Good morning, Hankets Tuesday. So later this month, we'll be making a big announcement about working with partners in Health Sierra Leone. But before that, I thought it might be helpful to consider why Sierra Leone is so poor. Now, poverty is complex, and we are not going to get to the bottom of it in a YouTube video. But I do think this can be some helpful context. Okay, so Sierra Leone, located here, is a nation of around seven and a half million people. It's ethnically and religiously diverse. Most Sierra Leoneans are descendants of people who've long lived in West Africa, but many former slaves in the British Empire were resettled here. And so there are Sierra Leoneans who traced their descent to Canada, or to England, to Nigeria, and many other places. And while it was in Sierra Leone earlier this year, someone told me that to understand its impoverishment, I should look at a map showing all the railroad tracks that were built in Sierra Leone while it was a British colony. As you can see, the train tracks didn't really connect cities to each other. They connected the mineral-rich areas of Sierra Leone to the coast of Sierra Leone, so those minerals could be exported. And this is a very important thing to understand about colonization. It was in the business of resource extraction. And so the systems that were built in colonies were resource extraction systems. There was not much colonial investment in, say, health systems or education systems. And since Sierra Leone achieved independence in 1961, it has struggled to transition away from resource extraction and to build the kinds of systems, infrastructure, health care, even male delivery, that would lead to a more balanced economy and a healthier population. Now, it's easy to blame these tailors on a single cause, like, say, corruption, but while corruption is a serious problem in poor countries around the world, the bigger problem by far is that it's very hard to build health and education and infrastructure systems in communities that have been built around resource extraction. That's true all over the world. But also, a community just cannot spend what it does not have. Like, if Sierra Leone spent the same percentage of its economy on health care and education, as, say, the United Kingdom does, Sierra Leone would have about $45 per person per year to spend on health care and a similar amount per child per year to spend on education. That's just obviously inadequate. Like, in the US, we spend over $10,000 per person per year on health care and over $12,000 per child per year on education. Okay, so all these challenges were compounded in Sierra Leone by a long and extremely violent civil war, which lasted from 1991 to 2002. Tens of thousands of people died. Millions were displaced. The health care system was devastated HIV. Infections increased deaths from every cause increased. An education and professional development were interrupted as schools closed or students had to flee violence. Like, Dr. Byler Barry, who founded the widely respected well-body clinic in Sierra Leone, had to leave his studies for a time to escape to a refugee camp. And I heard similar stories from several health care workers. Because the civil war was on all sides partly funded by trade in diamonds and other valuable minerals, the war was especially devastating to Sierra Leone's diamond mining district, Kono. And as we traveled through Kono, I kept thinking about that old Faulkner line about how the past is never dead. It's not even past. In the end, the government paid for a mercenary army and weaponry in part by selling the rights to the country's largest diamond concession. And so today, almost none of the wealth generated by Kono's diamond mines ends up in Kono. And this is led to a paradox that is common in poor countries. While Kono is one of the richest parts of West Africa by some measures in terms of poverty rates, malnutrition, disease burden, and child and maternal mortality, it is one of the poorest and least healthy places in the world. Because while diamond mining produces a lot of money, there aren't actually that many jobs for Sierra Leoneans in the mines. Meanwhile, all around the mine, just outside the fence, you will see many people working at breaking stone to eventually be sold as gravel. This is how you end up with a country where $100 million in diamonds gets exported annually and 6% of all women die in childbirth. And this poverty can become a vicious cycle. I think the Ebola outbreak really epitomizes how impoverished and fragile healthcare systems can lead to emergencies. When Ebola first appeared in Sierra Leone in 2014, the entire country had about 150 doctors. For context, my home state of Indiana has a similar population and over 16,000 doctors. Lack of running water made sterilization difficult, there weren't enough gloves or surgical masks and this systemic weakness is the reason that Ebola could ravage a country like Sierra Leone, but not say the United States or Spain. We met an Ebola survivor who now works for partners in health and who shared a bed with his son at an Ebola treatment facility, both he and his son survived, but his wife died just a few beds over. So there were only three beds and we killed four. So I told him, no, my son was not good, so I'm going to share the same bed with my son. Small bed. I said, no, I have no problem. As long as my son is comfortable to have no problem. So I was here lying struggling for 90s. He brought my wife also and she died at that ward. When I asked Dr. Barry, his memory of treating patients there, he told me, we're in and seen like maybe 50 patients that they come in the next day and finally 20, and I mean it's a problem. The Ebola crisis was caused by a fragile healthcare system and it led to a more fragile healthcare system and that vicious cycle is often the story of poverty. So I understand that these problems can feel far away and like they aren't our problems, but first, you can't separate the wealth of nations like the United States and the United Kingdom from the poverty of Sierra Leone. You just can't. We industrialized with their natural resources and we built lucrative systems of trade by trading in West African slaves. But also secondly, if these problems aren't our problems, I'm troubled by how we're defining us. Like I don't want to be part of an us that makes a them of the world's most vulnerable people. And I think the idea that Sierra Leone can somehow solve its own problems in isolation wrongly imagines that its problems exist in isolation. Now of course one of the risks of philanthropic work is that it's possible to make things worse or to create new problems while trying to solve old ones. And I think it's important to be aware of those risks and to try to minimize them by grounding your work in listening and deep partnership. But I just think it's inaccurate to say that nothing can be done or that investment is pointless. I have seen the difference that partners in health and the Sierra Leone and ministry of health have made in the Kono district even with extremely limited resources. I mean five years ago, the hospital in Kono had no electricity and very few supplies and as a result almost no patients today, it is well staffed and well supplied and widely utilized. There's a blood bank and a functioning operating room for C-sections and other procedures. Now it's still totally inadequate. There are only 40 maternal beds for a population of 550,000 people, but the progress is real. And I believe that progress will continue if the Ministry of Health and Partnership with organizations like P.I.H. is able to make the kinds of long-term investments that address long-term problems. So why is Sierra Leone poor? Because its systems have for centuries been structured around resource extraction, because of war, because of disease burden, and because of colonialism and its legacies. But I am hopeful, not because I think these problems are easy to solve, but because I have seen the extraordinary commitment of Sierra Leone and healthcare workers to their patients. And because those patients have helped me to understand that despair is not the right response to big problems, even existential problems. There is nothing natural or inevitable about Sierra Leone's poverty. And so I don't think it's permanent. We have much evidence from around the world that over time systems can get stronger. More moms can survive childbirth and more children can survive childhood. Educational opportunities can improve and infrastructure can begin to connect people to each other and not just minerals to ports. Hank, I'll see you on Friday.