By Courtney E. Martin

What do sperm donation, marathon runners, disabled rockstars, and yacht racing have in common? They’ve all been subjects of the careful eye and artistic vision of British director Jerry Rothwell, the winner of the first annual Sundance Institute | TED Prize Filmmaker Award, who has received $125,000 to spend the next 18 months documenting TED Prize winner Sugata Mitra as he builds a School in the Cloud.

Rothwell is a documentary filmmaker whose work includes the award-winning feature docs Donor Unknown, about a sperm donor and his many offspring; Heavy Load, about a group of people with learning disabilities who form a punk band; and Deep Water (co-directed with Louise Osmond), about Donald Crowhurst’s ill-fated voyage in the 1968 round-the-world yacht race. His latest film is Town of Runners, about young runners from Bekoji, an Ethiopian highland town that has produced some of the world’s greatest distance athletes.

Rothwell is a pioneer in participatory production, working with people to tell their own stories on film. He played a lead role in developing Hi8us Projects’ improvised dramas with young people for Channel 4, in establishing First Light, the UK Film Council’s scheme for young filmmakers, and in setting up digital storytelling exchanges among marginalized communities across Europe.

We caught up with Rothwell to ask a few questions about his vision for the project ahead.

What attracted you to the project?

From the beginning of my filmmaking career, I did a lot of work with communities and in schools with kids on making films about themselves. That kind of educational methodology has always really interested me. As I’ve moved into more traditional forms of filmmaking, I’ve tried to keep that participatory element in what I do. For that reason, I found Sugata’s TED talk very inspirational.

What was your own experience of education?

When Sugata talks about Britain’s “empire education,” that’s me. I didn’t get on badly in that system, but I am really aware — from my own work in schools — how the institutional structure of the school system fails some kids. My view is that the English education system, in particular, fails boys between the ages of about 8-13. It tries to work with them in a way that they are not very adapted to working.

It seems like there is a big trend in documentary films being intentionally tied to action campaigns (like Girls Rising, Waiting for Superman etc.). What are your thoughts about the role of films in this regard?

In general, my feeling is that films that directly campaign don’t make the best films. The best films are complex, nuanced, and engage the viewer in a thought process rather than hitting them with a message. At the same time, films are a powerful catalyst for action.

It’s a mistake to force the film to carry the message; instead you want to develop empathy in the viewer through a human story. If people are engaged in that process for an hour, or even 25 minutes, they will desire to do something, especially if it’s emotionally engaging. The task of making a film is about, first and foremost, making the film, but also to account for the power of filmmaking to galvanize people around a certain issue.

Filmmaker Jerry Rothwell (center) with (from left) TED Prize Director Lara Stein, producer Daniel Demissie, TED Prize winner Sugata Mitra and TED Curator Chris Anderson.

Will Sugata’s theories influence, not just the subject matter, but the actual making of the film in any way?

There is potential to make the film a counterpart of the methods that Sugata uses — take that notion that children may be able to self-organize and see if they can self-shoot and tell the story through the Schools in the Cloud.

Do you see any thematic threads from your past work to this project?

A lot of work that I’ve done in the past focuses on the subject matter in a unique way. Whether I’m looking at sperm donation or runners in Ethiopia, the common theme is about how you build empathy between audiences and people they may never encounter, how you get them to walk in the shoes of someone else for 90 minutes and come out with a totally different idea about what they knew.

What do you anticipate will be your biggest challenges?

I wonder, is a year enough time to show the real potential of the method and the project? It’s also hard to make films remotely. I’m going to try to work with Indian filmmakers and local kids. I also don’t want to make a film that’s promotional. I want to make a film that is true to the experience.

You’ve just met Sugata here at TEDGlobal. What is your first impression of him as a subject?

He’s all you’d hope for as a filmmaker. He’s funny. He’s very engaging. He’s humble, despite the enormous amount of attention that is thrust upon him, which would turn anyone’s head. He’s very grounded and able to keep things in perspective. Every talk we have gives a slightly different dimension and makes me realize a new possibility for the project.

How can the TED community, and those reading this, support you in this effort?

I would love help from the tech community here to think about how we embed ways of shooting in the communities. Any ideas they have about how to break the conventional ways of documentary using remote technologies would be great. We want to keep it personal and keep it owned by the kids.

Courtney E. Martin is the author multiple books, including Do It Anyway. She is also a member of the TED Prize team and co-lead of The City 2.0, the 2012 TED Prize focused on the future of cities.

Physician and anthropologist Paul Farmer, who co-founded Partners in Health, comments on the new TED Book, “The Upstream Doctors.”

By Paul Farmer

At the end of almost a decade spent in teaching hospitals and clinics, most (we hope all) physicians have honed their clinical acumen by focusing on the care of the patient who is right in front of them. Perhaps this is as it should be: as patients, we don’t want our doctors (or nurses or social workers) distracted by “outside” considerations such as the suffering or concerns of other patients not there in the exam room or, heaven forfend, by abstractions such as the extra-personal social forces that place people in harm’s way. We want the doctor focused on us, by bringing expertise and attention to our specific “illness episode” and even to our minor aches and pains. That’s what we want: laser-like focus, to use another term from the medical profession, on our own “chief complaint.”

Or do we? What if most of our aches and pains and many of our serious ailments come largely from those outside forces and abstractions? What if we want to prevent disease or complications of it by altering our risk of poor outcomes (not just death, but predictable or unforeseen complications of the chronic conditions and growing infirmity that most of us will one day endure)? What if we acknowledge that we live not only in bodies but in families, homes (mostly), neighborhoods, and cities? What if our lives outside of the clinic or hospital are often difficult and even, for some people and at some times, almost unendurable? What if our clinical diagnoses are not our chief complaints?

1. The Upstream Doctors, by Rishi Manchanda

Dr. Rishi Manchanda’s TED Book addresses all of these questions with clarity and vision and humility. His vision is informed by long experience, illuminated by the experience of his patients, and solidly buttressed by a great deal of data. The book’s title is borrowed from a well-known parable. Three friends come upon a terrifying scene: as a broad and swift river approaches a waterfall, they see floundering children being swept by in the current, heading towards the cataract. The three friends do the right thing: they jump in and save the drowning children. But the rescuers’ horror is compounded when more kids keep coming down the river. Finally, one of the three starts swimming away from the struggling children. Over the objections of her fellow Samaritans, panicked as they continue their heroic rescues, she swims upstream “to figure out what or who is throwing these kids in the water.”

It’s not that Manchanda is arguing in these pages that we don’t need to save all those already swept into perilous waters. It’s rather, he argues, that we need to divert some of our attention and resources—perhaps more than a third of them—to addressing the root causes of that peril. In other words, we need our physicians to be technically competent, excellent listeners, and able to understand pathogenesis—especially when sickness is not caused, or caused solely, by a microbe or an accident or a readily identified genetic mutation. Make no mistake: Most sickness in this world, whether in South Central Los Angeles or in my workplaces of Boston and rural Haiti, is caused not by a single event or pathological process but by many of them in concert. And most of these causes are to be found far upstream of the etiologies we are taught to seek in medical school and in teaching hospitals.

Effective care for most illness requires understanding the social conditions of one’s patients.

These “causes of the causes” are largely social and environmental ones, as laid out in the clear prose of Dr. Manchanda’s book. Even when etiology is more downstream, effective care for most illness requires understanding the social conditions of one’s patients. Take, for example, the case of Veronica, one of his patients from South Central Los Angeles. In clinical parlance and practice, the story would go something like this: Veronica, 33 years old, presented with recurrent and worsening headaches; these were accompanied by fatigue and malaise. The headaches interfered increasingly with her “activities of daily living.” She sought care for her symptoms in an emergency room, where she was “worked-up” for recurrent headache, given medication for pain, and told to return if she did not get better. She returned twice, still in pain, and subsequent work-up included a CT scan, routine blood tests, and a lumbar puncture. These revealed nothing. One doctor, we learn, suggested that Veronica “was exaggerating her pain simply to get narcotics.” The emergency room staff, probably frustrated, referred her back to a primary-care doctor, which is where she started in the first place. Still her headaches persisted, she took more sick days, and felt she wasn’t doing enough for her young children; she worried, in fact, about losing her job. One of these three ER visits alone cost more than her monthly rent.

When Veronica came to his clinic, an “upstreamist” approach led Dr. Manchanda and his colleagues to do a different kind of diagnostic work-up and to propose a different kind of treatment plan. With little probing, Veronica, still in pain and by now exasperated, allowed that she lived in an apartment that was damp, infested by roaches, and full of mold; she couldn’t afford to move and the landlord wasn’t about to repair the leaky plumbing of her small, ground-floor apartment. The diagnosis, Manchanda thought, was migraine headache triggered by chronic allergies and complicated by sinus congestion. Allergens in the damp apartment probably also accounted for her son’s frightening asthma flares, another source of anxiety for Veronica.

Decreased costs and better outcomes for all concerned: if that’s not a formula for value, I don’t know what is.

So far so good: any competent physician or nurse ought to be able to make the diagnosis. Most could do so without advanced medical training; many mothers could, certainly. But the upstreamist approach is not merely to inquire about the causes of the causes; it also calls for addressing them. The clinic in which Dr. Manchanda practiced as an upstreamist works with community health workers and tenants’ rights groups which, in essence, extend the clinic right into their patients’ homes (if they have them) and lives. The medical staff connected Veronica to a community health worker, who could visit her at home and help make sure she was able to obtain and take the medications likely to give her short-term relief from her symptoms. That’s one of the things that community health workers do—or would do if only we had enough of them around. As for her housing conditions, another partnership came into play: a tenants’ rights advocacy group, long active in Veronica’s neighborhood, petitioned the landlord—this time with a doctor’s note in hand—to make the improvements that were always part of his contractual agreements and were in keeping with local building codes. Veronica got better, as did her son. She also stopped using the emergency room for primary care; from then on, most of her care occurred right in her home or in a nearby clinic termed a “patient-centered home.”

It’s not that Dr. Manchanda and his colleagues were not involved in her ongoing care but rather that, in an upstreamist vision, Dr. Manchanda’s colleagues necessarily include community health workers and advocacy groups and citizens concerned to promote healthy neighborhoods. This approach works with, not on, patients. Together, Veronica and her new partners in care, from clinic staff to community health workers and other advocates, improved the quality of that care, increased the effectiveness of her physician, and lessened her utilization of high-cost but ultimately ineffective, for her, emergency services. Working together, this team also improved the quality of Veronica’s housing, lessened her son’s affliction, and thereby broke a vicious cycle all physicians see far too often: study after study, in city after city, has shown us that it is very expensive to give mediocre medical care to poor or near-poor people living in a rich country. One might even argue that this upstream approach improved the quality of her doctor’s life, too.

Decreased costs and better outcomes for all concerned: if that’s not a formula for value, I don’t know what is. But a better understanding of efficiency, effectiveness, and value in health care is not the only reason to adopt upstreamist approaches or to read a book about them. Understanding more about the causes of the causes will help make medicine matter, help make it better, in part because it forces us to be better listeners. Bertolt Brecht’s haunting verse, “A Worker’s Speech to a Doctor,” published the better part of a century ago, tells a story all too similar to Veronica’s:

When we come to you

Our rags are torn off us

And you listen all over our naked body.

As to the cause of our illness

One glance at our rags would

Tell you more. It is the same cause that wears out

Our bodies and our clothes.

The pain in our shoulder comes

You say, from the damp; and this is also the reason

For the stain on the wall of our flat.

So tell us:

Where does the damp come from?

It can be argued, and often is, that controlling the dampness and mold in Veronica’s flat is not the job of a physician. But to argue that such understanding of causality is not the job of an effective health care system is wrong-headed for a host of clinical, moral, and economic reasons. Explaining these reasons is the primary task of Manchanda’s book, just as it is the primary task of social medicine and its many component disciplines. Addressing the causes and consequences is the primary task of all practitioners, whether based in hospitals or clinics or communities. Seeing them addressed, upstream and downstream, is very often the primary concern of our patients.

These are not new insights, as Brecht’s poem suggests, but as our nation’s health care costs continue to spiral out of control without leading to the expected and wished-for results—looking at the usual indicators of population health, the United States lags far behind most wealthy countries, even though we spend more than any other—these insights are more urgently needed than ever. In Dr. Manchanda’s words, our current standard of care isn’t working well for those who need it most. It’s not that modern medicine isn’t living up to our hopes for new diagnostic and therapeutic tools, although we could, if his prescriptions were heeded, always use more of those. It’s rather that medicine, as it is now practiced, has sharply defined boundaries. These borders keep us from understanding ill health and from doing our jobs well. All the technological fixes in the world are not going to repair our broken health system, not if helping the Veronicas of our world matter to those who now debate its future.

2. Just who is Rishi Manchanda, and how is he qualified to make this diagnosis and to write such prescriptions?

For one, his experience as a clinician and an activist is both deep and broad. Deep because it takes a long time to train as a physician and longer still to complete training in both internal medicine and pediatrics, as Manchanda was the first to do at the University of California, Los Angeles. His experience is broad not only because he is formally trained in public health, but also because he has studied health disparities and their remediation in Botswana, Mozambique, South Africa, and India. Such settings can be the font, as emerging consensus has it, of significant “reverse innovation.” And from South Central LA to the rural reaches of northern India to the cities and towns of southern Africa, Manchanda has learned, again and again, that those who help design health systems need to better understand these upstream determinants of health and ill health.

But it’s one thing to understand and other to act. It’s still another to act in a manner that draws on sound analysis. In other terms, it’s one thing to diagnose an illness and another one to treat it; it’s yet another matter, as Manchanda explains in reflecting on Veronica’s experience, to shoulder real responsibility for treating illness effectively. It’s not as if the many doctors and nurses that she saw, in the emergency room or the clinic, make the wrong diagnosis. It’s our collective practice that is malpractice. Our models of caregiving and care delivery can themselves be altered by more upstreamists’ analysis only if we do as Manchanda does and learn to work with others outside of the hospital, in the neighborhoods in which our patients live, in the schools in which they learn, and in the settings in which they work.

Rishi Manchanda began learning these “delivery” and civics lessons well before he had a string of letters after his name or the clinical credentials he earned at UCLA. It was during early visits to northern India that he first worked with grassroots groups seeking to promote health equity, democratic governance, and social and economic development. When he returned to Boston for medical school and public health training, which he undertook at Tufts University, the young Manchanda also joined the National Health Service Corps and a number of groups promoting health equity. It was shortly thereafter, in 1998, that I was lucky enough to meet him at a clinical conference and to hear of his goal: to lead a life of service as a physician to those too often left behind by medical progress and to see their rights to health care expanded through improving systems and through civic engagement at many levels. It’s gratifying to me, and fortunate for his patients and students and co-workers, that Rishi Manchanda has met these goals and many more.

How much of the problem was due to fractured and inconvenient systems of care? Were the upstream problems really beyond the reach of a coalition of concerned providers?

Dr. Manchanda’s interest in the planet’s poorest and most medically neglected has led him back to southern Africa to help design delivery systems to address AIDS, the leading killer of young adults there. It’s an illness so clearly distributed and worsened by large-scale forces beyond the reach of conventional models of care—labor migration, deep poverty, civil conflict, and jarring inequalities of all sorts, including gender disparities—that any system designed to treat AIDS based solely within the hospital or clinic will fail. That’s a lesson Partners In Health, an NGO seeking to promote health and social justice through both “upstream” and “downstream” efforts, first learned in Haiti and then again in Peru, Mexico, Rwanda, Malawi, and Lesotho. The good news is that we can innovate and change, and we did that by working with community health workers and other partners in each and every one of these settings. These systems innovations can be brought back to the United States. The year I met Rishi Manchanda, I’m proud to say, he was an intern at Partners In Health.

While still a student in Boston, he was lucky enough to work with another upstreamist innovator, Heidi Behforouz. Since, as The Upstream Doctors notes, the pantheon of social medicine doesn’t count as many women as men, I will add that Heidi is another hero of mine: a primary care doctor at the Brigham and Women’s Hospital and true “partner in health” in every sense of the term, Heidi and her team have spent years providing care for patients struggling, in the shadow of Boston’s teaching hospitals, not only with AIDS (and other chronic medical conditions) but against poverty and its attendant social disarray. Some are homeless or almost; many are jobless or work in dead-end jobs with few benefits; many don’t speak English or speak it poorly; few have good health insurance; some are “illegal aliens” (surely one of the most bizarre labels we’ve yet cooked up) and some have other problems with the law; some are elderly and frail; most have more than one affliction. In short, these were Rishi Manchanda’s preferred patients.

In the eyes of most of our colleagues, however, these particular patients were “failing medical therapy” for AIDS, which was revolutionized for some by the advent, about 20 years ago, of effective therapy. But in Dr. Behforouz’s view, medical therapy was failing them. Even though most were and are eligible for such therapy through publicly funded programs, they were not adhering to the treatment nor enjoying ready access to many other social services. Was the primary problem the non-compliant patients, or were their upstream problems, from housing instability to running afoul of the law and the other “synergy of plagues” that ran together in their lives, limiting their ability to comply, keep appointments, fill prescriptions, and all the other things we ask of patients. How much of the problem was due to fractured and inconvenient systems of care? Were the upstream problems really beyond the reach of a coalition of concerned providers?

For many of these patients, we learned, the problem was delivery. Dr. Behforouz has shown that by providing regular care and social services with the help of community health workers, as in Haiti and Peru, we could expect patients who are failing (or being failed) to do much better than those receiving “standard” care, which is delivered primarily in clinics and at the time of the providers’ choosing. This is true whether the outcomes followed are clinical ones (regarding AIDS, these would include CD4 count, viral load, and incident opportunistic infections, as well as mortality) or markers of health system utilization (for example, emergency room visits or failure to fill needed prescriptions or to show up for an appointment) or patient satisfaction. Dr. Behforouz’s team has also shown that the cost of providing good community-based care is less than providing hospital-based care with little in the way of follow-up at home—the standard of care that emerged in the United States over the course of the previous century.

For patients with chronic diseases, like AIDS or poorly controlled diabetes or major depression, good hospital care with little community-based care usually adds up to mediocre outcomes.

Shifting efforts towards the home and towards prevention, including secondary prevention of poor outcomes among those already diagnosed with AIDS or diabetes or major mental illness, leads to better outcomes. Quality goes up, as of course does convenience to patients and their families; costs go down, especially if we tally the costs of inaction.  Again, this is what value in health care looks like.

Sustaining this work, and making these arguments against a constant undertow of censorious opinion, is hard work—even though the arguments are, as readers of The Upstream Doctors will learn, increasingly irrefutable. The formal health care system, including the hospitals and clinics, don’t routinely recruit, train, credential, or pay community health workers; its institutions are not rewarded for doing so any more than they are for helping clear an apartment of mold or mildew. It is against precisely such perverse incentives that the protagonists of systems change in U.S. health care, including physicians like Heidi Behforouz and Rishi Manchanda, and innovative organizations like HealthLeads and HealthBegins, now struggle. And a struggle it is.

Some of these protagonists, including those of HealthBegins, are featured in this book. That’s because Rishi Manchanda and two other physician-rescuers decided to swim upstream against this undertow to found a health start-up, a “think-do tank” that might help address upstream problems in Los Angeles and beyond even as they seek to train a new generation of providers able to make these links between the large-scale and the local and to remake our very notion of what medicine is. HealthBegins’ protagonists include the patients, of course, but also community health workers and health activists and human rights lawyers and others who are building a vibrant movement in Los Angeles. They are, for example, the authors of the important “South LA Declaration of Health and Human Rights” and have worked within high schools and hospitals and other institutions to teach and learn more about health equity and to engage the citizenry to do so, too. Manchanda and others have helped to start and staff a clinic for homeless veterans in LA, who are often, because of a lack of a safety net to catch them before they hit the ground, among the “super-utilizers” of emergency and hospital care. They are also key faculty in an ambitious effort to train or re-train doctors and nurses as upstreamists, and thus to improve care delivery while leveraging the very care process with the opportunity to learn and to innovate, and to improve health for those who too rarely enjoy it.

Our world badly needs more upstreamists, especially those who do not ignore the need to innovate in system design and to incorporate new technologies into an equity agenda.

Clinicians need, early in their training, to understand the ways in which poverty and other structural or extra-personal forces (including institutionalized racism and gender inequality) can constrain the agency of patients. We’ve used the term “structural violence” to describe the harm done to people in this way, and have documented this harm, and discordant claims of causality regarding its origins, in Haiti and other settings of extreme poverty. But that harm is readily enough registered in the United States and, as Manchanda recounts, in a wealthy, inegalitarian and (sometimes) ostentatious metropolis in California. The state is the birthplace, after all, of some of the technologies that might be harnessed to the needs of those served by organizations like HealthBegins or the Homeless Patient Aligned Care Team. Given all of the resources there, can’t we find new gizmos to prevent or mitigate that harm? The Upstream Doctors answers this question with a cautious optimism born of experience in a broken system. Manchanda wants new tools and new “platforms” but knows they will be effectively deployed—they will only prove “scalable”—if they are linked to serious efforts to reform the system.

The lessons learned by Manchanda, which are succinctly summarized in this book, are also an antidote to simplistic “solutionism,” which holds that the U.S. health care crisis (or other complex social problems) can be addressed through technological innovation alone. Evgeny Morozov cites a couple such enthusiasts, who are representative of such strains of solutionism. According to one of them: “Instead of paying doctors and hospitals to repair your body, you can monitor yourself to avoid illness. Instead of heeding marketeers’ offering of fast foods and instant pleasures, you can set up your own life so that you’re bombarded with messages promoting health and conscientiousness.” Morozov’s riposte is caustic but dead-on: “Here is the mid-set of an atomized consumer who couldn’t care less about health care reform but is only preoccupied with maximizing his or her own well-being.”

In contrast to some of our colleagues in social medicine, Rishi Manchanda is no Luddite. His book is rife with enthusiastic stories about new technologies that can help us “quantify the self,” and about the need for electronic medical records and new online platforms that can help upstreamists and their neighbors and allies come together to solve many of the daunting problems laid out in The Upstream Doctors. This is the work of social entrepreneurs. Nor does Manchanda believe that we all need to focus on prevention rather than care, or to reject sound, if downstream, clinical strategies and tools as distractions. Too often, the Stanford pediatrician Paul Wise warned us 20 years ago, “those who elevate the role of social determinants indict clinical technologies as failed strategies. But devaluing clinical intervention diverts attention from the essential goal that it be provided equitably to all those in need. Belittling the role of clinical care tends to unburden policy of the requirement to provide access to such care. In a time of growing conviction, in certain circles, that smart technologies will solve all of our social problems, it’s important to acknowledge that technology, including diagnostic and therapeutic innovations, can help us solve many health problems, but only if we remember the importance of using it fairly and wisely and compassionately. The real problem with many new technology schemes, as Morozov notes, is not that they’re “too smart” but rather that they’re not smart enough: “a truly smart system would find a way to turn us into more reflective, caring, and humane creatures. Technology can certainly assist in that mission, but both the technologists and the social engineers guiding them would have to have a very different mind-set.”

Rishi Manchanda and his colleagues at HealthBegins have the right mindset: a deep respect for the tools, new and less so, we need to take care of the sick and to prevent unnecessary suffering; a knowledge of our health care system and its weaknesses and assets; an awareness of the importance of civic engagement in addressing upstream and downstream problems; a good sense of the human resources we might need, upstreamist clinicians among them, to transform American health care delivery. HealthBegins counts a number of practitioners of clinical medicine who do not scant the lessons of social medicine. They want, as do those working with HealthLeads and with Partners In Health, to build “delivery platforms” able to use these tools, and those sure to follow, in an equitable and humane manner.

So in response to my rhetorical question about Dr. Manchanda’s credentials and experience, note that he has, despite his relative youth, already emerged as one of the leaders in the field of social medicine, a field to which he has contributed for well over 15 years. His book will teach or remind you of the importance of this approach—an upstream approach that does not ignore downstream problems—in addressing the structural problems faced by the working poor, like Veronica, or the homeless veterans who are “super-utilizers” of a system not designed to link community-based care to hospitals or even to community health centers. Manchanda’s social activism and civic engagement—the hard work of being a doctor who is also a citizen—can help us to re-imagine a delivery platform that might deliver true value for all those who need.

3. Why should all of us, regardless of where we live and how healthily, care so much about social medicine?

Why should people outside of the medical profession, however broadly conceived, read this book and consider deeper civic participation in the quest for improving our health and our health care? I will offer three reasons to act in support of the proposals laid out neatly in Part V of Manchanda’s volume.

First, understanding and addressing upstream causes of ill health is one of the best ways, as the data almost always show, to improve our collective well-being. But neither the understanding nor the addressing will ensue without the engagement of a broader public beyond health care providers and the administrators of our fragmented health care system. Using a common enough trope, Manchanda terms this “health care transformation powered by you.” Among the reasons that Manchanda returns so frequently to the importance of citizens’ engagement in the pressing topics of our times: there are not enough primary care providers in our country and far too few upstreamists to complement them. All of them who seek to acknowledge and address their patients’ social determinants of health and illness face, in our current system, “regulatory, cultural, and financial obstacles,” including, invariably, the “fee-for-service straitjacket” that has slowed much innovation in care delivery. Manchanda and others know we need a  cultural shift that comes only with broader participation and changes in systems and in the rules that govern them. Mindful of Morozov’s critique of the idea that we must bring every citizen-consumer up to speed on arcane and complex topics (“Why do we expect citizens to care about every single issue under the sun, as if the very idea of delegation would ruin our democracy?”) in order to solve them, I would argue that all of us need to learn a lot more about how and when our medical system works—as it did last month in the Boston Marathon bombings—and how and when it doesn’t, as laid out in The Upstream Doctors. Dr. Manchanda and other upstreamists, fond as they are of certain new tools, are not seeking to promote some sort of “omniscient cosmopolitanism” through technological fixes such as those seen in “the quantified self movement.” They argue, rather, that health care—your own, others’—should not be only in the hands of specialists and experts like him.

Second, the current system is, it is widely noted, unsustainable. I will repeat myself here: it is very expensive to give mediocre medical care to poor people in a rich country. Although it may sound crass to say so, the overall health system doesn’t give good value for money. It’s neither efficient nor effective in addressing or preventing many of the chronic problems most of us will one day face. And we all know health care costs an awful lot, although how much it costs isn’t really clear and we can’t rely on hospital bills to tell us much about the true cost of care. It certainly can’t be termed a cost-effective system by any of the standard, often fetishized, criteria so often tossed about in policy and academic debates.

Health care systems can be imbued with the values that may refocus medicine on caregiving.

Third and finally, it’s urgent that we go beyond utilitarian arguments to continue to stake moral claims for improving access to quality health care for all. Increased efficiency and lower costs, though important, are not the alpha and the omega of health care improvement, and still less of improvement in health itself. There is a great need, these days as ever, for compassion for and—dare we say it?—solidarity with those who shoulder the heaviest burdens of illness and premature or unnecessary suffering. Most of these people are not likely to read a TEDBook, nor can they easily heed even loud and incessant reminders to improve, by themselves and with “will power” and perhaps a few new gadgets, their diets, their exercise patterns, and their living conditions. Many of them still live in poverty or hover above it in frightening proximity, only a chronic disease or two away. It’s clear that these patients, on the edge or over it, are Rishi Manchanda’s primary concern, as they are mine. But there’s no reason to believe that we cannot all be part of a broader movement to reject market fundamentalism and its attendant belief that health and health care are just two more in a long line of products that we, the customer or “client,” can consume to good effect. Health is created with others, just as we can together dismantle systems that usually deliver mediocre or downstream or tardy care to the poor and otherwise vulnerable. This is true in rich countries as in poor ones.

We doctors can also work with others—from professions ranging from law to education, from businesses ranging from tech start-ups to food producers, from sectors public and private—to re-imagine and rebuild a health care system that is safe and effective and efficient and able to serve especially those who would benefit from it most. For health care systems, if built by informed and compassionate people like Rishi Manchanda, can be imbued with the values that may refocus medicine on caregiving. For all those concerned with the health and well-being of the poor or otherwise marginalized, of the frail or the elderly, of those bent under the weight of serious illness, The Upstream Doctors offers important ideas and examples of solutions to their current predicament—and thus to our own.

The Upstream Doctors is available now. Get it directly from TED Books, on Kindle, Nook, or from the iBookstore.

Physician and anthropologist Paul Farmer is co-founder of Partners In Health, a nonprofit that provides health care in poor communities in Haiti and across the world. He is the Kolokotrones University Professor and chair of the Department of Global Health and Social Medicine at Harvard Medical School, and chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston. His most recent book is To Repair the World: Paul Farmer Speaks to the Next Generation.

John Legend hosts TED Talks Education—tonight, May 7, on PBS at 10/9c. Patricia Harrison, the CEO of the Corporation for Public Broadcasting, shares why this event is so vital. Photo: Ryan Lash

By Patricia Harrison

When I attended the taping of TED Talks Education last month at the Brooklyn Academy of Music, I knew I was witnessing an innovative collaboration with the potential to make a difference in the lives of many young people.

This milestone collaboration between TED, WNET, PBS, and the CPB American Graduate “Let’s Make it Happen” initiative moves us beyond the terrible statistics — that one million young people fail to graduate every year (see more stats in the infographic below) — and toward solutions. It’s the first TED event to be broadcast on television and, with it, public media has affirmed its commitment to investing in lifelong learning in every area we serve and given power to the notion that caring communities can make a difference.

So many of us had a school experience different from that of students today. I grew up in Brooklyn, NY, where, at the time, everyone in my community played an important role in keeping kids on track. Our parents and our neighbors wanted to know how we did on our report cards. If I brought home a “B+” my parents, aunts and uncles wanted to know who got the “A” and then asked, “Why wasn’t it you?” Everyone from the candy store owner on the corner to the man at the newsstand had an opinion about our activities and behavior — and conveyed this information to our parents. As a kid, I remember it as very annoying, but in hindsight, it was very effective. We knew they cared, so we had to care too.

This is a very different time. During TED Talks Education, you’ll hear the stories of high school students who have dropped out — or who considered it, but ultimately decided not to. You will find that in most of these cases, what made the difference was a student having someone in their corner — a champion who cared. Establishing a culture of caring about our young people and education is essential and it all begins at a community level.

Education and the relationship with each community has always been a core value for the more than 1,400 locally owned and operated public media stations that are dedicated to ensuring all Americans have free access to educational, commercial-free programming. Over the past two years, more than 75 public media stations in 33 states have worked in partnership with 1,000+ community and national organizations to create content that engaged with their communities. They also provided classroom resources through American Graduate to help young people stay on the path to a high school diploma.

During TED Talks Education — which airs on public media stations tonight — we will hear from students and teachers, plus business and community leaders, who show us how we can be champions for America’s young people and turn the statistics below around.

Patricia de Stacy Harrison is the president and CEO of the Corporation for Public Broadcasting (CPB), the leading funder of public radio and public television programming in the United States. In 2011, she created American Graduate: Let’s Make It Happen, a nationwide public media initiative to help communities across the country identify and implement solutions to the high school dropout crisis. 

Bill Gates speaks on teachers’ need to get better feedback. Watch his talk during our first television special, TED Talks Education, airing Tuesday, May 7 at 10/9c on PBS. Photo: Ryan Lash

By Bill Gates

I spend a lot of my time working to help improve America’s schools. I’m also a big fan of TED Talks. So when TED’s Chris Anderson asked me to give a talk as part of a special TED session on education, I jumped at the chance. The show premieres on PBS this Tuesday, May 7, at 10 p.m. Eastern/9 p.m. Central. (Here’s a preview. And you can find your local broadcast time.)

John Legend hosted the show and did a fantastic job. John cares a lot about improving education and is investing a lot of his own time on the issue. I first met him when we were both involved with the documentary Waiting for Superman, and I could tell right away that he was an impressive and well-informed guy, in addition to being a super-talented musician. It’s great that he’s using his fame to draw attention to the need to improve our schools.

We taped the TED show last month in a beautiful hall at the Brooklyn Academy of Music in New York City. I was very impressed with the lineup of speakers. One of the great things about the TED format is that it can accommodate lots of different kinds of speakers, from energetic storytellers to more analytical people like me who are hardcore about numbers and systems. That helps the audience look at the topic from lots of different angles.

In this case, they had education experts like Geoffrey Canada, who runs a terrific program called the Harlem Children’s Zone, and Dr. Angela Lee Duckworth, whom I’ve met with a few times as part of my own learning about education. They also had several passionate teachers from around the country. One of them, a chemistry teacher named Ramsey Musallam, startled everyone with video of himself blowing stuff up in class. John brought the house down with a beautiful performance.

For my part, I talked about what I think is the most powerful idea in education today: getting teachers the feedback they deserve so they can improve their practice.

It’s amazing to think about how much coaching is given to, say, professional athletes. I have a coach who gives me feedback too. (You’ll have to watch the show if you want to know why.) But most teachers get almost no feedback at all. And the vast majority of countries that outperform us in education have some formal way to give their teachers feedback. So this is an area where innovation and investment can make a big difference for teachers and students in this country.

As always, the TED team put together a great show, and I’m happy to have been a part of it. I hope you get a chance to watch it.

Find out more about TED Talks Education, airing on Tuesday at 10/9c on PBS »

And stayed tuned to TED.com on Wednesday, May 8, when we will post a full-length version of Bill Gates’ inspiring talk. Curious about his favorite talks in the meantime? Watch his TED playlist »

The morning of our wedding, my wife and I only had one major discussion: Should we bring our cell phones? She loved Facebook as much as I loved Twitter, and since we’ve lived and made friends all across the country, the social networks made it easier to stay connected to our loved ones far away. We wanted those who couldn’t make it to the wedding to feel connected, too. But we decided to put the smartphones away. Our decision turned out to be the right one: I can honestly still remember every single moment of the ceremony. I was fully present.

A few months later, my favorite uncle shared some good news: He had pictures — hundreds of pictures — from our wedding day. He’d gotten some gorgeous shots, he said, and he couldn’t wait to send them to us. He also told me that he couldn’t wait to get the official video, since he’d been distracted and missed a lot. He was excited to watch a recap of what had happened because he had been busy trying to capture the beautiful moments as they were actually happening.

At this point, the discussion usually veers into our overly plugged-in society — the subsidized cell phone industry makes photo-ready smartphones really cheap, the prevalence of phones encourages everyone to take more pictures, our phones encourage us to use them every time they buzz, etc. But let’s throw that red herring back into the digital river. Our need to capture our memories certainly didn’t start with Instagram.

The decisions I, my wife, and my uncle faced are part of the same conflict humans have had throughout time: how do we capture and save a potentially significant moment? It is the prehistoric caveman making images on the wall, the elementary-school class creating a time capsule, every man in an army platoon getting the same tattoo right before a battle. Each moldy Polaroid, FourSquare check-in, and uploaded YouTube video creates a breadcrumb trail back through our lives. We want these archives, whether digital or physical, to point back to the very real experience we had, or, just as importantly, to give us insight into someone else’s experience. Silicon Valley tech culture expert Paul Philleo calls these mementos anchors of memory.

If you picture all the experiences in our lifetimes as drops in the ocean, anchors of memory are those manmade landmarks reminding us that something of note is located there. Without them, we risk forgetting our most important moments in a sea of mundane recollections. For instance, the first time you visit the Statue of Liberty, you may create an anchor of memory that is physical, like writing a passage in your diary, or an anchor of memory that is virtual, like checking into the location on an app. The physical anchor of memory takes up physical space and requires physical maintenance: keeping your diary dry, finding a safe place to store it, etc. A virtual anchor of memory takes up virtual space and requires time maintenance: making sure your account is active, managing relationships on the check-in service, etc. The physical anchors of memory represent the stuff we make the space to own, which constitute our possessions; our virtual anchors of memory represent the stuff we make the time to upload, which create our virtual shadow. In both cases, we’ve reserved a spot for a particular symbolic gesture in our life.

To better understand the anchors of memory, let’s look at them as what a programmer would call them: pointers. A pointer is an empty object whose sole purpose is to represent something else with actual content. The Polaroid doesn’t contain your 1978 family reunion, but it points to the memory of that event in your mind. A Twitter status is 140 organized symbols that, for you, trigger a particular idea. Or, in more physical terms, a city mile marker is merely metal with scribbles on it, but it shows you where you have to go to get to that particular place.

But what happens if the pointer, this empty piece of symbolism, aims at something that is inaccurate, incomplete, or, worse, not of value at all?

This essay has been excerpted from the new TED Book Our Virtual Shadow: Why We Are Obsessed with Documenting Our Lives Online, by culture writer Damon Brown, creator of the app Quote Unquote and author of more than a dozen books, including Porn & Pong: How Grand Theft Auto, Tomb Raider and Other Sexy Games Changed Our Culture. His new TED Book takes a look at what happens to us as individuals in a world of infinite status updates, constant tweeting, obsessive Instagraming. It answers the question: Does documenting our lives keep us from living them? And more important: How can we use social media tools, which satisfy a real need to be heard and remembered, to help us stay present in actual life?

“Our Virtual Shadow” is available for the Kindle, Nook, or through the iBookstore. Or download the TED Books app for your iPad or iPhone. Read more »

Kylie Dunn embarked on a mission to change her life by emulating TED Talks. Here, illustrations of her “30 days of drive” and “30 days of fashion” activities. Illustrations: Matthew Dunn

By Kylie Dunn

What do you get when you cross a 39-year-old perfectionist with 54 TED Talks and far more honesty than any person probably needs to experience? You get my Year of TED.

I’ve been inspired by TED Talks for years, and felt the urge to do something noteworthy and challenging to ring in my fortieth year on the planet. Matt Cutts: Try something new for 30 days Inspiration struck when I watched Matt Cutts’ talk, “Try something new for 30 days.” Something in this talk reminded me of A.J. Jacobs’ “My Year of Living Biblically” — and the seed was sown. I decided to develop a list of new-to-me activities based on TED Talks, and to try each one of them in my life for 30 days.

How did it work? On the 1st of the month, I’d start one new activity, and then roll out another on the 15th — so at any given time I was doing two activities that were new to me.  Some activities were practical (30 days with less meat), others more philosophical (30 days of vulnerability). To plan out a year’s slate of 23 activities, I listened (or re-listened) to around 200 TED Talks. The whole list took a couple of months to plan out, and I left a few gaps in case there were any new talks during the year I really wanted to include. I pledged to blog the full experience, being completely vulnerable as I wrote.

I also decided to contact each of the speakers whose talks inspired my activities, to let them know just how much their talk resonated with me. Many of them wrote back — I cannot tell you how it feels to open your inbox and find emails from Seth Godin, Alain de Botton, Barry Schwartz, JD Schramm, Susan Cain, Derek Sivers and Richard St. John. Their words were powerful, and many were generous with support and encouragement, too. Jessi Arrington: Wearing nothing newCarl Honoré and Sheena Iyengar tweeted about the project, which gave the blog a massive boost; David Logan had a lengthy email chat with me about leadership.

On November 1, 2011, I started the year-long challenge. My first activity was 30 days of fashion, inspired by Jessi Arrington’s talk “Wear Nothing New.” I thought this would be a fun, easy way to start the project — to break free from my standard black, white and gray wardrobe and do some strategic shopping at secondhand clothing stores to make my appearance more colorful. But by the end of day two, I was feeling incredibly exposed to the world. When it comes to clothing, my subconscious mantra had always been  ”just don’t stand out.” Not caring whether people thought I was a little odd for dressing a certain way?Graham Hill: Why I'm a weekday vegetarian It felt like a big change.

I realised that this entire project would be harder than I ever imagined.

By Activity 4, in mid-December, I had a pretty good routine down: think through the activity, then set up practical steps to put it into action. And by Activity 9, I was pleasantly surprised to find that 30 days of less meat was an easy challenge. For the month of February, I became a weekday vegetarian, as suggested in Graham Hill’s talk. Not only was this activity inspiring, but I liked the change in my diet … and in my weekly grocery bill. I’ve kept it up ever since.

“30 days of choice” and “30 days of compassion.” Illustrations: Matthew Dunn

As I got into the second half of the year, my Year of TED became a struggle. The last six activities were all so introspective that I’m surprised I made it to the end of October. Barry Schwartz: The paradox of choice 30 days of choice was based on three talks — Barry Schwartz’s “The paradox of choice,” Sheena Iyengar’s “The art of choosing” and Alain de Botton’s “A kinder, gentler philosophy of success.” This activity involved putting a magnifying glass on my choices — being aware of what was driving my choices, setting boundaries to limit my choices when I could, and recognizing that there is no such thing as a perfect choice. I also took time to think about what success means to me — writing this out helped me understand myself better and gave me vital information to help inform future choices. That said, who enjoys looking at themselves on paper in the third person? I wasn’t always proud of how I dealt with past choices.

Speaking of being unprepared, the 30 days of time activity brought a revelation that helped me understand some of my not-so-good perceptions of myself. Based on the talk “The psychology of time” by Philip Zimbardo, I took a careful inventory of how I think about the past, present and future. Philip Zimbardo: The psychology of timeI found that what Zimbardo calls “past negative” weighs heavily on my mind. I thought hard about what I needed to do to shift my focus.

My complete list of activities, in order: fashion; thanks, praise and mindfulness; better listening; living the 3 A’s; an Asian diet; drive; slowing down; simplicity; less meat; more happiness; preconceptions; letters; starting a movement; choice; being wrong; vulnerability; time; compassion; and balance.

By the end of October 2012, I had completed 21 activities and one project — the development of the Do-Pad, a notepad for people who like to doodle, based on Sunni Brown’s “Doodlers, unite!” I learned so much about my strengths, my weaknesses, my hopes and, most of all, what I really want in this world. I am extremely proud that I finished the full year.

These activities were emotional, particularly since they coincided with the stresses and demands of day-to-day life. At times, they helped me get through hard times — I’m so glad that I was working on “more happiness” when we visited my father-in-law for the last time. At other times, these challenges made my life so much more difficult. I spent way too much time on “choice” and “being wrong” when I was far too busy with work.

Overall, here are the main lessons that I’ve taken away from this project:

• You never really know what you are capable of until you try. I’m stronger than I thought I was — certainly more so than I ever thought I could be.
• Being open about imperfections is important. It has deepened my connections with so many others.
• There is a power in simply doing something. Really, don’t underestimate it.
• Sometimes you can be too introspective, to the point that it is not good for your mental health.
•  If you are going to try something like this, you need to build in time to be kind to yourself.

In the end, I’ve developed a new appreciation for my capacity to be courageous. I’ve always known that I am a survivor, and that I usually come out the other side of life challenges as a better person – if not a little more scarred and cynical. I always thought of strength and courage as things I wanted in my life, but wasn’t quite sure how to harness them. Now I see that this is already inside of me. It’s just one of the realisations this project allowed me to discover, and which I’m still trying to process.

I’d like to thank TED for providing me with such a fantastic source of inspiration. And I’d love to thank the speakers who inspired me to take action and think differently. Most important, though, I couldn’t have done this without the love and support of my partner, my family (particularly my wonderful brother for his artwork, featured above) and my close friends. Hopefully it wasn’t too onerous.

Read Kylie Dunn’s Year of TED Blog »

See nore artwork from Matthew Dunn »

The exhibit Public Interest Design gets set up at TED2013. Here, a look at Embrace Nest, an affordable alternative to an incubator, aimed to provide the 20 million low birth-weight and premature babies born each year with critical warmth. It was created by students at Stanford. Photo: Michael Brands

By Courtney E. Martin and John Cary

Editor’s note: designer John Cary and journalist Courtney E. Martin are the curatorial brains behind the show, “Public Interest Design: Places, Products, & Processes,” which opened at the Autodesk Gallery in San Francisco last October. The entire exhibit has been reinstalled at TED in Long Beach, and we invited the duo to give us a sense of the thinking behind the installation.

Momentum is building at the intersection of design and social justice, or what is called “public interest design”—akin to public interest law and public health. In recent years, there has been a real proliferation of high-profile exhibitions, books, and events. Back in 2007, for instance, museum goers began flocking to the Cooper-Hewitt National Design Museum’s “Design for the Other 90%” exhibition series; in 2010, “Small Scale, Big Change” was installed at the MoMA, also in New York. Meanwhile, books like Design Like You Give a Damn and its recent sequel, by 2006 TED Prize winners Cameron Sinclair and Kate Stohr of Architecture for Humanity, as well as events such as the 2012 Clinton Global Initiative (CGI) Annual Meeting on “Designing for Impact,” led by 2007 TED Prize winner Bill Clinton, underline the growing interest in this important topic. Next month even sees the first-ever Public Interest Design Week.

We joined the curating fray last October, working with the Autodesk Gallery team to assemble an exhibition focused on covering the most provocative and interesting areas in the space. In doing so, we aimed to be very intentional about filling in some of the gaps in earlier attempts at displaying and explaining this burgeoning field. We tried to break new ground in a few key ways.

Jane Chen: A warm embrace that saves livesFirst and foremost, we wanted to put people at the center of the show, focusing on stories of those who were impacted by design as opposed to the stories of the designers themselves. The design itself, after all, is ultimately a means to an end. We wanted to be clear and transparent about the effect and influence of this work.

For example, among the products on display, is the Embrace Nest infant warmer, pioneered by TED Senior Fellow Jane Chen. Many families in India wait to name their babies until nine months after they are born. The reason? High infant mortality rates, caused in part by the inability of low-birth-weight babies to regulate their own body temperature. One mother, Shivamadamma, from a farming family in rural India, gave birth to a premature baby boy weighing only 3.5 pounds. Keeping her baby in the Neonatal Intensive Care Unit was impossibly expensive. Fortunately, doctors were able to provide thermal support to Shivamadamma’s baby with the Embrace Nest infant warmer. Now nine months old and feeding well, the baby is ready for his naming ceremony.

The Butaro Hospital is a 150-bed, 60,000 hospital built in the Burera District of Rwanda by MASS Design Group in association with and operated by Partners in Health. Photo: Iwan Baan.

Also included is the Butaro Hospital by MASS Design Group and Partners in Health in rural Rwanda, which sets a new standard for healthcare design, not just in the global south, but beyond. Opened in January 2011, it is a 150-bed, 60,000-square-foot world-class hospital, bringing health care to a district of 400,000 people who previously had to travel long distances to access even the most basic of health services. The building, created from local materials with local laborers—employing 4,000 people over the course of its construction—became something of a symbol of the renaissance of health care in Rwanda. As Neal Emery, writing last week at Atlantic.com, explained it, “Amidst the barrage of stories about failing states and civil wars that characterize the dour American media coverage of the developing world, the reinvention of Rwanda offers hope. Since the genocide with which its name is still synonymous in the United States, Rwanda has doubled its life expectancy and now offers a replicable model for delivery of high quality health care with limited resources.”

The exhibit also deliberately includes products, places, and processes. To be honest, this last category was the hardest to curate. It’s challenging to explain the critical nature of systems in our lives and the lives of the most vulnerable citizens—both domestically and abroad. In some ways, this is the invisible category of design. We hold and touch products. We work, live, and learn in buildings. Both are physical and tangible. Systems, on the other hand, affect our quality of lives in profound ways, but are often difficult to conceptualize, and most certainly, to display.

Home for Good, a multi-organization initiative to end chronic homelessness among veterans in the Los Angeles area, redesigned and streamlined the process of the number of days and steps it takes to get people off the streets and into housing. Graphic by Megan Jett, courtesy of Autodesk.

We drew inspiration from projects like Annie Leonard’s Stories of Stuff and Purpose’s unPAC, which increase systemic literacy with crystal clear, highly visual communication. That’s not always easy to come by, we understood, after trying to figure out a way to demonstrate the efficacy of Community Solutions and Home for Good for the exhibition. These organizations have collaborated to develop a process to get homeless Los Angelenos off the street. Before, it took an average of 47 steps and 168 days for a homeless veteran to get into permanent housing. Since their intervention, the average has dropped to 21 steps and 93 days, with an ultimate goal of 10 steps in 10 days. Our Santiago-based designer Megan Jett worked through at least a dozen iterations before we were convinced that our graphic installation really showed the innovation at the heart of the process.

Ultimately, our aim was to communicate something not about design, per se, but about dignity. Environmental psychology tells us that the moment we are born, the world around us—the rooms we sleep in, the classrooms we study in, the outdoor spaces we have access to, the bureaucracies we see our parents wrestle with—signals something about our own identity, our own worth, what we can expect from life. In this way, we are a reflection of the design we experience in our lives. Which leads us to the critical question: how do we make a world that is more hospitable and healthy for all of us, that signals back to us that we belong, that we deserve beauty and functionality and dignity? And in instances where design, be that of products, places, or processes, is less than ideal, what changes can be made quickly, simply, easily, or painlessly?

Courtney E. Martin is the author multiple books, including Do It Anyway. John Cary is an architect, author, and the founding editor of PublicInterestDesign.org. They are also members of the TED Prize team and co-leads ofThe City 2.0, the 2012 TED Prize focused on the future of cities.

How are China, Estonia and Germany different from India, Greece and the UK? To an economist, one answer is obvious: savings rates. Germans save 10 percentage points more than the British do (as a fraction of GDP), while Estonians and Chinese save a whopping 20 percentage points more than Greeks and Indians. Economists think a lot about what drives people to save, but many of these international differences remain unexplained. In a recent paper of mine, I find that these countries differ not only in how much their residents save for the future, but also how their native speakers talk about the future.

Keith Chen: Could your language affect your ability to save money?

In late 2011, an idea struck me while reading several papers in psychology that link a person’s language with differences in how they think about space, color, and movement. As a behavioral economist, I am interested in understanding how people make decisions. Could a person’s language subtly affect his or her everyday decisions? In particular, could the way a person’s language marks the future affect their propensity to save for the future?

In a nutshell, this is precisely what I found. After scouring many datasets with millions of records on individual household savings behavior—along with a number of peculiar health performance metrics like grip strength and walking speed—I find that languages that oblige speakers to grammatically separate the future from the present lead them to invest less in the future. Speakers of such languages save less, retire with less wealth, smoke more, practice more unsafe sex and are more obese. Surprisingly, this effect persists even after controlling for a speaker’s education, income, family structure and religion.

Back when my first paper on this topic circulated, many linguists were appropriately skeptical of the work. Their concerns are concisely explained in two well-thought out posts (here and here) by the linguists Mark Liberman and Goeffrey Pullum on the blog they founded, Language Log. Mark and Geoffrey also invited me to write a guest post explaining the work. In that post, I discuss which of their possible concerns are unlikely given the patterns I find across the world in people’s savings and health behaviors, and also try to clarify which of their concerns I was not yet able to address.

This exchange prompted a broad set of discussions as to what different types of data, analyses and experiments could, in principle, answer the questions raised by the patterns I find. Cross-disciplinary discussions took place in a subsequent post by Julie Sedivy and followup posts by Mark Liberman, and also at the Linguistic Data Consortium’s 20th Anniversary Workshop. Several new avenues of investigation and work came out of these interactions, three of which are now ongoing projects.

One new idea that I’ve begun to explore entails measuring a language’s time reference by scraping the web—to search for natural patterns in language—in addition to using linguistic classifications. This led me to search the web for the simplest form of writing about the future I could find: weather forecasts. Why weather forecasts? Well, forecasts rarely talk about the past, so they’re a natural place to look for speech about the future. Weather forecasters also generally communicate in natural, straightforward language, and often convey similar content across different settings. Can patterns in weather forecasts measure how languages structure the future, and can these differences predict how people save for the future? Amazingly, they do.

A team of linguistics and economics students assisted with this analysis, and managed to scrape the web for weather forecasts in 39 languages from around the world. The figure below summarizes what we found: wide variation in how often, when talking about future weather, forecasts in a particular language grammatically mark the future as something distinct from the present. In English, for example, this comes down to the relative frequency of sentences like:

Rain is likely this weekend.                (present tense “is”)

It will likely rain this weekend.          (future tense “will rain”)

What’s surprising is that when I repeat the statistical analysis I did in the paper, I find an incredibly strong relationship between how forecasters talk about weather and how much people choose to save. Essentially, a 20 percentage point increase in the frequency of future tenses results in 1% less of GDP saved. This finding holds even after taking into account a country’s level of development, rate of growth, demographics, social security protections and major religions.

What does this mean? I don’t believe it demonstrates extreme weather forecaster persuasion. Rather, I think it shows that many different ways of measuring how languages mark time share a strong and striking relationship with how speakers of those languages save. In short, I believe more than ever that the data suggests a strong and robust relationship between linguistic and economic data, a relationship that leaves us at an exciting crossroads: one where economists have a tremendous amount to learn from linguists.

The figure below measures the percent of time weather forecasts use future vs. present tenses (download a larger version as a PDF). See the paper here for details.

By Shyam Sankar and Gabe Rosen

The Internet is the new Wild West, a frontier big enough for every pioneer and outlaw to roam free. Today, The New York Times revealed that hackers in China had spent the last four months infiltrating its computer systems and pilfering employee passwords. As in the old West, it’s not a question of if you’ll be hit — but when and how. Online, primitive DDOS attacks rain down like arrows, while artful hackers can steal the data equivalent of 5,000 head of cattle before any breach is detected. There’s no choice but to defend the homestead as best you can – and retreating to civilization is no longer an option.

According to Mandiant, the infosec firm that conducted the investigation, the Times was first compromised on September 13. The attackers established at least three backdoors and installed 45 pieces of malware, only one of which was detected by Symantec security software. After two weeks, the attackers found the domain controller that contained all staff passwords. Times executive editor Jill Abramson maintains there is “no evidence that sensitive emails or files” were accessed, yet the investigation found that the attackers “created custom software that allowed them to search for and grab [Times journalists] Mr. Barboza’s and Mr. Yardley’s e-mails and documents.”

As the TED Blog recently recounted, we know a bit about this sort of thing at Palantir. Our platform was used to investigate “GhostNet”, a Chinese cyber espionage network. In 2008, an unnamed country received an email from China warning them not to host the Dalai Lama for a scheduled visit. The email was startling because this visit was not public knowledge. The country sought to find out how this sensitive information had been leaked. Not only the Dalai Lama’s personal computer been hacked, but 1,300 computers across the globe had been infected in the same way. This network had been operating for two years without notice.

Naturally, when we heard about The New York Times hack today, we looked for parallels. The Dalai Lama’s office was infiltrated by “spear phishing” — where hackers research a person and create an email, with an attachment, that looks like it came from a confidant. Spear phishing is suspected, though not confirmed, in the Times attack. Like GhostNet, the Times attackers covered their tracks through intermediaries in numerous countries, and employed remote access tools (RATs) and malware. The attacks also appear related to Chinese political sensitivities, though the exact loyalties in play are murky.

While it’s important to resist easy conclusions, Occam’s razor and common sense shouldn’t be ignored. The difficulty is that positive attribution is rare in cyber warfare, so when something looks like the work of someone who was never actually identified, it may not be exceptionally meaningful. As open-source sleuth Jeff Carr points out, there are several doubts. Beijing’s time zone includes numerous other cities. The attacks were ultimately traced to Chinese IPs, though their geo-locations encompass millions of people. The attackers used RATs, but these are widely available and hardly confined to China. According to Richard Bejtlich, Mandiant’s chief security officer, “When you see the same group steal data on Chinese dissidents and Tibetan activists, then attack an aerospace company, it starts to push you in the right direction.” Given the vast spectrum of potentially interested parties, it’s a very general direction – but it’s a start nonetheless.

The lack of clear answers notwithstanding, Mr. Bejtlich is certainly correct that cyber defense “requires an internal vigilance model.” You have to sleep with one eye open, and preoccupation with one mode of attack leaves you vulnerable to others. As in the old West, it’s essential to make common cause with your neighbors, however distant. During the recent spate of suspected Iranian DDOS attacks, two global Top 20 banks shared threat data in real time with each other as well as US law enforcement, and collaboration across public/private lines is essential to countering the matrix of state and non-state combatants.

Above all, we need to adopt a Wild West approach of our own. The sheriff’s only hope is to become as swift, resourceful, and adaptive as the outlaws.

Shyam Sankar is the Director at Palantir Technologies. He gave the TED Talk “The rise of human-computer collaboration” at TEDGlobal 2012, as well as the talk embedded above at TED2010. Gabe Rosen works in Business Development at Palantir.

By Courtney E. Martin & John Cary

Pregnancy is supposed to be about life. And yet, every day, 800 women across the globe die from preventable causes related to pregnancy and childbirth. In Malawi, which has one of the worst maternal mortality rates in the world, a shocking 1 in 36 pregnant women die rather than become proud mothers.

But could this oversized problem be tackled through design? Malawi’s new president, Joyce Banda, certainly believes so.

More and more, global health experts are teaming up with designers to tackle daunting challenges like food scarcity, water contamination and, yes, maternal mortality — be they environmental, product, or systems design challenges. David Kelley on human-centered design Using what IDEO.org calls “human-centered design” — essentially putting the user at the center of a deeply iterative process — some of the most cutting-edge thinkers in public health are seeing old problems in new ways. Design is no longer just a tool of the global elite; it’s increasingly becoming a lever for the poorest, most vulnerable people in the world.

Two activists with a deep-seated interest in how design can transform lives, we spent the first two weeks of the year doing fieldwork in Malawi. Despite the fact that it is considered one of the world’s least-developed countries, leaders in Malawi are looking to dignifying design. Banda, who came into office in April after her predecessor passed away, has pledged her precious time in office to emulating places like Rwanda, where human-centered design has improved the lot of many rural poor. Banda faces her first official election on May 19, 2014, giving added urgency to her efforts.

The Aspen Institute’s Global Leadership Council on Reproductive Health coordinated our visit to the country, and is also marshaling resources and support Banda’s way. She is the second female president in Africa, following in the footsteps of Liberian Nobel Peace Prize winner, Ellen Johnson Sirleaf. (Watch Sirleaf’s Q&A on the TEDWomen stage in 2010.) The two are allies and perhaps symbols of a new dawn of women’s leadership on a continent that has long suffered from the corruption and violence.

One of Banda’s first acts in office was to double-down on a Presidential Initiative on Maternal Health & Safe Motherhood, focused on reducing maternal mortality from its current rate to 115 or less per 100,000 live births. She aims to do this by 2015.

Above, Michael Rosenblatt asks “How can we stop death during childbirth?” at TEDMed 2011.

One idea to this end: getting more women to give birth in clinics staffed with health providers and equipped to handle complications. In countries like Malawi, women have historically given birth in their homes with traditional birth attendants. This can be extremely dangerous. Should something go wrong, most traditional birth attendants aren’t trained to respond; many are also known to encourage women to push too fast, one cause of the scourge of fistula in the country.

So what is a country to do when 85% of its population, including women of child-bearing age, live in rural settings far afield of the few equipped clinics and hospitals in the country? It’s a question ripe for a design approach. The Malawian government has pledged to build as many as 150 “maternal waiting homes” near clinics where rural women can stay in advance of their due dates. One waiting home is already in service in Northern Malawi and seven more are currently under construction.

Jane Chen: A warm embrace that saves lives

Blueprints for these brick and concrete structures were developed by the Ministry of Health, taking two forms — a 24-bed version and a slightly larger 32-bed structure. Each is projected to cost between $70,000-$80,000, and will be funded by Malawi’s private sector and outside philanthropic support. These waiting homes have the opportunity to become beacons of hope in a country caught between natural beauty and devastating poverty.

But it’s not just bricks-and-mortar that Banda is using to change women’s lives; it’s also a human-centered design for the healthcare system — too long understaffed and disproportionately urban. The Presidential Initiative on Maternal Health & Safe Motherhood, for example, is already training tribal chiefs in the importance of clinic birth for rural women, recognizing that their influence will largely determine what kinds of healthcare options women feel compelled to access. Once the chiefs have encouraged women to get to clinics, they will be met by new community midwives (Banda aims to train over 1,000 by 2014) and training opportunities at the “waiting homes.” Indeed, the Malawian women we interviewed expressed that they would love to gain new skills and knowledge while they wait for their babies to arrive.

Resource-limited settings, like the rural villages of Malawi, seem like unusual places to find this kind of systemic and environmental design. But there are important precedents. For example, the breathtaking Butaro Hospital in Rwanda, designed by MASS Design Group and operated in January 2011 by Partners in Health (PIH).

Above, Marika Shioiri-Clark talks “Empathic Architecture” at TEDxStellenbosch, describing Butaro Hospital.

Perched on a hilltop once home to a military base, the Butaro Hospital proves that “if it can happen here, it can happen anywhere,” as Dr. Paul Farmer of PIH is known to say. Farmer is referring to the fact that this world-class hospital is found in a setting where there was no basic electricity until the advent of the hospital. But Farmer is also referring to a unique design imagined by professionals embedded in the community they sought to serve — rural villagers, doctors, and nurses. Further, the hospital was built by local community members using primarily local materials. Thousand of people were employed in making the facility’s exquisite lava rock walls, virtually all of them gaining new skills that may improve their livelihood in the future.

Many details at the Butaro Hospital tell a story about the ways that humans really heal. Rather than being a fortress of internal hallways and small, secluded rooms, like so many American hospitals, it is characterized by open-air external walkways and big, collective spaces with beds directly facing bright windows with beautiful views. Ernest Madu on world-class health care There are also countless places to gather and sit outside — including a beloved koi pond. Color-coded signage paired with the color of wards is bright and easy to understand for potentially anxious visitors, unlike the bureaucracy and bad lighting one finds too often in stateside clinics.

If all goes well, Malawi, like Rwanda before it, will have the potential to teach the so-called developed world something about dignifying design. It’s what many cutting-edge development and design experts are calling South-to-North strategies — where Western countries look to the Global South for the next, big innovations. It’s a refreshing reversal of fortune and a huge opportunity. Not just for the mothers of Malawi, but for all of us.

Courtney E. Martin is the author multiple books, including Do It Anyway: The New Generation of Activists. John Cary is an architect, author, and the founding editor of PublicInterestDesign.org. Together, they traveled to Malawi and Rwanda this month with a delegation from The Aspen Institute’s Global Health & Development program. They are also members of the TED Prize team and co-leads of The City 2.0, the 2012 TED Prize focused on the future of cities.

Top of page: A mother and baby in a sunny ward at Butaro Hospital. Here: Mothers and children await care at health clinic in the Doa district of Malawi. Photos: John Cary