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Keynote Address - Building Equity in Global Health: The Role for Global North Actors — Transcript

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0:05- So our speaker today is Professor Madhukar Pai.
0:08He is the Chair of the
0:10Department of Global and Public Health at McGill University.
0:16He's asked me to keep this short.
0:18I will just simply say he is a leader in the field
0:21of public health and in particular and two areas.
0:24One is the diagnosis and treatment of tuberculosis,
0:27especially in vulnerable populations around the world.
0:30And the other is really being an important voice
0:33for global health equity.
0:35And so we're really fortunate to have you here today.
0:39Dr. Pai has already taken advantage
0:41of opportunities to meet with people
0:43and he had the rare privilege of being able
0:46to actually see the only tsetse fly colony in North America.
0:51So in lieu of that, we won't be giving you an honorarium,
0:54(audience laughing)
0:59but we also won't ask you
1:01for any documentation or paperwork.
1:03So please, Dr. Pai.
1:04(audience clapping)
1:15- The slides working?
1:16Yeah. Okay.
1:18Good afternoon, everyone.
1:20It's such a privilege and honor to be here.
1:21It's the first time ever at Yale.
1:24And normally, this would be a stressful talk
1:28to give, I'm speaking from experience.
1:30But I feel very safe with you.
1:33And I know many of you in the last one day
1:36that I've interacted, and even before that, many
1:39of you are thinking a lot about what I'm about to say.
1:42So in some ways, you are ahead of the curve,
1:45and I feel very, very safe
1:47in discussing these issues with you.
1:50A talk like this should never begin
1:51without a positionality statement, okay?
1:55You should know exactly why I am even qualified
1:58to talk about some of these issues.
2:00Somebody once on my face called me
2:02a double agent in global health.
2:04I hated it, initially.
2:06I thought that sounded bloody sinistrous, right?
2:10I think they meant this in a nice way
2:12that I came from the Global South,
2:14but now I'm giving in the Global North,
2:16and therefore I had some magical divination abilities
2:20to understand both worlds.
2:22I resisted that label.
2:24But over the last 20 years
2:26or so, I've come to make peace with it.
2:29I am a double agent.
2:31And I know it brings lots of privileges to me.
2:35The ability to even speak on this issue is a privilege.
2:38But it also puts me in very awkward situations.
2:41I was just discussing that with Brian Wall earlier today.
2:46I'm no longer sure who I can speak for anymore.
2:49Do I speak for India, do I speak for Canada?
2:52I don't even know what I can say or cannot say.
2:56But regardless of where I came from,
2:59which is a small town called Vellore
3:00in India where I lived for 30 years,
3:03if you ask me today, I will unhesitatingly tell you,
3:07I'm one of the most privileged people on this planet.
3:10Why?
3:11Full professor, male, chair of a department
3:13in one of the richest countries in the world.
3:16There is nothing about me which doesn't reek of privilege.
3:20And I will tell you,
3:21for the sake of this talk, you and I are the same.
3:24I'm you, you are me.
3:26We are critiquing each other here.
3:29So I'm not here to critique you, I'm critiquing myself.
3:32So everything that follows equally applies to me.
3:35And you can ask me questions and hold me accountable,
3:39and I will tell you in what baby steps I've taken
3:41to act on what I'm about to show you, okay?
3:44So I don't exempt myself from the critique that follows.
3:47I am very much a part of the Global North industrial complex
3:52of global health, okay?
3:54I'm not magically standing somewhere here
3:57and talking about what's happening here, no.
3:59I'm a hundred percent baked into the system
4:01that we are about to critique, okay?
4:03Right, so conclusion slide, you can leave after this.
4:07(audience laughing)
4:10I've learned the hard way not to bury the lead, right?
4:13Always give people the conclusion at the start.
4:16Global health has a very long tradition of failing
4:19on equity again and again and again.
4:22We'll see examples. Why is that?
4:25My guess, I could not show it to you
4:28in a research study in, "The New England Journal",
4:30but my informed guess is
4:32that the field itself is structurally inequitable.
4:37And I argue a structurally inequitable field
4:41can never truly solve inequities, okay?
4:44It's like a structurally racist institution
4:46cannot solve racism.
4:49It's just simply not possible for that institution.
4:52Regardless of how good individuals are,
4:54it is not designed to solve it.
4:57We, you and I, I'm including myself here,
5:00that's why I'm gonna be using the word.
5:02Anytime I use we in this talk, take it
5:04that it's me and you, okay?
5:07We, the Global North privileged elite,
5:10dominate every single aspect of global health, even today.
5:15As we did in the colonial past, even today,
5:18as of 2024, correct.
5:21To bring equity, I would humbly propose
5:25that we have to really rethink what our role is.
5:28I would say we cannot be leaders
5:31in global health, we can only be allies in global health.
5:35Because the most privileged people,
5:37in my opinion, cannot be the ones
5:39to solve problems on the ground, right?
5:42Inherently, we are not designed
5:44to solve problems that are very far away from here.
5:47And the more privileged and elite you are,
5:50the less and less you have the ability
5:51to solve problems that are far away from you, okay?
5:55To bring equity, not only do we need
5:57to shift from saviorism to allyship, we have
6:00to confront some of the serious obstacles to allyship
6:03within our institutions, including what we just discussed.
6:07If you can't even pay an honorarium for somebody
6:09in Liberia, that's the kind of structural issues
6:12that we are all facing with, okay?
6:16So, Global North though, as much as we can shift power
6:21or try to shift power here, is only half the story.
6:25Global South is missing here.
6:27What does a Global South need to do
6:30to bring equity in global health?
6:33In my opinion, they need to rise
6:36as the true leaders of global health.
6:39And that will not happen at Yale or McGill or Canada or US.
6:43Similar conversations need to happen
6:45in Liberia, in India and South Africa.
6:47I was very lucky to have the exact same talk happen
6:50in two African countries, Kenya and South Africa.
6:55I just, they blew me away with their discussion, okay?
6:59They let me speak and they ignored me afterwards.
7:01It was all about them talking about what they need to do
7:05to reclaim control over their destinies, okay?
7:09And if any of you really have the courage, you should listen
7:13to what they have to say about us, okay?
7:17You're not gonna hear it in these rarefied environments.
7:20You need to go there and honestly ask them,
7:22"What do you think of what we're doing?"
7:24And they have lots to say about us, okay?
7:28And this is the tragic story of inequities in global health.
7:32The COVID vaccine inequity probably is the most egregious
7:37I can even imagine in my life.
7:39But people like our friends like Gregg Gonsalves
7:41will tell you, "Oh yeah, we saw the same diamond inequities
7:44with HIV medicines.
7:45So what's new? Look at MPOX.
7:48I could have gotten my kid vaccinated for MPOX in Montreal.
7:51The whole of Africa had zero doses, right?
7:54And then Stephanie Nolen writes a piece
7:57that new sickle cell therapies will never be available
7:59in Africa.
8:00Of course they won't be. How?
8:02We couldn't even get a vaccine there,
8:03let alone sickle cell therapies, right?
8:06Here is the sad long history
8:08where global health consistently prioritizes you
8:11and I over Black, Brown, Global South lives.
8:15There is no debating this at all.
8:18Not after what we've saw in the COVID story, okay?
8:22There is no place to hide our greed, our ability
8:25to hold vaccines and products and not care about others.
8:29It's absolutely pathological and it's a recurring pattern.
8:32It is not a one-off story.
8:34It's the same pattern
8:35that happens again and again and again.
8:38So then why is global health inherently inequitable?
8:42Global health is this fascinating dichotomy
8:44that none of us can resolve in our heads.
8:47If you ask anybody studying global health,
8:49even an undergrad student, they'll say,
8:51"Yeah, global health is really about
8:53fixing inequities in health."
8:56At the same time, we never discuss the structural inequities
9:00within the field of global health.
9:03Why is that?
9:04If we really care about fixing inequities,
9:07then the structure is also open
9:08for critique, isn't it, right?
9:10Could we magically catapult to solving inequities
9:13and ignoring the structural inequities within the field?
9:17How is that feasible, right?
9:19And because we have that blind spot,
9:20we continue to make the same mistakes we do.
9:24Now, I have this cartoon
9:26that I made like two years ago, okay?
9:28If somebody asked me,
9:30"Who are the dominant people in global health?"
9:33When I say default setting,
9:35without intentional intervention,
9:39without deliberate planning,
9:41everything in global health defaults to these people.
9:45I see myself on this slide, okay?
9:48I already told you I'm on the slide.
9:49And I will tell you right now,
9:51every one of you is not in this slide.
9:53Okay? Who dominates Global health?
9:55Global, not people like you and I.
9:57White folks, men like me and people highly educated.
10:02Yale, MDs, PhDs, McGill, MDs, PhDs, Harvard,
10:06London School, Oxford.
10:08This is the phenotype that dominates global health.
10:11Now, if any of you are saying, oh, I don't buy this.
10:14Well, let me show you data, right?
10:16After all, I'm in a school of public health, right?
10:18(audience laughing)
10:19After all, I'm an epidemiologist.
10:20Here goes, where are the biggest global health organizations
10:25headquartered in this world?
10:26The start the map. I'm not gonna spend too much time on it.
10:31Who is running these organizations?
10:33Virtually all of them are run by Global North Men, okay?
10:38Who is serving on the boards of these organizations?
10:41We're talking about Gavi Global Fund, Gates Foundation,
10:45all of them, predominantly Global North folks.
10:48In fact, Americans and British Nationals alone occupy 50%
10:53of board chairs across 200 global organizations.
10:57Can you imagine the power that we have?
11:00Just by virtue of being on those powerful boards,
11:03we can dictate funding trajectory
11:05for the next a hundred years.
11:07We can make life or death decisions
11:09that impact people far away sitting
11:10in Seattle, Washington DC out of our London or Berlin.
11:15Okay? Where do all the global health dollars go?
11:19There you are.
11:22Much of American dollars go to American institutions
11:25and contractors, much of Gates Foundation dollars go
11:28to Global North organizations.
11:30You and I are the number one recipients
11:34of global health monies.
11:35And then as Kristina showed us, we have to resort
11:39to all sorts of shenanigans to move that money
11:42to where it finally needs to go, okay?
11:45I'm not expecting an honorarium. Don't worry about it.
11:48(audience laughing)
11:49This is more than me. Okay?
11:51Who's publishing, study, study after study
11:53after study shows the exact same thing.
11:58The dominant first authors you and I.
12:01Dominant senior authors, you and I.
12:04It doesn't matter which field of global health,
12:06which journal of Global Health, it doesn't even matter.
12:09UCSF where I trained,
12:11UCSF Global Health Institute led an audit
12:14of their own publishing.
12:15They found exactly the same,
12:17and they published it in BMJ Global Health.
12:20(audience laughing)
12:22I want you to look at Yale Global Health Papers
12:25and look at authorship patents without knowing a thing.
12:28I will tell you, it'll be the same.
12:30There was another massive study just published Coloniality
12:34and Patterns of Authorships by UN University.
12:36Exact same findings. Who's editing?
12:41Me. You.
12:44We are the gatekeepers of knowledge in this world,
12:48dominant, beyond dominant, Global North,
12:51mostly men, mostly American and British men edit most
12:57of the scientific global health journals in the world.
13:00And this is in me saying study after study
13:02after study shows that, okay?
13:07Look at this paper, which critiqued Lancet.
13:10I was so impressed, Lancet invited a critique of itself.
13:14200 year history of Lancet, right?
13:17I was talking to a colleague there
13:18who was a Lancet reporter,
13:20"Lancet editors in chief over its 200 year history.
13:24All white, all male,
13:25all educated exclusively in European institutions,
13:29have had great influence in setting priorities
13:31in research methods, medicine and health."
13:35Published a week ago.
13:38Where are the global health degrees offered?
13:40Here, Yale, Miguel, Emory, Harvard, UCSF, right?
13:47These, and for who? Look at the tuition fee.
13:50An average cost
13:52of a North American master's
13:53in global health is 66,000 US dollars just for tuition.
14:00You may not even get a visa.
14:02That's a whole nother story, right?
14:04You can't even afford the tuition, let alone come here.
14:08Where are the confidences held in global health? Oh my God.
14:12The visa, devastating visa issues
14:14that we spoke about earlier today.
14:16I mean, if the head of Africa, CDC couldn't get
14:19to a conference, where is the hope for you and I, right?
14:24I mean, this is insanity. Montreal kept away.
14:27Canada kept away.
14:29Africans out of an AIDS conference in the year 2022.
14:35I have no words to tell you what that means.
14:37We basically saying, come for our global health event,
14:41but if you are not there, it's okay.
14:45Right? That's exactly what message we are sending.
14:48Canada is a basket case right now for visas.
14:51US is a nightmare. UK is downright hostile.
14:55(audience laughing)
14:57I'm wondering what is left now, right
14:59after Montreal, they moved the conference to Australia
15:02for Christ's sake AIDS conference.
15:04I'm like, are these guys not even seeing what's
15:07happening on the ground, right?
15:09It was devastating for us.
15:11That's an actual picture
15:12of empty chairs at the plenary panel
15:15in AIDS conference in Montreal, actual picture.
15:20I don't know what we are doing,
15:21but the bottom line summary of all of this is that you
15:25and I hold enormous power and privilege in global health.
15:30And to approach this field without a deep appreciation
15:34of our own power and privilege is a massive mistake.
15:38To paraphrase Peter Parker,
15:40"Great power comes with great responsibility."
15:43Are we even aware of our privilege?
15:46And if we are not, that itself is a privilege.
15:50Only the most privileged in the world don't know
15:52that they're privileged, right?
15:54So I, when I teach global health at McGill,
15:57and I teach the biggest 101 global health course every
15:59fall, my entire first lecture is this.
16:03I want every McGill student to know
16:05that they are learning global health
16:07or engaging in global health from a place of great power.
16:12And that differential needs to be in
16:14that thought process in every single way
16:17in which they engage in global health.
16:20Now, you may say, just for the sake of discussion,
16:23somebody asked me once, "So Dr. Pai, what's wrong
16:27if we are dominant
16:28and we make all decisions in global health?
16:31We are smart, we are trained at McGill, Yale,
16:35UCSF, Berkeley, right?
16:36Harvard London School. We are compassionate.
16:40We are kind, we are well-meaning."
16:43I grant you all of that not
16:46for a second am I debating your intentions.
16:49You are coming from a very good place
16:51as am I, I think, right?
16:55That does not protect us from making really bad mistakes
16:59because our privilege totally blinds us to reality.
17:04The more privileged we are,
17:06the less we are likely to get things right?
17:09Right?
17:10It is the person who's most impacted,
17:12who will get things in a second that you
17:14and I will not be able to see.
17:16It's like men sitting here
17:18and making decisions about women's health.
17:21What the hell do we know about it?
17:23And yet, men have made massive decisions
17:26that impact women in this country, right?
17:29How do you explain that? It's the same phenomenon here.
17:32So I can think of many reasons why this is problematic,
17:36but I'll ask you to look at the last one.
17:38We will make mistakes.
17:42The COVAX Initiative is a stunning example
17:46of an initiative cooked up by Global North people,
17:49totally naive to the realities of the Global South.
17:52And as much as it tried, it failed
17:55to achieve vaccine equity, right?
17:57What would a genuinely Global South
17:59initiative would've looked like if it had come
18:02from the grassroots, from the Global South?
18:04That's a question we should have asked.
18:07And I am summarizing all of this
18:10to give me a guidepost of where we should be frame shifting.
18:15I humbly, humbly propose, based on everything I've told you,
18:20our current model of global health is the first column.
18:24We see global health as a charity case,
18:27donation of vaccines, aid, philanthropy.
18:33We will come and save you one day. Just wait for your turn.
18:36(audience laughing)
18:37Right? The vaccines will come maybe two years from now.
18:40But wait, HIV medicines did come to Africa 10 years
18:45after it was available here.
18:47By which time millions of people died.
18:50We could stay on in that model.
18:51In fact, your government
18:52and my government believes in that model, right?
18:56Because it's power for them, right?
18:59I will withhold aid from you if you don't play ball with us.
19:02That's how your government and my government looks
19:05at development assistance.
19:07What our Global South colleagues are clearly articulating.
19:10You just need to shut up and listen to them for once.
19:13And they have said this article
19:16after article, they have written
19:17during the pandemic saying, we are sick
19:20and tired of this charity model.
19:22We want to make our own vaccines, right?
19:25Just get off, give the recipe. We'll take care of it.
19:29Right? No, we didn't.
19:30We didn't back the Trips IP waiver,
19:32we holded all the vaccines.
19:33We still don't have a pathway
19:35for manufacturing vaccines where it's most needed, right?
19:38They've set this any number of time.
19:41They're saying it is not a matter
19:42of charity, it's a matter of human rights.
19:45If you have a right to a vaccine, I have the same, right?
19:49Why? Because health is a human right end of discussion.
19:52It is not a question of how charitable Americans
19:55or Canadians are feeling today.
19:57We need, as a matter of rights, our own things
20:00that we need to survive.
20:02They're also talking about reparations.
20:05They're saying, what about all the damages we have endured?
20:08The only place I'm seeing reparations being discussed
20:11is climate change.
20:13Who caused the climate change? You and me.
20:18In fact, America is the number one contributor
20:22of carbon emissions.
20:23Bar none. Okay?
20:26So this country owes a lot to the Global South
20:29for the climate change for the crisis, right?
20:32That's what they're saying, autonomy, respect,
20:34self-determination is a word they use all the time.
20:38Not only Global South colleagues.
20:39You speak to any indigenous colleague,
20:42that's the first thing they tell you.
20:43We need to self determine our own agenda.
20:47No indigenous person in Canada will engage
20:49with me if I don't respect their rights
20:52for self-determination, because we messed around too much
20:56and they have been treated
20:57so badly they have zero trust left in us, right?
21:00So how do we shift from column one to column two is what you
21:05and I should be debating within these ratified corridors
21:09that we have the be a privilege to walk in.
21:12And if you ask me, do I see any role for myself?
21:15The only role I see for myself
21:17with great clarity is one of allyship.
21:21I will not be solving India's TV problem.
21:24Indians in India will be solving their TV problem,
21:28but if they invited me, I could be their ally.
21:33Ugandans will have to solve the malaria problem.
21:36Not you. Not me.
21:37But if they invited you, you could be their allies.
21:41Indigenous communities in Canada will have
21:43to solve their mental health and suicide crisis.
21:46Not me. But if they invited me, I could be their ally.
21:50So we can have a theoretical discussion on allyship.
21:53There are courses being taught on anti-racism
21:55and allyship, even though DEI is under attack all
21:59over the world.
22:00But instead of giving you a theoretical discussion
22:02of what allyship is, I thought it'll be very illustrative
22:05to just talk about examples.
22:09This is an example of failed allyship.
22:13It's not a good example, right?
22:15The Global North had the opportunity of a lifetime
22:19to save millions of lives during the pandemic
22:21if we had done the right thing.
22:23We could have just given the vaccine recipe
22:25to anybody who ever needed it.
22:27We could have changed the face of this pandemic.
22:30We didn't. Okay?
22:31And so when the Africa CDC Chief says,
22:34"Africa must take control of its vaccine manufacturing
22:37to protect against a new pandemic", that is the articulation
22:42of African leaders that we should be listening to.
22:45I was in South Africa in December.
22:47I cannot tell you how many African leaders came
22:49to the podium at the ASLM conference
22:51and said the same thing.
22:53We have to listen to them.
22:55They're saying, we do not want your charity.
22:58We wanna make our own stuff and save our own people, okay?
23:02Listening to them and acting
23:04on their desire is an act of allyship, right?
23:08Because they're articulating and telling us what they want.
23:11So now we still can be allies right now as we speak. Why?
23:16Because the pandemic occurred is being negotiated.
23:19And guess what our wonderful governments have done?
23:22Yours and mine.
23:24They've gone and deleted all equity clauses out
23:28of the pandemic agreement.
23:30Look at this Lancet cover, a hand far from making amends.
23:35A handful of powerful countries code US, UK, Canada, EU.
23:42Same countries that do devastating stuff again
23:46and again and again.
23:47Your governments and my governments.
23:49Powerful countries are sabotaging the best chance
23:53to translate the lessons from COVID pandemic
23:55into legally binding commitments that will protect us all.
23:59So if this is how the pandemic occurred is going,
24:02do you think the next pandemic will be any different
24:04from what we saw in COVID?
24:06Do you expect even one thing to change?
24:09I will tell you right away, Canada will hold vaccines again.
24:12Why?
24:13Because fundamentally we've changed nothing
24:16in our attitude, our governance, nothing.
24:18Will US continue to protect big pharma?
24:21A hundred percent, yes. Nothing has changed.
24:25You can't afford medicines in your own country.
24:28Forget equity, right? We can't afford medicines in Canada.
24:34How are we going to fix this?
24:36You know, big pharma industry
24:37and governmental collusion that that's what's happened.
24:41Canadian law policy makers were lobbied so heavily
24:44by big pharma, they pretty much killed
24:46the Trips IP waiver right.
24:48So this is where we are.
24:51Advocacy for conference equity.
24:53I mean, I can't tell you how much advocacy we did
24:55to prevent the AIDS conference disaster in Montreal.
24:59Thankfully, IAS woke up and said, okay,
25:02we will do a global rotation of our conference.
25:05One conference in the Global North,
25:06one conference in the Global South.
25:09To me, if you are calling any conference global,
25:14if you even use the word global in your conference, this
25:17to me is the rock bottom expectation.
25:20One in the Global North, one in the Global South.
25:23If you're gonna consistently hold global confidence
25:26in the United States, you have no idea what global means.
25:30'Cause you've already knocked off millions of people
25:33from your conference.
25:35How do you call that global? I kid you not.
25:38They were gonna have a tropical medicine conference
25:40in Toronto.
25:42Tropical medicine conference.
25:43(audience laughing)
25:45Of course, we are tropical
25:46for two weeks in a year, aren't we?
25:48(audience laughing)
25:49I'm like, guys, what is wrong with this picture?
25:51I don't, I'm not understanding it.
25:52Who do you expect to come to Toronto
25:54for a tropical diseases conference?
25:56What does it even mean? Malaria conference in Lausanne.
26:00I mean, we've lost our heads.
26:02We are basically saying we will talk about a disease
26:05that primarily kills you without you in the room.
26:09Right, we've got to wake up
26:12and ask ourselves, what is our modus operandi?
26:15Who do we want in the room?
26:17You want an AIDS confidence without Africans?
26:19Is that what you want? Because that's what happened.
26:24Male allyship.
26:25Now I'm addressing all my fellow men in the room.
26:28We have a lot of work to do as men. Women in global health.
26:33Women lift, have published millions of articles saying
26:36that guys, women dominate the global health workforce.
26:41And we are not even at the table 99% of the time
26:45when you make the biggest decision.
26:47So they're saying, guys, lean out. You've too leaned in.
26:53You've taken up all the real estate,
26:55there's nothing left for us.
26:57Okay? "Pass the mic.
26:59Or better still just get the heck out
27:00of the room", is what they're saying.
27:03I'm paraphrasing them. Okay?
27:05(audience laughing)
27:06I have a very strong wife who's telling
27:08me exactly this at home, okay?
27:11And I have a very sassy 16-year-old daughter
27:14who's giving me hell already, okay?
27:17She lectured me on patriarchy the other day.
27:19(audience laughing)
27:20I kid you not. She's 16.
27:22I don't know what they're teaching in schools these days.
27:24Anyway, I have written a piece on male allyship.
27:27There's gonna be a whole panel on male allyship
27:29at the women lift conference in Tanzania this week.
27:32They are wanting, and I don't know how
27:35to support them with this.
27:38They want an army of male allies in global health.
27:42That's what they're wanting, okay?
27:44And they're saying, "It's not enough
27:45to mentor women anymore, you need to sponsor women,
27:49which is qualitatively very different from mentorship."
27:52Okay? Lots of work to be done in this area.
27:56Journals, man, if there is one thing, I can speak
27:59with some conviction, it's journals.
28:02Because I had done a study,
28:04which I showed you earlier, showing
28:06how skewed global health journals are.
28:09And then I get an invitation from PLOS
28:11to build a brand new global health journal.
28:14So I said, "Here's my paper.
28:16Okay, if you want me to do that journal,
28:19will you let me fix what I myself have published on?"
28:23They said, "Do it."
28:24Then I said, "If that's the case,
28:26two editors in chief, one male, one female."
28:29They said, "Done."
28:31"One in the Global North, one in the Global South."
28:34They said, "Done."
28:35"Editorial board. 50% Global North, 50% Global South.
28:3950% women, 50% men."
28:41They said, "Done."
28:42I said, "Nobody should be turned away
28:44because they can't pay the APC."
28:46They said, "Done." I said, "Now, now we are in business."
28:50That's how that journal got launched.
28:52(audience clapping)
28:53And we published this.
28:55No, no, don't clap yet, please.
28:57(audience laughing)
28:58because you've not seen the outcome.
28:59Okay? You've only seen the intent.
29:01Remember, intent is worth very little.
29:04'Cause we are all well intentioned, right?
29:06So we published our intent
29:08and then two years later we did the hard look at our math.
29:12'Cause that's when numbers don't lie, right?
29:14You have to look at the numbers.
29:16So that's a two year, two year progress report.
29:19Here are the numbers. 43 section editors
29:23from 21 countries, three fourths women,
29:2750% Global South, okay?
29:30Are section editors are primarily women.
29:33You should see the zoom meetings.
29:35I'm like the only males lurking in the corner there. Okay?
29:39700 academic editors, including some wonderful people
29:42in this room.
29:4353% from the Global South.
29:45We featured work from authors from 85 countries
29:49with half the countries in the Global South.
29:52We intentionally commissioned papers
29:55from people far away from here.
29:58When I say here, not Yale, far away from the Global North,
30:01because we know we always get into Lancet if we want to.
30:06That's not the people we wanna be platforming again
30:09and again and again, okay?
30:10We've intentionally gone and invited papers
30:13from the community, from youth, from people
30:16in the field who never be asked to write.
30:18This is one heck of a work. Can you imagine?
30:22You think this happened just by, by just dreaming about it?
30:26No. This is my biggest lesson in this two years journey.
30:30If you are not intentional, you gravitate back
30:33to the default settings in global health.
30:36If you're not intentional, I would've recruited all
30:38of you to be my editors.
30:40'Cause I know you, you know me.
30:42You invite people who look like you.
30:44That's what we do, right? 90% of the time we lift the phone.
30:47It's like being at any JM, new England Journal of Medicine
30:50and commissioning a piece from Harvard.
30:53That's what we do in the normal course of things.
30:56So if you wanna break that pattern,
30:58you gotta spend much more energy than you would normally do.
31:02So diversity and inclusion doesn't happen,
31:04by just dreaming it.
31:06You gotta put an extraordinary amount of hard work.
31:09And we were delighted when this paper came out.
31:12This has got nothing to do with me.
31:14An independent study ranked us
31:16as the world's most diverse journal in all of global health.
31:21When I saw this piece, I'm like,
31:24I'm breathing again in my life
31:27because this is an external validation of what we've done.
31:30We can talk internally, but that's not the same
31:32as being ranked by an independent group.
31:35This is three years worth of hard work
31:39to the point that I'm thinking of giving up.
31:41'Cause it's taken that much outta me, right?
31:44And the minute you stop putting
31:46in this effort, it'll revert back to where it does again.
31:49Right, it will shift beautifully towards, in fact,
31:52for a while, we opened the portal for anyone
31:54to nominate themselves for the editorship.
31:57Guess who put in the nominations?
31:59(audience laughing)
32:00Go ahead. Men.
32:03Where?
32:04- [Audience Member] From the Global North.
32:05- Men from the Global North by the first ones in.
32:09'Cause that's what we do. We are very aggressive.
32:12Even if we don't know half the things we put something in.
32:15(audience laughing)
32:16Right?
32:17And women will be third guessing themselves.
32:18Am I really qualified for this?
32:20By the time they decide the opportunity is gone.
32:23Men like, I don't even know what it is.
32:24I'm submitting my CV.
32:26(audience laughing)
32:27Sorry guys, I'm letting you down today.
32:29I'm giving away some of our secrets. (laughs)
32:32Okay, last few slides. Equity and authorship.
32:35We have done so much to come down
32:38on parachute science, all PLOS journals, okay?
32:42PLOS medicine blew me off.
32:45They said, "As part of PLOS medicine commitment
32:47to addressing parachute science,
32:49we now require local researchers, we first
32:51or last authors of publications based on global research."
32:56This is serious progress. Okay?
32:59The next time we get a paper
33:00from Botswana, we are not a single Botswana author,
33:03we are sending it right back.
33:05Said, explain this to us. What is going on here?
33:08Right? Think about this for a second.
33:10This has been happening for decades.
33:13And we are finally starting to ask questions here.
33:15And so you may say, okay, Madhukar, this is all great.
33:19What the heck have you done? Ask me, okay?
33:22I'm hoping you'll ask me because I have a slide there.
33:25(audience laughing)Okay?
33:26And not even in the last few years,
33:29for several years now, I'm no longer
33:32the senior corresponding author
33:34in any of my students' thesis papers.
33:37It is my co-PI in India, Peru, South Africa.
33:41I am no longer look at the papers.
33:43This is just to tell you
33:44that this isn't a figment of my imagination.
33:47Okay?
33:48So it is possible if you wanted to lean out
33:51as the senior established pi, my thinking is,
33:54do I need yet another paper in my life at this stage?
33:57No, I don't need it. I don't care, right?
34:01But I wanna make sure my colleagues in India
34:03or Peru feel like they have been recognized.
34:06The data came from there. They own the data.
34:09It's their patients, right?
34:13Training in global health can be completely reimagined.
34:17I spent the whole first hour
34:19of my global health course telling students
34:22what white saviorism is and what I don't want them to do.
34:26Okay? That's our Lancet piece.
34:27We've returned so many papers saying we cannot continue
34:32to teach global health as if we know everything.
34:35How often have your global health courses
34:37platform Global South speakers, right?
34:41So I said, I'm not talking about AIDS in anymore in Africa.
34:45I'm getting an African AIDS expert to talk to you. Why?
34:48Because Zoom works, right?
34:51I totally changed how I teach global health thanks
34:54to the pandemic.
34:56One silver lining of this pandemic
34:58is I'm no longer accepting
35:00that all the speakers in my course need to come from McGill.
35:04Okay? We can change a lot of how we do things.
35:07Global health partnerships. This is Sunil and Yaps paper.
35:10I don't have a slide here after this.
35:13I was just talking to Sunil.
35:14I wanna know, give me one shining example
35:18of a truly bilateral equitable partnership in global health.
35:22If you know any, let me know.
35:24I'll put it in the next version of my slide deck, okay?
35:27'Cause I'm looking for case studies to show you.
35:30Allyship with local communities.
35:33Megan said this beautifully today.
35:35Somebody else said this as well. in the day to day.
35:38I genuinely think we look super disingenuous.
35:41If we only want to get on a plane
35:43and travel a thousand miles to do global health.
35:47If we continue to ignore inequities
35:49within our own countries, we have no credibility left.
35:53None at all.
35:55We have to do good by our own communities as well.
35:58It is not an either or.
36:00It is doing both and committing to doing both, right?
36:03And that's the piece that we wrote on Global Health Local.
36:06And look at that, this is two days ago Lancet said,
36:10"Partners in health, after working for decades
36:12in Liberia, Rwanda, Haiti,
36:15and Peru are now doing community health worker training
36:18in America", right?
36:20They're doing the right thing.
36:21They have to use their talents also
36:24to serve rural, underserved communities in America.
36:28And lastly, funders.
36:30I think you and I will all instantaneously agree
36:33if the funders don't change, this is all doomed.
36:37Why? Because you and I are so dependent on funders.
36:40So we wrote a piece, Samuel wrote a piece
36:43on institutional allyship.
36:45We have a whole set of checklists, just
36:47like the checklist that Yap and Sunil did for partnerships.
36:51We have a checklist for funders. Okay?
36:53What should the Gates Foundation do? What should USAI do?
36:56What should Fogarty do? And they are thinking about it.
36:58Okay? USAID has a localization agenda.
37:02Welcome Trust is saying,
37:04"Our grant making is not doing well by their own account."
37:10And so they now have funding calls only
37:12for black researchers, only for Global South researchers.
37:15Fogarty, Roger Glass wrote a piece on decolonizing it.
37:18They're tracking it.
37:20I think our funders are finally starting to wake up.
37:23But I do not have a shining example to show you yet.
37:26I wanna see a funder in global health
37:29with genuinely moving money straight
37:31to Global South bypass me bypass you go where it needs
37:37to go so that we don't have to do the song
37:39and dance on how to pay them $50, right?
37:42Long ways to go, but some promise from all
37:45of the people that on the slide.
37:47And advocacy. I was talking to Kristina yesterday.
37:51Should this indirect cost not be better?
37:55How will they develop capacity
37:56if we keep giving them measly indirect costs?
38:00Right?
38:00So I was pleased to see again, yap and Jessica's paper.
38:03All of you can and should convince NIH to do better, right?
38:07So please continue to advocate
38:10with your own funding agencies say
38:12this is not an acceptable situation
38:14because their infrastructure will never get better
38:17if you don't do good here.
38:19And last comment.
38:21Can you truly, truly make a change
38:24when all the power continues to be held
38:27in a Global North headquarters?
38:29You can see there are many international NGOs.
38:32Headquarters is in Seattle, headquarters in DC,
38:35headquarters is in Boston.
38:37Unless Boston signs off, nothing happens, right?
38:41So Anu Kumar who heads an international NGO, called Ipas.
38:45She wrote a piece, beautiful piece
38:48on White privilege in global health.
38:51Please look it up, Anu Kumar.
38:53She wrote the piece and then she said,
38:55"Oh my God, what have I done now?
38:57Because I need to make a change
38:59as the CEO of an organization", right?
39:02It took her years. She did it.
39:05She decentered power away from the US office
39:10and shifted power to her country offices.
39:12And she says, "That's the way to truly take power away
39:17and move them to where it needs to go."
39:19So you may say, are they good examples of this?
39:22I've been accumulating them.
39:23Compass, which is associated
39:25with the HIV group recently said,
39:28"We are decentering away from the US
39:31and moving the secretariat to Africa."
39:34Here is another organization which was originally
39:36at the London School, is now moved to South Africa.
39:39This is intentionally being done.
39:41This is not an accident, okay?
39:43They're saying, "If this is truly
39:45a global health organization, let it be headquartered
39:48in the Global South itself."
39:50So I'm accumulating more examples to show you soon.
39:54Last slide is as much as I'm starting
39:57to give you some hopeful signs
39:59that one can make a change like the journal,
40:02like these examples, I worry a lot about what's possible.
40:07Why is that?
40:08Look at our own culture of soft money
40:10in global health academia, we are all suffering
40:14because of this soft money culture, right?
40:17That's what makes us fight for scraps.
40:20That's what makes us hold power.
40:21Hold money, hold authorship that our criteria
40:25for promotion and funding, gimme one institution
40:29that has a more liberal, thoughtful promotion criteria
40:33where you actually get a gold star for being an ally.
40:37Where it's okay if you're not the first author, it's fine
40:40if you're a joint first author or a joint senior author.
40:43I pat you on your back 'cause you did the right thing,
40:46right?
40:47University of York, York University
40:49in Toronto sent me their promotion criteria
40:51where it clearly says we are not happy if you are the first
40:56author all the time or you hold the money all the time.
41:00I'm like, this is good. I need to now use that at McGill.
41:05I'm not sure they'll let me at McGill.
41:07I'm not sure they'll let you at Yale either, right?
41:09Because our promotion criteria are hundreds of years old.
41:12We hold onto it like our life depends on it.
41:15Just like our authorship criteria.
41:17How often have we kept people away from the authorship list?
41:20Because they didn't check every box
41:21on the ICMGA criteria.
41:24So we've loosened that too.
41:25At PLOS GPH, we do not believe in the ICMGA criteria
41:30because it's too dumb rigid.
41:32If people have genuinely
41:34to your paper, please make them an author.
41:36You may not even be paying them much.
41:38At least give them credit
41:39for the hard work they put in, right?
41:41So just like human beings invented
41:44these criteria, human beings can change them.
41:47It wasn't given to us by God.
41:50The promotion criteria didn't come
41:51from God, nor did the ICMJ criteria come from God.
41:54It came from people like you and I.
41:56If we wanted to change it, we can change it. Okay?
41:59So take some risks, do the right thing in your work.
42:02And I also want to say this,
42:05the last thing scares the heck out of me.
42:08You may be the most reciprocal person on the planet,
42:12but if your own government won't give a visa
42:15to the person you are inviting from Uganda
42:17or Liberia, what do you do?
42:19What do I do?
42:21I told you how disgraceful Canada was
42:24with the AIDS conference.
42:25So we've returned a letter to the immigration minister,
42:27as I mentioned to you earlier,
42:29and they sent a four page reply back, okay?
42:32We have to put pressure on our own leaders
42:36to do the right thing, right?
42:37But with all the populous, far right governments
42:40that are there everywhere in the world,
42:42I'm terrified about your upcoming election, I'll be honest.
42:46Because it's not just your election.
42:47The whole world is watching it, right?
42:50And I'm terrified about my upcoming election in Canada.
42:53I'm scared about what's happening in India, right?
42:56Everywhere the pendulum is swinging far, right?
43:00And the first thing they do is cut immigration,
43:02cut refugee programs, cut international aid.
43:04They do this with no hesitation.
43:07That's what we are up against, right?
43:09And we were discussing the yesterday,
43:11I believe, is it possible
43:12to do global health anymore without getting political?
43:16It's not.
43:17We saw during the pandemic everything finally
43:19is ruined or made by politics, right?
43:22So we have to figure out what this means.
43:25How do you show global solidarity in front
43:27of a leader who is absolutely far right populist?
43:31How, what argument do you make
43:33to share vaccines or share IP?
43:36I don't know the answers, but I'm scared.
43:41Lastly, remember I told you, none
43:44of this makes any sense if you don't ask
43:46what the Global South people are doing or should be doing.
43:49And they are starting to write pieces of their own.
43:53This is a piece from India and you know what they're saying?
43:56Yeah, we agree there is a massive power dynamic
43:58Global North, Global South,
44:00but within India it's the elite cast
44:03that dominate global health.
44:05I'm like, yes.
44:07When I gave this talk
44:08in South Africa, you know, they shut me down quickly.
44:11And they started discussing
44:12among theirselves, somebody in the audience said,
44:15"Dr. Pai, we have a Global North
44:16and Global South within South Africa.
44:20We want White South Africans
44:22to be better allies to Black South Africans."
44:24I'm like, yes.
44:26This is the same discussion
44:28in India, except that it's caste, right?
44:31So decolonizing is not just the global, not south dynamic,
44:35but even within countries, what equity means needs
44:39to be addressed, beautiful piece.
44:42One of the best ones that I've read
44:44to say my cynical way of thinking is this, as much as you
44:50and I will try hard here to shift power, okay?
44:55We know from the great Frederick Douglass who said this,
44:59Decades ago, that "Power will not give up power ever.
45:05Privileged people will never give up their privilege."
45:08There has to be a demand for them to do so.
45:11And to me, that is what's gonna come from the Global South.
45:15The Global South is one day gonna say,
45:17we are done with you guys.
45:20We do not need you to solve a malaria problem.
45:23We know what to do. We'll take care of it.
45:26And when that happens, we will all have nowhere to go.
45:30But to say, please, good luck with your work.
45:33If there's anything at all we can do, let us know
45:36because I don't see any other path for us.
45:39What has been happening all these decades
45:41is simply not working.
45:42Because if it was working, we wouldn't be
45:44in this mess that we are in.
45:48If none of this was enough,
45:49to rile you up, I invite you to join this amazing set
45:53of people who will be giving a whole online course
45:56on reimagining global health.
45:58Okay? It's coming up very soon, next month.
46:01But just look at the lineup of people.
46:03Somebody when I tweeted this, somebody said,
46:06"This looks like a real global health course.
46:10Not just taught by those privileged of us
46:12in the Global North."
46:15And this didn't magically appear.
46:16I intentionally went after every one of them
46:19and said, I want you to teach in my course.
46:21Okay?
46:22We have a lot to learn and unlearn more than anyone else,
46:26I will be learning the most in this course.
46:28That's the number of amazing people I've invited
46:31from whom I wanna learn about.
46:33So reimagining global health
46:34is not a static, it's happening.
46:36Every version of this talk I have changed as I'm thinking,
46:40as I'm trying to do something different in my career.
46:43And I'm so, so grateful to all
46:45of you, especially this amazing set of people.
46:48And I hand off to Sunil and Rosana. Thank you.
46:51(audience clapping)
47:04- Well, I'm tachycardic, hypertensive
47:07for public health after that talk.
47:11Probably the last thing you wanna do is hear me talk
47:13and you want to hear Madhukar talk some more.
47:17Absolutely inspiring.
47:20You know, just a quick reflective comments
47:23and then maybe something that I hope you would address.
47:28One, you know, just very quickly on the advancement
47:30and promotions, the authorship is so critical.
47:34Haven't done the best job in my career so far.
47:37But, you know, just thinking, I filled out the faculty end
47:40of year questionnaire for Yale.
47:41All of us here asked,
47:43specifically asked how many first author publications,
47:45how many last author publications?
47:47So everything else,
47:48who cares? - It doesn't matter.
47:49No, it doesn't matter, right?
47:51So we can make some changes.
47:54The checklist was a really amazing experience
47:58for me and I wanted to really highlight
48:01that it was two students that really came up with the idea.
48:05You know, Yap was really the inspiration for it.
48:09But Daniel Hudson, who's a medical student here now
48:11at UCLA and Yanique Embargo, who's a Cameroonian student,
48:16it was really them together that started
48:19to have the idea of, you know, at every step
48:22in the process, where can we think about equity?
48:25A lot of us kind of I feel like an imposter in this a lot.
48:30You know, we are intending to do the right thing,
48:33but we forget along the ways because we're busy.
48:38But trying to remember at every single step
48:41in the process, just do a check.
48:45Have we incorporated our colleagues in an equitable way?
48:49Are they benefiting from the design,
48:51from the statistics, from the dissemination,
48:54from the money to go to the conferences?
48:56So actually having something on paper,
48:58but it was really the students that were the genesis.
49:01And I think it's really hopeful for the future.
49:06Walking down here, Madhukar asked me, you know,
49:08can you tell me one of the examples
49:10from where you work where you've fulfilled the checklist?
49:13And my answer's no, (chuckles) there's not even close.
49:17So I think that's just a reality of the situation.
49:20But we're trying, I wanna ask you questions about language.
49:26So language is important both
49:28in how we talk about global health
49:32amongst ourselves and in our platforms.
49:36You know, something as simple,
49:37but as hurtful as saying things like the third world.
49:40I still hear it, I hear it all the time.
49:42I hear it last week here at Yale.
49:46So just in terms of an allyship
49:48versus other ways we can talk about our partnership,
49:52I think there's importance and I really appreciate
49:54how you highlight that in your writing.
49:58But I think the other aspect
50:00of language is the challenge that comes.
50:03You know, now that I've been working
50:04in Francophone Africa, my colleagues are really held
50:09back by the inability to speak fluently in English, right?
50:14So it comes from not being able to write
50:16and publish in journals properly.
50:18Not being able to comfortably speak
50:20in conferences, not being able
50:21to necessarily understand what's being taught,
50:24what's being spoken at conferences
50:26or even what they can read.
50:30So I love to hear your thoughts on how
50:32to really make language more accessible.
50:34'cause if 50% of the board seats are the UK and the US
50:39and the funding's all coming, it's English dominated,
50:43but that's structural inequity is gonna make
50:45it really impossible to be truly global.
50:48So I wanted to get your thoughts on that.
50:55- Good afternoon and in fact, thank you so much
50:58for such an inspiring talk.
51:03Much of what you said,
51:04we are speaking or preaching to the choir here.
51:08And the question is how to make the business case
51:11for the equity in global health?
51:13I also have a question about language.
51:15I represent the Global South, south, south in Spanish.
51:20I'm coming from Latin America.
51:23And much of the work that is published is
51:27in English ChatGPT consulted.
51:32I was just in a meeting with friends.
51:36Someone asked me to translate a email
51:40that they were going to say,
51:41and a South American friend said, "No, you don't need her.
51:45There is ChatGPT."
51:47Which was great to hear.
51:49So why we cannot do that, right?
51:52If a machine can solve that problem
51:54and many others, why we cannot do it.
51:57Thank you for that response.
52:00And the other response would be,
52:02how can we follow the money?
52:05Much of the investment in global health is many times fold
52:08what much of the people that we want to help make.
52:14And that is a tremendous inequity.
52:17So can we follow the money please? Thank you.
52:21(audience clapping)
52:25- So on the language front, all
52:27of you had a troublemaker called
52:29Christine Ngaruiya here, right?
52:32So Christine was one of my section editors.
52:34She gave us hell over the language issue.
52:37So then she,
52:38along with all section editors, wrote a complaint
52:40to Paul's CEO saying that how can PLOS GPH be considered
52:45a true global health journal if everything is in English,
52:49right?
52:50So what we have baby steps we've taken now is
52:53that we allow authors to translate
52:55into any language they want the abstract
52:58and we post it on the journal site as a supplement.
53:01That's easy. Other journals are doing it too.
53:04Lancet microbe, for example, allowed us to translate
53:07into Spanish for a paper Peru and post it.
53:10In terms of AI, the publishers are telling me
53:14that they cannot stand by the scientific accuracy
53:18of an AI translation.
53:20Imagine if the odds ratio is mangled
53:23or if the words are not authentic
53:25in terms of what it is looking like.
53:27They say legally they cannot take responsibility
53:31and stand by what the machine translated thing looks like.
53:34I think it's those translations are okay
53:37for our everyday purpose,
53:39but for scientific purposes, journals want
53:42to know whether it's accurate
53:43in terms of what the English abstract says.
53:47I think it's soluble.
53:49And this is one area that I really want AI to help us.
53:52I'm nervous about many other aspects of AI.
53:55We are getting so many potentially fake papers submitted.
54:00We don't know who wrote them and we have no idea what's AI
54:04and what's not AI anymore, right?
54:07We don't even know if the authors are human.
54:09We don't know if the editors are human.
54:10I got critiqued that you rejected my paper based
54:13on a machine peer review.
54:15And I'm like wondering,
54:16what on earth am I supposed to do now?
54:18Right? So all journals are running helter skelter right now.
54:22None of us have clarity on where AI and how it can be used.
54:26There are tentative guidelines coming out.
54:28It's a fast moving area.
54:30If the accuracy is very good,
54:32then I think AI is the right way
54:34to get translations happened in multiple languages.
54:38But in terms of money,
54:39I think money is where the real, real challenge lies.
54:43Changing funding flow, if it can be done,
54:46will have phenomenal impact in how things can be done.
54:50All of you're following the funding model
54:52by MacKenzie, what's her name?
54:56Former wife of Jeff. - Scott.
54:59- Scott, she's totally changing how to do philanthropy,
55:03right?
55:04So there are people who are creatively thinking about how
55:06to move money directly to impacted communities
55:09and bypassing all of this stuff.
55:11And I think we need some bold examples
55:14in the area of global health to inspire us.
55:18I have shared all of this with the Gates Foundation too.
55:21They invited me to speak on decolonizing global health
55:24to the entire Gates Foundation.
55:27Can you imagine the stressful time I've had?
55:29(audience laughing)
55:30There were 500 Gates Foundation staff on the Zoom call.
55:35I was just absolutely terrified. Okay?
55:38I'm not sure what they've done structurally,
55:41but there are people,
55:42I assure you they're thinking about it.
55:44They're absolutely thinking about it. So is Fogarty.
55:47So is Welcome Trust.
55:48Welcome Trust has made big changes
55:49in the last couple of years.
55:51So it's possible, I think.
55:54- Madhukar,
55:55can I ask maybe one more? - Yes.
55:56- [Audience Member] One more quick.
55:58So we're in a, again, a position
56:01of privilege on the senior faculty side.
56:04I'm gonna throw myself in there maybe generously
56:08where we can be fine with being anywhere on a paper.
56:14How do we create a system
56:16where junior trainees can be supported
56:19and encouraged to those risks and be supported
56:25and rewarded for being an ally
56:28and not a- - Yeah, yeah.
56:31- So I get asked this question a lot.
56:34I would be very happy right now
56:37if just the senior established people started doing the
56:41right thing because it's a low hanging fruit.
56:44We do not need yet another first authored paper.
56:48We do not need yet another award.
56:49We don't need another plenary talk. I promise you.
56:52We have enough medals on our wall to last us for a lifetime.
56:57So I wanna see us.
56:59So I'm including myself to role model this for others. Okay?
57:03And on the junior front,
57:04I've started creatively doing something
57:06which I discussed yesterday.
57:08We now take all four author positions.
57:12Joined first authors Indian, I mean Peruvian, Canadian.
57:16Canadian, Peruvian, joined senior author Canadian, Peruvian,
57:19Peruvian Canadian.
57:20So we count all of them as equal first authors,
57:23equal senior authors.
57:25We now have four places
57:27that we can equitably divide two north, two south,
57:30which I think if we started accepting joint first
57:33and joint senior authorship as first authorship
57:36as senior authorship, suddenly I think we have creatively
57:39improved the space.
57:41Is it perfect? No.
57:42But is it possible? You can do it tomorrow.
57:44I've done it right?
57:46My Lancet microbe papers, the two ones
57:48that I showed you are about that.
57:50And Lancet microbe gave me no hard time over this.
57:53None of them said it said a word, right?
57:55So let's come up with these creative things
57:58and let's not ask for permission.
57:59We just do it, right?
58:01And if the pushback comes, we'll deal with it.
58:04Thank you.
58:06(audience clapping)
58:09- Thank you very much.
58:12(gentle music)

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