either in advance of us or alongside side us. Because I think we are either always growing or we really are falling flat. Catherine the Great said that states and people are the same, either were growing or we're rotting. I don't think we're quite rotting. The dean is laughing, that's a bit extreme.

But I do think each of us wants to continue to be more efficient and effective. And I think that we get there by continuing to have a clear sense of what we're good at and not and what we're passionate about and not. And kind of drawing on our cohorts or our mentors to help us define each of those in a way that drives us forward.

GAWANDE: Well just over a year ago, we had our 100th anniversary and you were the recipient of our Next Generation Award and I can see exactly why. Thank you, Chelsea for this and creating such a significant impact.

CLINTON: Thank you very much.

[Applause]

GAWANDE: We'll ask you to stay with us stay tuned for the Next Generation Award presentation for the successor to Chelsea.

JULIO FRENK: Thank you, Atul. Thank you Chelsea for this fascinating conversation. I think you've illuminated the way people can work together and have that unique combination that Chelsea was talking about at the end of introspection, passion, and commitment, and even that channeling of anger for all of those things that we feel we cannot tolerate in the world.

As Atul mentioned, you've got a great example of why Chelsea Clinton was the recipient of the first Next Generation Award. This award was instituted last year, last academic year when we were celebrating our first hundredth years of life as the School of Public Health. And the idea was that along with centennial medals that were given to President Bill Clinton, alumni Gro Harlem Brundtland, and former alumnus and faculty member Jim Kim, we wanted also to look forward to the next 100 years and therefore institute an award that would identify outstanding leaders under the age of 40, who have already shown a light on the world a positive light for the commitment to health as a fundamental human right and a commitment to achieving health for all around the world.

So you who are here to attend that memorable celebration in October of 2013, will remember Chelsea's passion and words back then. And it really made me realize what a great idea this Next Generation Award was and the notion that we should continue that. Because it is this generation and then the generations to come who will be here for our second and third centennials. So we are truly delighted that Chelsea is here with us. And we've asked her to present the next Next Generation Award to a very inspirational and distinguished individual.

And I'm delighted that Blake Mycoskie has accepted to receive this award. Blake is the founder and Chief Shoe Giver, that's his official title, of Toms. He's also the creator of One for One, which is really an innovative, transformative business model to help a person in need for every product that gets purchased. So please join me first, in watching a very brief video highlighting Blake's accomplishments.

[Video Playback]

-Thanks to Blake Mycoskie, a simple idea has grown into a global movement. And with that idea, the company he founded, Toms Shoes, has provided over 35 million pairs of shoes to children since 2006. As if that were not enough, Toms Eyewear has restored sight to over 275,000 people by providing prescription glasses, sight-saving surgery, and medical treatment. Toms Roasting Company has helped provide more than 100,000 weeks of safe water in seven countries since 2014. And now Toms Bag Collection is funding training for skilled birth attendants and distributing birth kits to help women safely deliver their babies.

Toms has had such an impressive impact, thanks to the One For One business model Blake has created. That model ensures that a person who needs help with every product purchased. The Harvard T.H. Chan School of Public Health is honored to present its 2015 Next Generation award to Blake Mycoskie for his leadership and commitment to improving lives by providing shoes, sight, water, and safer birthing services to people in need, from Nepal to Kentucky.

[End Playback]

FRENK: Chelsea, will you step up to the podium to present the award to Blake?

CLINTON: Thank you, Dean. If it were quite so cold, I would be wearing my Toms Shoes. So I just have to say that I will make that up to Blake when it gets a little bit warmer because spring at some point has to finally arrive.

I think there are so many remarkable things about what Blake has created. Some of what you saw in the video, but arguably, equally remarkable is how, now so many of us take for granted that this is a viable business model. That the One For One model that Blake pioneered is a viable approach to achieving social good and having a real impact in the world. And if imitation is the greatest form of flattery, then Blake is flattered many times over. And I wouldn't be surprised if some of you are thinking about your own ideas under this One For One Aegis.

I couldn't really imagine a world without Toms Shoes, partly because of all the work that you saw highlighted in the video, but also partly because of what a remarkable partner Blake and Toms has been with the Clinton Foundation. When my father asked Blake if he would open a shoe factory in Haiti, he just said, yes. I don't know if he kind of realized he could have said no. He could have said no. My father would have still been equally kind of an enthusiast and fan of Blake and Toms.

But thankfully, Blake said yes. And a place that was deeply connected to my family's heart, my parents took their honeymoon in Haiti, and where my father has been working to improve good governance to help remedy so much of what Atul talked about, kind of at the institutional level in Haiti, clearly having a vibrant economy is part of ensuring that Haiti is on a path to success. And Toms has kind of and part of that solution and I know only will be even more so in the time ahead.

And when my mother and I asked Blake if he would partner with us on our work around saving Africa's elephants because at current rates poaching, the African elephant will disappear in a little bit more than a decade, Blake and his wife, Heather, said absolutely. And we've been thrilled by the results of that effort, which have provided vitally crucial funds to the Wildlife Conservation Society's African elephant preservation efforts across the continent.

Again an issue that may seem sort of disconnected from health and development, but actually is intimately connected to both because of the groups that are now engaged in poaching across the continent such as Al Shabaab and Boko Haram. And so Toms Shoes is not only at the forefront of ensuring that more people have the ability to walk to school or to play and that more mothers have the confidence to deliver their children in a safe and healthy manner, but also helping to change the shape of the Haitian economy, to help protect the African elephant, and I have no doubt doing so much more that so many of us will never even hear of. So please join me in congratulating Blake on his Next Generation Award.

Speech from https://www.youtube.com/watch?v=kSGVQh1b-TE