My name is paul, im a reporter with the washington post, and it is my pleasure to introduce this distinguished panel. We have one of americas greatest Television Journalists in conversation with two of americas most formidable intellectual, dr. S amy gutmann and jonathan moreno. They will be discussing their book, everybody wants to go to heaven but nobody wants to die. [laughter] subtitle, bioethics and the transformation of health care in america. Let me introduce this distinguished panel. Andrea mitchell, no introduction, Everybody Knows Andrea Mitchell. [applause] to come press the very extensive resume down, veteran chief Foreign Affairs correspondent, correspondent for nbc news, also host of Andrea Mitchell reports on msnbc, noon. Check local listings. [laughter] joined nbc in 1978 and has covered seven president ial administrations. Every president ial campaign since 1980. Youve seen her on nightly news, today show, meet the press, shes been everywhere. Conflicts in haiti, bosnia, kosovo, been to iraq, north carolina, pakistan, israel, the palestinian territories. The awards shes won would take me all day, so i will just go to one. She just won, this year, the women in washington journalism Lifetime Achievement award. [applause] andrea mitch em. Mitchell. [applause] dr. Amy gutmann is president of the university of pennsylvania and [applause] [laughter] and has been since 2004. When her current contract expires in 202 the2 2022, she will be the longest is serving president in penns 280year history. [applause] now again, a master resume, and they can get into it, but heres one stat that i really particularly like. Under her tenure with at penn, she has more than doubled the number of students from low income, middle income and First Generation College students. [applause] and shes only the author of 17 books. [laughter] dr. Jonathan moreno, philosopher, historian, bioethicist, he has written seminal works on sociology and the politics of biology and medicine. He is officially a professor of medical ethics and the history and sociology of science at penn. He has served on numerous president ial Commission Advisory commissions, and he has published more than 20 books, monographs, anthologies, textbooks, etc. Were honored and lucky to have this unique group with us today. Without further ado, as lester holt would say to Andrea Mitchell, over to you, andrea. I think first, though, we have a video. Enjoy. Today there are over seven billion of us on earth. Tomorrow there will be more. Each and every one of us is different, and yet all of us are the same. We are born, we age, we die. But today science is altering the equation of life. Modern medicine, advanced research, new testimonies are changing new technologies are changing how we live. Were now able to reengineer genes and blood cells. We can create babies with up to five parents. We can from long the lives of even the sickest patients. The question becomes, just because we can, should we . And if we do, how do we get it right . The doctor patient relationship has evolved. Who should decide ethics . Where do we draw ethical boundary for what medicine and science can do . How much power should governance and big business have over our health . Is health care a right for all or a privilege for some, and who pays the bills . These are the issues that every person, every family, every community will face. Everybody wants to go to heaven but nobody wants to die by amy gutmann and jonathan moreno, an eyeopening look at how bioethics is transforming health care in america. The reviews are in. Now you can read it for yourself. The choices we make today determine the future world well live in. Life as we know it is on the line. [applause] welcome, all, im Andrea Mitchell, as you know, and i cant tell you how exciting it is for me, i feel a little overwhelmed not just by this wonderful audience, but by the brain power next to me on this stage. And the fact that these are the questions were all asking in our families, in our, well, our political conversations. These are some of the questions that weve heard but havent fully been answered on the debate stage this primary season, questions of who has the right to health care. Many of us would argue everyone has the right to health care. Who pays, how do we pay. What about the advances in science, what expert challenges do we have as we, you know, face the issues of where science is going and where science has been. What is the role of the doctor in our society. All of these questions are addressed in this Remarkable Book with its Country Music title. [laughter] so i am thrilled to be here. Everybody wants to go to heaven but nobody wants to die. We think we should set it to music, amy and jonathan. But lets talk about the question that has been debated in the midterms most recently and now again in the general election. How do we address the challenge of insuring everyone in america deciding what to do about these hugely expensive advances . Then of course we wouldnt have written the book of that was the case. I think those of the right questions to ask. In the context is really an incredible moment in american history. Its been a long moment since the 60s. Where modern medicine gives us more choices than weve ever had before in human history. But with those choices comes more moral dilemmas. We could add questions about scarce organs for transplant. Who should get them if they are scarce. Would like to ask the larger question, which bioethics has sometimes neglected, which is, how do you create system in which encourages more people to be altruistic and donate their organs. We want to do is open up the conversation to everybody because if you look at these issues, every one of us in our lifetime faces almost every one of them actually, there are very few that we or our family or friends dont face up to and if we dont make the choices and we have a lot of power to do that collectively as well as individually. Other people are making them for us. Big ab since the 1970s at least, economists have said we are on an unsustainable course in terms of amount of gdp spent with healthcare yet we are not getting enough bang for our buck. This is not a new problem. We kind of punted on it. You mentioned the right to healthcare. In 1980s the president ial Bioethics Commission avoided the question. We dont pick it avoidable anymore. We believe there is a right to a decent level of healthcare. For everybody. And part of the book is we cant just idealize these things we actually have to grapple with the problems ahead of us. We have kind of not done that historically. So with regard to the right to healthcare for everyone, the hard question is, how are we going to afford it . What kind of a plan will actually allow us to provide affordable healthcare to all americans . Lets just talk about the u. S. That prompted us to write the New York Times oped, which advocated for revising and reinforcing the Affordable Care act because all reviews are very reluctant to take away effective healthcare from people who already have it but we have to give it we need a public option. We need medicare for more for those people who would prefer medicare over their own private insurance or who dont were not now covered. This is something we all have to as americans, i think the billy the optimistic part is, healthcare is ranked as the number one sensitive issue on voters minds. When we look at cost we know that we in america are spending more on healthcare and getting less. We see political figures showing graphically literally that you can drive a few miles from detroit to windsor canada and get insulin that you cannot afford. We see stories on my network and other networks of people rationing their insulin. Which is dangerous and potentially fatal. Just so people know, you all may know this but i think all americans need to know this, we spend about twice as much as any other affluent democracy on healthcare per person and we have lower Life Expectancy Life Expectancy has actually gone down in this country since 2015. It is totally unacceptable. Thats the risk of both worlds. We have Great Innovation and we can keep it going only if we start controlling drug pricing and other medical costs. Is not just mortality and more ability its the quality of life. We have a chapter on Public Health, which is somewhat neglected in our field of bioethics, bioethics tends to be in this country focused on a very high tech questions. We have a section on Public Mental Health which has been horribly neglected. He just walk around here and you can see whats happened to our streets have become day rooms as the old mental institutions were. There is a sculpture my wife and i never noticed before a sculpture of homeless person on a bench. We asked the question, is that sculpture they are to recognize he there are Homeless People in our midst or keeping one of them from sitting on the bench. We have moral failures we have addressed. Speaking a moral failures come i want to ask about something you wrote in the book. Which i find fascinating as we experience all these advances today. Human experimentation. He went to this history and i found it rather shocking we now know about pe and other experience decades earlier. I found what you wrote about Henry Beecher and the 1964 paper about what happened in Brooklyn New York where elderly disabled Senior Citizens were being experimented upon with live cancer cells from institutions that celebrated as memorial kedric. And then in 1966 i believe another exposc. Talk to us a bit about human experimentation and what safeguards there are now . Whats the most important single document in the history of human experiments is called by posterity the nuremberg code written by the judges at the end of a trial of nazi doctors. When he was a medical student at harvard in the late 40s during this trial of the nazi doctors in the decision by the judges that included an amendment to the nuremberg code. The famous first tents in the voluntary consent of the human subject is absolutely essential. Jay said the reaction harbored for pastors was, thats a really good ethics code for barbarians. But we are not nazis. The most 20 years later harvard professor in anesthesiology that shook things up in an exposc that included a couple dozen cases of said what he said were unethical human experiments. This is a part of the bigger story about we tell in the book about the change in doctorpatient relationships from the late 40s to 1960s. Thats where i was going with that. And the way that the patients and we as voters, one hopes, have insisted on getting more control over the power in that relationship. And how do patients get more control as a patient myself i dont know whether im getting it right information or told to get a second opinion. Im a cancer survivor, as you know. And all of us as consumers feel a little bit intimidated by the doctorpatient relationship. Because of the gap in our knowledge. Its intimidating and if you look at the economics of practicing medicine, most clinicians really wring their hands at how little time they have to actually sit down and talk with the patient. And no matter how many how automated how technologically advanced medicine becomes or has become, there is no substitute for the knowledge you can get in a two way conversation with a patient doctor. We went from doctor does best with marcus welby being played by robert young, fathers knows best. Those of you laughing, have to be either of a certain age or maybe no tv history but i remember it well. That was the culture it was not just the practice. We have an ethos now that the patients should have be able to give informed consent and should have control over our own lives medical lives but the actual practice of medicine has not caught up to the east coast. There are three things we think in your position and my position be open about what your alternative treatments are and know your goals. For some people its extremely important to get through a wedding in the family or bat mitzvah or bar mitzvah and not go directly into treatment. Doctors are experts in medicine but not experts in us. Its not good to be able to make decisions all on your own. I think a patient shouldnt be i shouldnt be my own doctor. Or my own nurse. But we should make Healthcare Providers earn their trust. Our trust. One of the more provocative questions that you raise in the book is what legal means are appropriate for endoflife decisions . Doctor marino do you want to speak to that . Is headed by students the last two years, other than gay marriage, the most amazing change in the culture about these kind of value issues is the changing attitudes toward physicianassisted death. I gave a talk in kansas city a couple weeks ago and i was getting ready, once in a while i look at my slides before i give a talk. I realized i had a slide that was out of date in terms of the number of jurisdictions in the u. S. That permit physicianassisted death. Seven only a couple years ago now if you include montana which has made legal judgment about this, not a statute, its 10. Its really a remarkable change in attitudes and whether you approve it or not, something is happening that we think also reflects the change and balance in the nature of the doctorpatient relationship. I think what is a great example of why its important for all of us to be informed and involved. And informed in broad ways. The question of physicianassisted death is so controversial that we dont even agree on what to call it. Opponents tend to call it physicianassisted suicide. Whatever you call it, a very small number of people, even in the states where it is legalized, use it, where its a huge, millions of people use hospice care and many more millions would if only it were known, accessible and affordable. Its very important that we understand that the things that are most controversial arent necessarily the most important things. Even though we need to discuss them abi think its really important. The culture is shifting as the physicianassisted death is the tip of the iceberg of how much patients have been taking healthcare into our own hands. 2 and a half years ago my mother died in a nursing home in rockville, we had hospice, Montgomery County hospice, they were terrific. Anybody who is ab its another way that we have kind of is a political culture avoided getting arms around the issue. I dont know, i saw zeke emanuel before but hes written extensively on this. Its been totally distorted but really by people who want to make just a craft political issue but in fact, we talk about this in the book, there is broad agreement on endoflife care but not a recognition of peoples rights to end their lives in a way that they have some control over the pain and the suffering and the dignity of how they perceive it. There is also probably the care at home where there are hospital visits and doctors and nurses visiting nurses decisions that are made with informed consent over not being brought into the hospital and emergency. If you have the wherewithal to access the services. We were fortunate we were able to in my mothers case but its a system you have to be able to figure out and have the time and the energy to address. Which is why its so important to face up to these kinds of issues before there is an urgent situation and you really dont have the time. This is the time when i think the American Public putting healthcare at the top of their issues with concern should spread far beyond the politics of it to how we inform ourselves in our daily lives. Both to ourselves and our families. You alluded to your New York Times oped, which was great and talked about medicare for more. To define the term, how are you envision medicare for more adding on to the Affordable Care act because the debate of course is great variations of medicare for all and other options. I think when we started to write the book we didnt really think about the election cycle. Now we find ourselves in the thick of it in the book is so relevant in that respect. Although there are a lot of other issues in the book. What we are most concerned about is making sure people who are running for office and the incumbent are very clear about what they are going to do and that we not throw the baby out of the bathwater. We think there have been some important advances as a result of the Affordable Care act. There is a way to go but millions of more people are covered now. There are problems, there is a a theres problems with deductibles, problems with copayments, we would like to see the candidate meet very specific about how they are going to address those details and what they propose to do. We have our own views in the book, but ultimately we want to make sure that everybody has basic healthcare coverage. It is a right not a privilege that if you suffer from insulin dependence, diabetes you should have access to affordable insolence. In this country it isnt true right now. Its just not true. The same is true for asthma patients. The fact that asthma abany program that builds on the Affordable Care act and enables everybody in this country to have basic healthcare and affordable rates. It is something that we would defend and i believe from everything weve seen in the pose, a vast majority of americans would defend it. With regard to the candidates we should hold our feet to the fire. For those that want to place results is to repeal and replace movement had no replacement. Now with the democratic candidates, we ought to ask ourselves and them, if you are going to scrap the aca, how are you going to enable any fraction of the one 60 a160 million americans where private Employer Healthcare coverage who want to keep it, how are you going to be sure they have as effects of healthcare coverage and for the ones who want to leave their employer coverage because there is some employer coverage that isnt effective should be a public option for them. We also think that medicare should be authorized to negotiate drug price controls. They are the largest player of prices of drugs and treatments and we are the only advanced society that doesnt allow a government player to actually look at the effectiveness of different drugs and judge how much it is worth paying for. Its really some kind of insanity that we dont do that. It is really. Let me give you an example of why we think the title is appropriate to so many things we are facing in healthcare. All of us are facing. Our university is the home of several other universities are great discoveries in immunotherapy. They are saving lives. Perhaps the most famous cases is that of a a girl who is now 14 years old, she was seven years old on her deathbed, her name is emily whitehead, and Carrie Whitehead her parents searched, she was all traditional treatments, didnt work. They search for an experimental treatment. They found one at the university of pennsylvania and a childrens hospital. Carl june found a treatment. Emily is now cancer free 14yearold. Shes become a spokesperson with her parents for access to the treatment. This treatment now can save the lives of children as well as adults it saves lives now of hundreds maybe thousands but its a very expensive treatment. Yet it is by every measure costeffective. It saves lives. There are other things that are very expensive that dont save lives. Many treatments we get we be better off without. We believe in access to healthcare for all. We believe in really improving our Public Health system. And we think, this is what amy was addressing, basic science need to be pushed forward we need to look on basic medical science. The nih and nsf have been constantly under threat for the last few years. Its a terrible mistake. A good example is sickle cell. Sickle cell first of all many sicklecell patients are not getting adequate care thats theoretically available now. Particularly after the pediatric period. The transition is really tough for sicklecell patients. In many cases they are really unable to function because of the crisis. We are not doing that well. We also have really some great opportunities in terms of crisper, the acronym Everybody Knows now. There are more than a dozen Clinical Trials for sicklecell. It can be cured. We cant walk and chew gum at the same time. We have to do well. But it does require society taking a serious look at our needs both in terms of access to healthcare and Public Health and one hand and pushing forward the medical science on the other. It can be a game changer for so many people and tremendously costeffective if it works. How do we deal as bioethicists, how do we deal with the situation on Reproductive Health and the Public Health sector . Where religious restrictions have changed the way the state department deals with population issues through the United Nations as well as the gag order, which is now being litigated from the ninth circuit. These are tough questions but how do we as a society deal with that. We talk about Stem Cell Research that i think its a great example of something that was once incredibly divisive and there is large bipartisan support developed for Stem Cell Research. Why . Because people like nancy reagan and others had people in their family who could benefit from the consequences of developing this kind of medical care. Things that were once really controversial when both prominent people and most importantly, the American Public recognizes and gets engaged and really pushes to have it move forward, thats when we really see progress. Most of us are easily forget and some of you werent even born then but for those of us who were alive when medicare was passed, all the same arguments it was communist plat it was socialism, the same thing with fluoridation we talk about fluoridation in a town where we both grew up. In newburgh new york. My hometown, which was quite a conservative town. I heard it was a communist plot to florida our water. Childrens carries are so much less than they were before. A dentist in newburgh said that when he saw a child with a mouthful of cavities, he knew that child didnt grow up in newburgh new york. It took eight years before new york city with the coalition of the most famous pediatrician spock. And doctor spock. The first doctor spock. [laughter] jackie robinson, eleanor roosevelt. It took eight years before robert ragnar, who is known to be a cautious new york mayor, he passed fluoridation. While there are some issues that produce these horrible deadlocks and almost every issue produces them in washington now, if we get engaged, we can change that. And only if we get engaged will that change. The fruits of modern medicine are worth our struggling for them. At an affordable rate. There is often unanticipated good consequences of letting the science move forward. In the case of embryonic stem cell that led to the use of what people sometimes call skin cells. They have been made potent in the laboratory, quite similar to embryonic stem cells. That helped to calm the debate. In the case of water fluoridation people you realize how important healthy gums are to help. Thats been proven over the years. With some of the technological advances ai and Everything Else happening, what are the big issues that you see to each of you and then i would love to bring in the audience for question. The biggest issues that are new challenges that you as a philosopher have to think through . Im obsessed at the moment with abthis is a very wonky term but i use it. What scientists call cerebral organ noise. These are little bits of cerebral organ noise, little bits of brain tissue that in the laboratory can be cultured and grow into lentil sized structures. That we can pixelate some of the ways that our brain cells talk to each other. Thats an incredible model for some of the illnesses which the well is dry we dont really have good significant improved therapies for people with schizophrenia for example. That terrifically promising. Some people will find it creepy but there are problems that neuroscientists cant address. You should talk about the mouse with the ear. Right. [laughter] about 15 years a to give you an example. 15 or 16 years ago when a colleague at stanford proposed to put human cells and brain cells in mice and then there was for purposes of trying to find solutions to terrible diseases and then there was a picture that went on the internet and the actual photograph of the laboratory eroded with the human ear growing on his back. And people were creeped out. Why was that being done . Understandably but that was being done because childrens an accident to lose their ears could have a transplant. If this were to be successful in such a way that their immune system would it reject it. So lets understand whats going on here. We need to kind of catch our breath on some of these things. I am a big sciencefiction fan, ask anybody in my family, and totally obsessed. Sometimes it can be very eyeopening to think about and some of the imaginative ideas. I love that stuff. At the same time, its not only not science is not science fiction. Science is only in the case of the stuff we talked about in the book its also about proving quality of human life. This is why we wrote the book together. Hes a sciencefiction fan, and i like italian neorealist films. I like to be very pragmatic. So my answer to your question are two things that i think that are very real in the future. In my realistic hope for the future. One is that we get cost controls that are reasonable so that the great new technologies like immunotherapy like the new Brain Science discoveries can move forward because only good Science Partners with good ethics dont move forward. The critics of bioethics think its putting the brakes on science. Thats precisely wrong. What good ethics does is it makes the science to move forward because the moment Something Like tuskegee or the brooklyn hospital, i was born in brooklyn, i really identify with this, happens big breaks are put on. It happened with gene therapy at the university of pennsylvania with jesse gelsinger. The bricks were put on for a decade. Thats one thing i love to see surge forward. The other thing, which we focus on in the book very early on is, we are experiencing Something Like the tragedy of the commons with regard to Public Health and Mental Health. We need to invest more in Public Health and Mental Health. [applause] when we do, because we will do it. Smallpox vaccines saved over 50 million peoples lives. China put a Public Health initiative in for the largest cause of Mental Illness which is iodine deficiency disorder. The Tobacco Control programs we put in more recently over six years have saved an estimated 22 million peoples lives. The context we need we talk about nudging people to do the right thing whether we like it or not we are being nudged. Im furious that every time i went to the supermarket with my child when you check out you have to check out and pay all the sugar loaded candies were there. Which appeal not just to her but to me because that was the environment i grew up in. Now you dont have to go to the supermarket i suppose but its not only in supermarkets. Its in all the stores. So we are being nudged. The question is, i call that nudging rather than nudging the bad kind. But we want to be nudged in the right direction. With that i could listen to you two forever but lets bring some of our audience in. Here are microphones set up, please get in line. Yes maam. Its a two part question. The first relates to 80 of medicare is spent in the last year of life i was a nurse for james brady. I was a nurse for many people with congestive heart failure, chronic renal failure, on respirators, i tried to tell the family enough is enough. abi made the mistake of saying only barbara bush can have this discussion with our nation and look what happened last year. Mrs. Bush made a decision enough is enough. And until this nation has an honest discussion that 80 of medicare is spent in the last year of life, we have to say no to something. Second question is Mental Health. I just moved back from philadelphia. [inaudible] but has one of the highest rates of suicide. In britain they have Heads Together initiative with the royal family because they know all the charities there mother started. Veteran issues, the Mental Health terms with doctor gottman 80 . Thank you for both questions. Theres part of this is the way that endoflife care is understood by people. The media has something to do with that. Love the media, nonetheless, the way the people have come to understand through film and television what it is like to be on a ventilator and indefinitely and how many people get out of the icu having had a heart attack and so forth. There was a really great paper that was published in the new england journal of medicine 20 years ago by harvard medical student who works for a tv doctor show. He wrote a paper from a journal of medicine compared the rate of successful departures from the hospital on television for somebody who has had an mri heart attack in the icu as compared to the real world. It was way over 80 . By the end of the hour you are doing great. Thats not always true. I think it takes the culture a little while to catch up with the cat technology. I think we are doing that right now in your illustration in this book is a fantastic illustration. On Mental Health, we had a year where we had a series of really tragic suicides and in the context of the society in which there is a Mental Health epidemic i know that term is used too often but truly if you look at the rate of Mental Health problems, serious Mental Health problems and the increased rates of suicide they been terribly troubling over the years. So what we did was we got a group of students, faculty, experts and Mental Health at our hospitals really terrific people to do a 360 and we now have we are the only institution that has a chief wellness officer and we have we totally reorganized our counseling and Psychological Services we posted on our website wellness in pens with all the resources. We really took ownership of the issue as much as we advised the book we have to do and it was amazing to me that last year when i met with the Student Group who really care a lot about this and i asked them, after i asked him direct questions i said, just tell me what you are feeling about a they said theres been a seachange from the freshman year to senior year because they feel the institution cares about their mental as well as physical health and wellbeing. I think thats what we have to do and we have to as citizens try to find ways of making sure Public Officials put the offending into medical aMental Health. It ought not to be stigmatized. The estimates are a fourth of our population has Mental Health issues and these are illnesses like any other that we should own and we should feel that people have a right to care. [applause] medical care is expensive and in a National Healthcare system there are limits to what the system can afford. In other countries the government set limited to what patients will give at certain points in their life. In this country it seems like the legislators and policymakers are developing a system where they put that decision on the provider and thus straining the provider patient relationship instead of saying Something Like, if you are 80 years old and you have kidney failure you cant get the house anymore. What you think about that those policies and you think the government needs to step up its side of making decisions in terms of healthcare . There are other choices between not just those two choices. In other words, think about it, we have to wrap our minds. We spend twice as much per capita as any other advanced society. We are a very innovative societies. If these societies dont have, germany and switzerland dont have singlepayer systems and we can actually, we are paying up we are coming close to 20 of the gdp. Between 18 and 19 percent and its just going up. So there are ways to enable people who need care, need endoflife care as well to get it and rain in the prices of treatments and drugs. You dont have to say when you are 80 years old, you cant get this. There are many people, i have friends now who are 90 going on 100 and they are incredibly wellfunctioning and we write about in the epilogue to the book about a dear friend of mine who is about to turn 90 who is a survivor not only of the holocaust but three different cancers. And was on a very expensive drug. Which is a kind of miracle drug. The alternative to what we are doing now, which is unaffordable and unacceptable, inequitable. It is not to tell people after a certain age, you dont get the treatment. There are other ways of doing this. And other societies have done it. Our politicians like to use the National Health service in what the studies that they are going to as the negative example. There are many positive things to say about it some negative things to say about it but they dont like to point to germany, which has very low infant mortality. Very high Life Expectancy and half the cost per capita in very high innovation. We also have a default in our system to gadgets and technology. I often like to tell young doctors and training, its not that you are stopping the caring, you might be withdrawing some treatment but you continue the care. That is often what people want near the end of life. They dont necessarily, its not that we have to translate every gadget into some form of care but care is a healing factor, not a technological factor. We have time for one more quick question and quick answer. Comparing u. S. Healthcare outcomes with those of other developed countries in relation to cost, arent there societal factors such as gun violence and poverty and racism that lead into healthcare costs and poor outcomes that are not included in the other countries . How can we improve healthcare outcomes and lower cost without addressing these societal . Great question. We cannot. Thats precisely why the nearly every chapter in our book is all about Public Health. Because two big things about healthcare, one is that the underinvestment in Public Health hurts disproportionately lower income and middle income and minorities in this country. The availability of infrastructure think about whats going on in new york city right now. Public health is incredibly important. The other fact about healthcare as we are runaway cost of healthcare of the single biggest problem that that creates outside of healthcare is it starts education at the state level. States have had their budgets being drained away with unaffordable healthcare away from public education. That of course also hurts just as people you spoke about. Thats another difference between our society in germany. Poverty is a risk factor for poor health. And so is inequality. It turns out there are some really interesting neuroscience that if you live in an Equitable Society that you tend to be more stressed and depressed. Inequality is a source of Mental Illness. We think about nutrition and all the other issues and environment, Climate Change and led but newark new jersey right now. But whats going on in terms of pollution. There is a way forward. I think its really important to recognize these problems and realize that all the progress that has been made would not have been made had the American Public not mobilized. We cant depend on the public, Public Officials doing any number of the things that we need to be done unless we really hold their feet to the fire and take ownership of it ourselves. Weve only scratched the surface but i just want to say that this book is, its philosophy, its obviously ethics, its science, its narrative, its just a wonderful book. It should be the primary i think for all of us in election cycle and in life. I just want to thank you im so grateful. Thank you. [applause] thank you andrea. Every yearbook tv covers book fairs and festivals around the country. Here is a look at some coming up this fall. In september look for us at the brooklyn book festival in new york city. On october 11 to the 13th its the southern festival book in nashville. The following weekend the boston book festival welcomes over 300 speakers in the wisconsin book festival anticipates over 15,000 people in attendance. Also later in the month tuning for our coverage of the texas book festival in austin. For more information about upcoming book fairs and festivals and to watch our previous festival coverage click the book fair tab on our website book