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September 11, 2009

BILL MOYERS: Welcome to the Journal.

That was one fighting speech Barack Obama delivered Wednesday night. Plain spoken and clear, he spelled out details of his own plan for health care reform, rallied his side of the aisle, met his adversaries head-on, and shamed the partisan wrecking crew that spewed lies into the summer's heat.

BARACK OBAMA: When any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom, and we can no longer even engage in a civil conversation with each other over the things that truly matter - that at that point we don't merely lose our capacity to solve big challenges. We lose something essential about ourselves.

BILL MOYERS: It was high political drama that would have pleased the two Roosevelts. But speeches are soon forgotten, and the atmosphere they create dispelled, and the rhetoric, no matter how dramatic or effective, challenged by reality. Now comes the fight to the finish, and we'll stay with the story as the weeks unfold.

But first, we turn to another big decision bearing down on the President, what to do in Afghanistan. A conflict Americans can no longer put out of mind or out of sight.

Once again, we have been reminded that war is not a video game. The photo of an American marine dying in Afghanistan created a controversy that threw the press into conflict with the Pentagon and the young marine's family - and it threw those of us in the press into conflict with ourselves.

On August 14th, Lance Corporal Joshua Bernard was on patrol in Afghanistan's Helmand province. An Associated Press photographer embedded in his unit. That's Bernard there, on patrol, shortly before a Taliban ambush. Hit by a rocket-propelled grenade, Lance Corporal Bernard was mortally wounded. He died later in a hospital.

The A.P. released the picture over the objections of his family and Defense Secretary Robert Gates, and it appeared in many newspapers and on websites.

I can't even imagine how I would feel if that were my son or grandson. I do understand the reaction. I would want to remember him the last time I saw him alive, not bleeding to death in a foreign place. For so intimate a matter as death to become a public event can only add to the pain and grief.

But as a journalist, I know that one reason Americans tolerate wars as long as we do is that most of us look the other way while others do the suffering in our stead. Our soldiers have been fighting in Afghanistan longer than we fought in the first and second world wars combined, but just try to remember the times you've actually have seen one of our fallen there.

Yet August was the deadliest month for our troops in Afghanistan since the U.S. retaliated there to destroy the bases from which terrorists had attacked us. 51 Americans died in August; 44 in July.

Now eight years in, the Taliban is resurgent, despite the additional 16,000 U.S. troops, almost two-thirds of the country is reportedly too dangerous for humanitarian agencies to deliver much needed help. Civilian casualties this year have reached more than a thousand, including suicide bombings and the so called collateral damage from air strikes.

As THE ECONOMIST nagazine noted last month, resentment against the Karzai government, NATO forces and westerners in general is growing. " seems clear," the magazine reported, "that the international effort to bring stability to Afghanistan... is failing."

And yet, consider this open letter to President Obama from some of the very same armchair warriors whose claim of expertise supported President Bush's decision to invade Iraq. They were wrong then - wrong time and again - but their tragic errors haven't stopped them from demanding that President Obama now escalate the war in Afghanistan.

Once again, their enthusiasm for war is as great as their distance from the actual battlefield.

Their letter lands as European leaders are calling for an international conference to assess the deteriorating situation and the commander of our forces in Afghanistan, General Stanley McChrystal, delivers a review to the White House. It's a report many believe sets the stage for an even greater expansion of the war.

But recently, the "McClatchy" news service reported that some top pentagon officials fear that without a clear definition of our mission there, further escalation will be in vain.

As a reality check, with me now is one of the reporters on that story, recently returned from Afghanistan.

Nancy Youssef is the Chief Pentagon Correspondent for "McClatchy" news. She covered the war in Iraq for four years, including two as Baghdad Bureau Chief.

Nancy Youssef, welcome to the JOURNAL.


BILL MOYERS: Before we get to Afghanistan, let me ask you about this photograph of a young marine who died. And the A.P. as you know circulated the picture, even though the parents and Robert Gates, the Secretary of Defense, objected. What was your reaction to that?

NANCY YOUSSEF: You know, when that photo came out, I talked to a friend of mine, she's a Colonel in the army. She served in Iraq and many years ago, she'd lost her daughter, who was a toddler at the time to an illness, so she could speak to it as a soldier and as a parent.

And she was really angry about the photo. She said, "No one has the right to tell me what my last memory of my child should be." And it really stayed with me. And so as I could have empathy for the family, and I felt a lot of pain, because I can only imagine having that image seared in your mind. But I'm conflicted, because as a journalist, and as someone who has to go out and see this war day in and day out, it's hard to say that these photos shouldn't be seen. In a way, I feel like the wars in Iraq and Afghanistan have been sanitized. And that photo, as gruesome as it is, captures the reality of war. It's ugly. And it's what these troops are facing day in and day out.

So, I always-- this is my ultimate objective in all of this is to maintain the humanity in the coverage of war. And so, I'm conflicted, because that part of me wants to preserve the rights of that family. And at the same time, I want the general public to know what's happening.

BILL MOYERS: Does it get difficult for you to separate your role as a journalist from your humanitarian impulses and instincts?

NANCY YOUSSEF: Yeah, but I think in a way they have to be connected. I think one of the mistakes in Iraq was and I think where "McClatchy" and Knight Ridder and at that time, was able to distinguish itself, was to bring that humanity to the war. I think it's easy to reduce people to numbers, 50 killed, 20 killed, four troops killed. But it's the humanity that makes it, I think, almost relevant to the viewer, to the reader. You know, I remember a time we were covering the war in Iraq and my editor called me. He said, "How many were killed?" And I said, "50." And I just said it like it was a number. And he said, "Well, isn't that a lot, Nancy?" And it occurred to me that I was losing my sense of what really mattered.

It got more challenging and it does get more challenging as those numbers rise to make people realize that these aren't just statistics that they're people. And I think it's the most essential we can do as journalists.

BILL MOYERS: As you talk I'm thinking about the time in '64 and '65 when I was in President Johnson's White House as we escalated the war in Vietnam. We never saw a photograph of a dead or dying soldier. We talked about body count and that still seemed anesticized. Then we started talking about body bags and that became more personal and disturbing, but we never really talked about individual soldiers or saw their death.

NANCY YOUSSEF: What I think the distinction is Vietnam had an impact on the nation, because of the draft, because everybody could be touched by it in some way. Where as when I go to Iraq or Afghanistan, I come back, and I'm always struck by how little I feel the war not only in the United States, not only among my friends, but in Washington itself. You don't feel the war. And I don't know what that feeling is supposed to be, but you would think that you would feel the impact of engaging in two wars. And you don't feel it. It's so distant. It's so, almost academic. So, maybe humanitizing it or putting a name on it is the wrong way. There must be some way to make people realize what the country's asked of its serviceman. There's a solemn oath we make with the troops that we won't send them into war unless it's absolutely necessary. We own part of that decision. And so, in a way, as a journalist, it bothers me when you don't feel that in the city, in the nation's capital, where these decisions are being made.

BILL MOYERS: What about at the Pentagon? You spend your days there, every week now. What's the sense there? Do they grasp what's happening to men like Lance Corporal Bernard?

NANCY YOUSSEF: I don't know. You know, when I go there again, it's so fortified because of security measures. During Vietnam, people would throw blood on the steps, and you would feel the anger about the war. You know, people think of the Pentagon as this big place where war plans are made. And it's really at the end of the day a place, it's a marketplace where contracts and decisions are made. And it feels like an office building. So, do you feel it? Not particularly, because people have a different vantage point. You know, it feels like at 4:00 the halls are empty. And I'm always sort of disturbed by this. Where is everybody? And again, I don't know what it's supposed to feel like. But I know it shouldn't feel like this.

BILL MOYERS: What about the soldiers you personally met in Afghanistan? What do you think they might say about the photograph? Whether to show it or not to show it?

NANCY YOUSSEF: That's a good question. I think it depends on who you ask. I think a lot of them would be offended, because it's so personal. These are guys that they were sitting next to the day before. It's something to them that's not for sort of public consumption. It's gruesome, it's graphic. It's something that belongs to them and something that they have to deal with. But at the same time, I think many would want to see a public that's more engaged on what they're doing there. More interested in what they're doing there. More aware of what they're being asked to do.

BILL MOYERS: Is it clear to you what our goals are there?

NANCY YOUSSEF: Well, the Secretary lays it out the following way. He says that because the Taliban cooperated and collaborated with Al Qaeda, the United States must make sure that the Taliban's not allowed to return so that it therefore doesn't allow Al Qaeda to return. I guess the question that I have, and that hasn't really been answered is, that may have been true then, but what is the relationship between the Taliban and Al Qaeda now?

Because if the premise of the strategy that is that the Taliban can't be allowed to return, because they'll provide sanctuary for Al Qaeda, I want to understand what that relationship is between those two, to determine if that, in fact, will really happen. For me, it's not clear yet. And it's a very hard question to answer. Because the word Taliban, in a way it doesn't mean anything anymore.

BILL MOYERS: Who is the enemy? Who are these soldiers fighting?

NANCY YOUSSEF: I don't know. I mean they're fighting this nebulous group called the Taliban. And some of them are fighting men who are joining because they need money. Or because they've been forced or coerced into fighting the Americans. Some Taliban are people who have no ties to the ideological Taliban at all, but are just angry that occupation forces, in their mind, are in their country. Some are people who are ideologically driven, who want an Islamic state in Afghanistan, who want to work with Al Qaeda. It's a very, varied enemy. And I think that's what part of what makes a strategy so hard and what makes it so difficult for the troops. Because everyone they're fighting could be a farmer the next day, could be a local. There are no borders. There's no uniform. There's no way to distinguish one from the other. So, I think that's what makes it so hard. The Taliban that I saw, and I was in Kandahar were people who--

BILL MOYERS: That's the southern part of the country right near the Pakistan border.

NANCY YOUSSEF: That's right. And it's one of the most important provinces historically. And you go there and the Taliban is this bullying organization that is a form of order that at least the Afghans are familiar with. And they control the community. The local government that we've established does not. The police chief, the Taliban police chief, lives in the city. The U.S. backed police chief doesn't. He lives on base or he lives in Kandahar proper. And I'm talking about in the provinces. The local district leader who works on behalf of the Karzai government. It's too dangerous for him to live in the city. He lives on the base, or he lives in Kandahar. So, it's a coerced, forced order. It's sort of the devil you know versus the devil you don't.

BILL MOYERS: And what about Al Qaeda? The guys who did attack us on 9/11. Where are they? And who are they now?

NANCY YOUSSEF: The United States believes that the leadership is in Pakistan. But, you know, something I struggle with personally is what happens if the next attack is planned in Somalia or Yemen or Europe, where they've expanded or have a presence there? What is the United States response then? I sometimes worry that we're fighting the last war instead of the next one. And I think when you look at Al Qaeda and how it's spread, you start to wonder. They don't use a sanctuary anymore. It's now an apartment and internet access to start planning these attacks, and how do you defend against that? I don't know.

BILL MOYERS: So, what do the generals whom you interviewed, the colonels and on down tell you remains our goal?

NANCY YOUSSEF: You know, I spoke to General McChrystal when I was there. And I think more than anything, he wants the opportunity to try this out. That if we're going to do it, let's do it. Let's really put our effort towards this. We think about this as--

BILL MOYERS: What does that mean? More troops?

NANCY YOUSSEF: More troops. More time, more than anything else. That this is not something that can be turned around in time for a political or an election cycle. He needs time more than anything else.

BILL MOYERS: You know, Nancy, that's what the generals kept telling President Johnson in the early days and at the peak of the escalation in Vietnam.

NANCY YOUSSEF: But, you know, we talk about Afghanistan as an eight year war. But the truth is it's been eight separate individual years of war. So, I think that's the--

BILL MOYERS: What's the distinction?

NANCY YOUSSEF: Because we've never gone after this in a real way. There was a strategy 2001 to 2003. And then we tried something else 2003 to 2005. And then it escalated and we tried something else. So, I think if we-- to me, I think what General McChrystal's really saying is if we're going to do, let's do it. Let's really do it. And I think that's the disparity that from the military perspective they'll tell you we haven't really been given the chance, because we were too busy in Iraq. So it's a true argument. It's a fair argument. That was an argument made in the past. We need more time. We need more time. But I think for the commanders on the ground, it feels a bit of a rollercoaster. It went from being the just war, during the campaign, and in the early days of the Obama Administration, to a potential quagmire that we're not sure we want to send more troops to.

BILL MOYERS: But now, Obama's made it a, quote, "war of necessity".

NANCY YOUSSEF: He's made it a war of necessity, but yet, there's a real debate about basic questions on this war. This war of necessity, what's happening now in Washington and all these assessments. We're trying to answer very basic questions, "What is the goal? What is the strategy? How do you implement the strategy?" So, even though we call it a war of necessity, I don't think it's ever been treated at a war of necessity, even now. That debate is just starting, in year eight of the war. It's extraordinary.

BILL MOYERS: Things just seem to be going off the rails there. Is that your judgment, too?

NANCY YOUSSEF: I think-- remember that President Obama sent 21,000 more troops, and what happened was the United States expanded its reach. Now, you ask the Afghans, they'll say that when U.S. troops show up, more problems show up for us. Because then the fight starts.

BILL MOYERS: They're caught in the middle.

NANCY YOUSSEF: That's right. Then they are caught in the middle. I mean, when you go to Afghanistan, the Afghans are not trying to work with Karzai, embrace their new democracy. They're trying to survive within the confines of the district. They're manipulating the Taliban, whichever local district leader or warlord in charge. They are not looking for some grand democratic process. That's not what's happening. So, when the U.S. troops show up, from their perspective, it's more problems. Now, the United States will say, "Things could get worse before they get better, because we have to engage them in the fight." But I don't think the Afghans are on board with that yet. I think they feel like we-- I can't tell you how many Afghans said to me, "I don't want the Americans. I don't want the Taliban. I just want to be left alone."

BILL MOYERS: What are they like these people who are caught in the middle? I mean, you got to know a lot of them. You wrote about them in your dispatches. What do they say to you?

NANCY YOUSSEF: You know, they're tired is what the sense I got more than anything else. There's this renewed effort in the United States to engage in Afghanistan. And they've been living with it for eight years. We talk so much about the Washington clock. And how the President--

BILL MOYERS: The Washington clock?

NANCY YOUSSEF: Yeah. How they have 12 to 18 months by the administration's estimates, the military does, to turn things around. I think the Afghan clock is ticking a lot faster. They're tired. They're frustrated that this country has brought a corrupt central government that doesn't serve their interests. They're smart. They're savvy. And they are trying to survive. You know, so many people tell me that Afghanistan's not ready for democracy. I would argue, "Look at the democracy that they've seen. Who would be ready for that?" And that's where they are. They--

BILL MOYERS: What do you mean? What democracy have they seen?

NANCY YOUSSEF: Well, the democracy they've seen is from their perspective a fraudulent election that's brought about a government that's more corrupt, in their view, than even the Taliban was. And by the way, they don't get any more basic services. They have to pay a lot more in bribes to get basic things done. Their warlords in some cases are more empowered under the system, not less. Who would want to democracy under that? I think we have to think about how we've defined democracy in their minds. It's really become about survival.

BILL MOYERS: I know from reading that our forces are trying to do some good things there. Roads, schools, they move into a village, get acquainted with the elders, try to establish some basis of trust and credibility. And yet, then, you know an attack during a wedding party, I was reading the other day, will completely negate those good intentions, right?

NANCY YOUSSEF: That's right. I was in Zhari District, which is about 20 miles west of Kandahar. When the Canadians first came in, they painted schools and they built new schools for the residents. And you know what happened? The NATO forces eventually had to destroy them, because the Taliban took them over. So--

BILL MOYERS: What do you mean the Taliban took them over? This suggest the Taliban are far more sophisticated than a lot of us think.

NANCY YOUSSEF: I don't think they need to be sophisticated. They own everything. They own the terrain. They know the terrain better than anyone. All they have to do is sort of bully their way in. Because without enough forces, how much security can you really provide that school. That's the thing. We've talked about this Taliban as they've come up with a strategy. I don't think they really had to do anything too complex. We have currently-- there are 101,000 troops, U.S. and NATO troops in Afghanistan.

It's an extraordinarily small number for a country of that size and that level of complexity to it. So, why build these schools if you can't establish security? It was a problem in Iraq, too. They would brag about, "Well, we put up this new school. We provided new electrical grid." And the next day it would be, it would be bombed. And Afghanistan's in that same place. But Afghanistan, I think, will take longer. It's just a far more complex country. And I'm not sure that the United States is ready for that yet. Or at least has been readied for it yet. It's going to take years.

BILL MOYERS: What's your greatest fear of what might happen there?

NANCY YOUSSEF: You know, because I'm the Pentagon correspondent, someone said this to me that stayed with me forever. My biggest fear from the military perspective is that Iraq doesn't fall apart quickly, but that--


NANCY YOUSSEF: Iraq. That Iraq falls apart slowly. And that we find ourselves in a place where we're doing this with troops. That as we're slowly bringing down troops in Iraq and slowly building up in Afghanistan, we find ourselves in a really difficult situation in both countries.

BILL MOYERS: So, you fear we have to reengage in Iraq?

NANCY YOUSSEF: I fear that we're going to find-- I don't know that the United States will. I mean, the Status of Forces Agreement makes it very clear that the United States is not going to engage.

BILL MOYERS: The Iraqis want us out.

NANCY YOUSSEF: That's right.

BILL MOYERS: There's a legal agreement to get out.

NANCY YOUSSEF: That's right. But what happens when the violence starts to escalate in Iraq and starts to escalate in Afghanistan, and we're say, at 80,000 troops in both countries? What is the United States role at that point? Is the plan to sit aside and do nothing? Will the Iraqi Government still feel that way? Depending on what the violence is? That's what keeps me up at night. Is that fear of that point where the United States finds itself engaged in both wars or at least heavily committed to both and not quite out of one, not quite in the other.

BILL MOYERS: President Obama has said that on the 24th of September, as you indicate, he will set forth his strategy. Do the officials you cover at the Pentagon have a sense of where his head is on this?

NANCY YOUSSEF: You know, that's the fundamental problem in all of this. You'll hear this. You might hear these phrases about counterterrorism versus counterinsurgency. Counterterrorism argues for a very narrow approach. We leave some drones there. We leave a few troops there. We keep an eye on things and we attack when necessary. And in Washington, that's sort of being led by Joe Biden. And then the counterinsurgency argument is we do everything. We build up a stable government so that there's no room at all for the Taliban to come back in. We build the economy.

We build better governance. And on this camp is, Hillary Clinton, General Petraeus, General McChrystal. And the problem is nobody knows where Obama is on that spectrum.

BILL MOYERS: Suppose he commits to a long war. Will the American people-do we have that kind of patience?

NANCY YOUSSEF: I don't know anymore because you see these polls come out and the majority now don't think this war is worth fighting. I was thinking about it. 60 days ago, when General McChrystal started the assessment, the political capital for this war was much, much higher. We hadn't had the health care debate the way it has.

We hadn't seen the kind of troop deaths that we had seen. And the political capital has diminished so quickly. At the minimum, General McChrystal's arguing for a strategy to build up the Afghan forces to a capacity that would cost about $3 billion dollars a year. This is in a country that generates $800 million of total revenue every year. So, at the minimum, he's talking about committing the United States and Europe and NATO to an indefinite financial commitment to Afghanistan. How do you sell that in this current economic climate? I don't know how you do that.

BILL MOYERS: And in the last eight years, there's been about $32 billion of foreign aid that's been splashed across Afghanistan. Can you see any of the effects of that?

NANCY YOUSSEF: It's very, very minimal because at the core it's security. I mean, that same number, you'll hear talked about how much has reached the Afghans. It's something ridiculously small. Like $4-$6 billion that actually has reached the ground in Afghanistan. Do you see it? Not really. You'll see it in pieces. You know, you'll see the ring road, or a paved road of some kind there. Or you'll see a new water system, or a new school, or a new crop buildup. But there's nothing linking all those things together. That's what's missing. So, it's very piecemeal. So, it's sort of like a mirage of a big pool of water in the middle of the desert. You know, you see it and then it sort of disappears, because it doesn't have any real long term impact.

BILL MOYERS: You're reporting depicts a very dismal picture there. So does every other bit of reporting I've seen, including the cover story a couple of weeks ago of "The Economist", which reaches a grim conclusion about the state of things there. But is there-- I'm not looking for a silver lining, but for a reporter's assessment, is there any good news there?

NANCY YOUSSEF: Yeah, the good news is that the United States is committed to it. The good news is that the world thinks that this is a priority. The good news is that there's now a renewed effort and that the best minds are on this and trying to come up with a solution. And that--

BILL MOYERS: The best and the brightest?

NANCY YOUSSEF: I don't want to say-- Maybe. But to me, I think the question at this point becomes either the United States commits to this and really commits to it. Or it walks away. But this middle ground of sort of holding on isn't going to work anymore. And that, to me, the good news is at least we are now coming to a head. We're at least coming to that decision point. And that's a critical decision that needs to be made. And to me, that's good news, because at least it gives everybody involved some sense of where this is going. I think that's something worth looking forward to because what's been going on up until now is unacceptable.

BILL MOYERS: But people say to me, you know, they're opposed to escalating the war. But they say, "How can we walk away from the people who joined this fight in no small part, because we've asked them to?"

NANCY YOUSSEF: Right. And what happens if the United States and the Coalition leaves? The Taliban invariably comes back. And there's the potential now for Al Qaeda to come back and we start it all over again. This is the problem with Afghanistan. You can't stay. You can't go. There are no absolutes in this. And it's this fine line that everybody's trying to walk. Are we prepared for the risk that comes with leaving and allowing the Taliban to come back in and potentially for that sanctuary to rise again? And now you've got a population that's more angry and more empowered in a very, very powerful and dangerous part of the region.

BILL MOYERS: But you're going back.

NANCY YOUSSEF: I have to go back. You know--

BILL MOYERS: Why do you have to go back?

NANCY YOUSSEF: Because I'm the Pentagon Correspondent, and I think it's really dangerous to depend on people in the Pentagon to tell you what's happening on the ground. There's no way to understand it other than to go. And I'm not smart enough to just sort of read reports. I have to feel it. I have to smell it and touch it and feel that fear in some way. I have to be in the humvee and feel the fear of not knowing what's going to happen. Or be in the car with the Afghan with my Afghan friends and feel what it's like to not know if that coalition soldier's going to kill you or not. There's just no way for me to understand it. And the vantage point of Washington, in some ways, doesn't matter. It just doesn't matter.

What matters is what the troops are doing. And you can't replicate anything going there. And I really do love it. It's a beautiful country. I love the people. I love hanging out with the troops. I love understanding it. To me it's a great privilege to have a job where I can go to the frontlines and really see what's happening. It's a great way to make a living.

BILL MOYERS: But just this week the "New York Times" correspondent, Farrell, was held hostage. And as he and his journalist friend, who in Afghan interpreted for him, was killed. He got away, but the Afghan was killed. And just this week, your colleague, who was in Afghanistan, Jonathan Landay of "McClatchy," was in a hostile action and in a perilous situation. Why do you put yourself in that?

NANCY YOUSSEF: It's sort of like Afghanistan, the alternative is far worse to me, which is to do nothing, which is to say nothing. You know, I have a unique background. My parents are from Egypt. And I'm, I'm raised Muslim and I feel like I have something to say. I feel like I can walk that line between what the local populations are feeling. What the military is feeling. And I don't walk in blindly. Every time I go, I sort of look at my hands and feet and say, "Oh, I hope I come back with all of these." I mean, I know what's involved.

I know those risks, and it's around. I mean, it's become personal, in a way. Every day this week, I wake up, and there's a bombing. And I worry about my friends in Afghanistan. And my colleague who sits right across from me at work is caught in an ambush. And I think, "What can I do to sort of tell people about this? What people have to know. They just have to know."

BILL MOYERS: So, since you know what you know, and since you say we have to know, where do we come down on showing the photograph?

NANCY YOUSSEF: It's really hard. Because as I said, you know, you can't lose your humanity in war. And I feel for that father. I can't imagine that image being foisted upon me of my son in that position. I just can't imagine. But sometimes I feel like we as a public need to be hit almost violently with the reality of war. And that's what that photo does. So, I'm really conflicted about it. You know?

BILL MOYERS: The reality of war is?

NANCY YOUSSEF: It's ugly. It's violent. It asks tremendous things of troops. And it puts troops in incredible danger. And we as a country have put these troops in that position. We have to know what that means. I want the war to be relevant. And I think that was the intent behind it. The details of how it was handled maybe weren't best. But I think at the end of the day, that was the goal. And it's an important goal.

BILL MOYERS: Nancy Youssef, thank you for being on the Journal. And good luck to you.


SOLDIER #1: Find out what they are shooting at! I need to know exactly what they were shooting at.

SOLDIER #2: When was the last time we took fire from that direction?

BILL MOYERS: If anyone understands the big challenges when it comes to healthcare systems, not just a domestic but a worldwide scale, it's the man you are about to meet.

Dr. Jim Yong Kim is a physician and anthropologist who has combined the skills of both to become one of the most acclaimed visionaries in the field of global health. "The world's troubles are your troubles," that's what he urged the recent graduating class of young doctors always to remember. That imperative has been the inspiration for his own work.

As co-founder of the humanitarian group, Partners in Health, and a senior official with the World Health Organization, Jim Yong Kim has been a crusader against infectious diseases and an advocate for the poor among the forsaken of the world in cities and villages in Haiti and Peru to Rwanda and Siberia. "U.S. News and World Report" said he is one of America's 25 best leaders. "Time Magazine" named him one of the 100 most influential people in the world. The Chair of three, that's right, three departments at Harvard University, Dr. Kim was a MacArthur Foundation genius whose efforts helped to treat 3 million new HIV/AIDS patients in developing countries.

By the way, he was also the quarterback for his high school football team in Muscatine, Iowa. So why at 50 years of age is this world renowned scholar and physician leaving all that behind for the hills of Western New Hampshire? Just a few days from now he will be formally inaugurated as the 17th President of Dartmouth College.

Welcome to the JOURNAL.

BILL MOYERS: Welcome to the Journal.

DR. JIM YONG KIM: Thank you very much Bill.

BILL MOYERS: I am indeed curious. You have spent the last 25 years of your life working with the sickest and the poorest people in the world. And here you are, now about to sit in the corner office of a wealthy, elite school with fewer than 6000 undergraduate students. What in the world did you tell the search committee?

DR. JIM YONG KIM: Well, it was entirely unexpected. I was minding my own business, working with colleagues who were interested in global health. But also colleagues in Harvard Business School and the engineering department at MIT, to try to figure out how to make health care programs in developing countries work more effectively. Dartmouth came out of the blue and said, "Would you look at this job?"

You know I work with Paul Farmer, who was chronicled in the book "Mountains Beyond Mountains," and he's one of my heroes and my closest friend in the world-

BILL MOYERS: Great public health--

DR. JIM YONG KIM: Great public health advocate, made a lot of personal sacrifices in his life. They call him the modern day Albert Schweitzer. But he is a person who works tirelessly for the health of poor people. And I have been very touched by the extent to which young people are motivated and moved by his life story. So I think that there's always a sense in young people that they want to do something great. I think there's a danger. A lot of young people don't think they can make a difference.

That's really what I am at Dartmouth to do. I'm there to tell the young people, "Look, a few committed souls can change the world." The famous Margaret Mead line, you know, that, never doubt the capacity of a small group of committed souls to change the world. In fact, that's the only thing that ever has. So I am there to give them that message. And you know I'm not sure. I'm not sure if that will work in my role as college president, but I'm going to give it a shot.

BILL MOYERS: But you know, you're coming with not the most popular message right now, because you know, when you told those young doctors graduating from medical school last May, "The world's troubles are your troubles." And that's the last thing many young people and old people in America want to hear right now, because we've got so many of our own troubles right here at home.

DR. JIM YONG KIM: Right. Well, I don't think that I would exclude our troubles. For example, one of the projects that I started just before leaving Harvard was a project looking at the health care of Native Americans in New Mexico. So there are a lot of problems right here. You know, in my own view, the life expectancy of Native Americans in the United States is one of the really great moral crises that we face.


DR. JIM YONG KIM: Well, the life expectancy is often very much lower than life expectancy in some of the developing countries that I work in, in the 40s and 50s in some communities. So the world's troubles are right here as well.

And I was just tantalized by the notion of reaching back into the undergraduate curriculum. And trying to think hard about what would it take to train a group of young people, who would leave the college energized, inspired, and really thinking that there's no problem that they couldn't tackle.

DR. JIM YONG KIM: And I think that this is a good time to get them thinking about, look, you know, there's global warming. There's the crisis in the health care system in the United States. There's global health problems. There's a lot of huge problems out there. What do you need to do to prepare yourself for a meaningful life, tackling those kinds of problems? That's the question I'm going to ask them every day, as college president.

BILL MOYERS: Why are we talking about the American health care system as a crisis? What's wrong with our health care system?

DR. JIM YONG KIM: My own particular take on it is that I think for many, many years, we've been working under the fantasy that if we come up with new drugs and new treatments, we're done.

The rest of the system will take care of itself. In my view, the rocket science in health and health care is how we deliver it. And unfortunately, there's not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences

In other words, what we've learned about organizations is that it is very difficult to get a complex organization, a group of people, to work consistently toward a goal. In the business world, if you don't do it well, the market gets rid of you. You go out of business. But many hospitals executing very poorly persist for a very, very long time. So my own view of it is that we have to rethink fundamentally the kind of research we do and the kind of people we educate, so that they'll think about the complexity of delivery as a topic that we can take on and study and learn about as a science.

BILL MOYERS: What do you mean, complexity of delivery?

DR. JIM YONG KIM: Well, just think about a single patient. So a patient comes into the hospital. There's a judgment made the minute that patient walks into the emergency room about how sick that person is. And then there are relays of information from the triage nurse to the physician, from the physician to the other physician, who comes on the shift.

From them to the ward team, that takes over that patient. There's so many just transfers of information. You know, we haven't looked at that transfer of information the way that, for example, Southwest Airlines has. Apparently they do it better than any other company in the world.

BILL MOYERS: Computers?

DR. JIM YONG KIM: No, they have taken seriously the human science of how you transfer simple information from one person to the next. And in medical school, and in the hospitals that I've worked in, we've done it ad hoc. Sometimes we do it well. Sometimes we don't do it well. But what we know is that transfer of information is critical. Now to me, again, that's the rocket science. That's the human rocket science of how you make health care systems work well

What we need now is a whole new cadre of people who understand the science, who really are committed to patient care. But then also think about how to make those human systems work effectively. We've been calling it, aspirationally, the science of health care delivery. And we do it at Dartmouth.

30 years ago, one of our great faculty members, Jack Wennberg, started asking a pretty simple question. Why is there variation, for example, in the number of children who get their tonsils taken out, between one county in Vermont versus another? 'Cause one of his children was in school at one place. Another of his children were in the school in another place.

And in one place, almost everyone had their tonsils out. And in another place, almost no one did. And of course, he found that there happened to be a doctor there who liked to take tonsils out and benefited from it. And he kept asking this question, you know, outcome variation. He called it the evaluative clinical sciences. And I think that's really the forerunner to what we're talking about in terms of the science of--


DR. JIM YONG KIM: --health care delivery.

BILL MOYERS: That's a fancy name. What does it mean to the layman?

DR. JIM YONG KIM: It means how do you evaluate clinical outcomes? How do you understand variation in doctors' practices, for example? And ultimately, how do you fix the problems? So the group at Dartmouth Institute does all of that. We look at variation. You know, why is a Medicare reimbursement rate, you know, almost a third in the Mayo Clinic area, as opposed to Miami?

It's around 6,000 and around 15,000, huge differentials. And they simply ask that question. That's the Dartmouth Atlas, that looks at variation in health care expenditures from one place to the other. And we keep asking the question. "Why does this happen? Why does this happen?"

And we continue to do that research. And then we find places that are spending a lot of money and not getting the outcomes that they want. Folks in the Dartmouth Institute have developed techniques that borrow from industry, that borrow from, for example, the Toyota production system models, Six Sigma, these great management tools, and try to bring them to the hospital.

So not only do we study the problem and try to understand why there's variation and why there's poor outcomes in one place, but we also work very hard in the kinds of interventions that will change the tide. I think that's the science of health care delivery. And that's what we're going to really grow at Dartmouth College.

BILL MOYERS: Why have we been so resistant to doing this? It sounds so sensible.

DR. JIM YONG KIM: Well, I've noticed over the years that when it comes to our most cherished social goals, not only do we tolerate poor execution, sometimes we celebrate poor execution. Sometimes it's part of the culture. You know, these folks are trying to solve this terrible problem. They can't keep their books straight.

They really don't know what they're getting. They don't measure anything. But they're on the right side, so that's okay. I think we're in a different time.

BILL MOYERS: So what can we learn, for our own health care purposes, from the partnerships you've spent the last 25 years creating around the world?

DR. JIM YONG KIM: One of the things that we've learned is that community health workers, which are really members of the community who help people go through very difficult treatment regimens, this can work anywhere. We've done it first in Haiti. Then we did it in Peru. And then in Africa. But most remarkably, we've also implemented that program in Boston, and are now thinking of implementing it on the Navajo reservation in New Mexico.

BILL MOYERS: And in essence, it means what? Describe it to me briefly.

DR. JIM YONG KIM: It means that for people who are, say, taking HIV medications that are very difficult, that they have to take every day, that they have to really be careful about, with nutrition, et cetera, that having someone who just visits every day, just to make sure that you're taking your medicines and you're doing okay, that has a huge payoff down the line in terms of overall outcomes, overall health outcomes.

You know, we found a group of patients living with HIV in Boston, who are really falling through the cracks. And we implemented almost an identical program in Roxbury. And we've had really astounding results. The cost of their care has gone down. And of course, they're back and they're working, and they're productive members of society. And they're not landing in the emergency room, when their disease gets out of control. So we think that that's one of the lessons. But there are many more that I think can be directly applied to health care in the United States.

BILL MOYERS: Does President Obama get it? Did you watch his speech?


BILL MOYERS: What do you think about it?

DR. JIM YONG KIM: Well I thought as a speech, it was really stunning and masterful. He's a wonderful speaker. But what was most interesting to me was the Republican response afterwards. And how many things that they seem to agree on. What do they agree on? One, everyone should have health insurance.

Two we need to lower cost. Three, we need to maintain quality, that the expenditures that right now, in health care, especially public expenditures are unsustainable.

But my view of this goes back to what I said earlier. There's no simple solution to this problem. I think we have to take very seriously that health care delivery is rocket science. And we've got to bring the best and the brightest to work on this problem.

And the only way to do that is to get more people thinking every day about it. Right now, the physicians who are running these hospitals have never been trained. Most of them have never been trained in system thinking, in strategy, in management.

And the places where there are leaders. Intermountain Healthcare, which President Obama mentioned, is run by a visionary leader named Brent James, who was a biostatistician and has been an expert on studying outcomes for a very long time. So when you bring that kind of expertise to the running of a hospital system, it gets better.

BILL MOYERS: One of the big disappointments to a lot of people is that the White House seems to have made a deal, reportedly has made a deal with the drug industry, not to use the power of the government to negotiate lower drug prices, or through Medicare and Medicaid. Now I know you know something about negotiating for lower drug prices, when you were at the World Health Organization, right?


BILL MOYERS: Tell me about that.

DR. JIM YONG KIM: It's a very complicated business. If you look at three diseases, the three major killers, HIV, tuberculosis and malaria, the only disease for which we have really good drugs is HIV. And it's very simple, because there's a market in the United States and Europe.

So what we know is that market incentives to drive drug delivery are critical. We have to maintain them somehow, because if you don't have market incentives, there are almost no malaria or tuberculosis patients, we have almost no new drugs. So somehow, we have to maintain the market incentives, for the pharmaceutical industry to keep working.

Now having said that, I've worked a lot with the drug companies to say, "Okay, so make as much money as you can on the HIV drugs in the first world. We will work with you to protect those markets and protect your intellectual property. On the other hand, in those areas where you make no money anyway, work with us to make those drugs available." And they've done that for HIV drugs, in a way that's really quite astounding.

So somehow-- you know, this is a complicated issue. We've got to make sure that the incentive for the drug companies to make new drugs is still there. But at the same time, be reasonable about making sure that people have access to them.

BILL MOYERS: Yeah, there was a strain of TB, if I--


BILL MOYERS: --understand the story, that could be cured by a drug, but the drug was so expensive that poor people couldn't afford it in the developing world. And what did you do about that?

DR. JIM YONG KIM: What happened was, we looked at the cost of these drugs and the drugs for a complete cure for a patient living in a developing world. When we started, was about $25,000. But what we later learned was that the only reason they were so expensive is because they were only sold in first-world countries.

So what we did was we got everyone who was interested in purchasing these drugs. We went to Doctors without Borders. We went to other health organizations and said, "Can you help us get the Indian and Chinese drug industry to start making these drugs?" And they did it. Now, the real key was at Eli Lilly and Company, that was making two of the drugs, they came on board and said, "You know what? We're going to help you with this program. We don't make any money off these drugs, they're off patent a long time ago. We're going to actually help you find manufacturers in those countries that can make these drugs at a lower cost."

So I think it's one of the greatest acts of corporate philanthropy I've ever seen, Eli Lilly and Company stepping in on two drugs that they don't make any money off anymore, helping us to craft the overall response to drug-resistant tuberculosis. We're not there yet. If there were a market for tuberculosis drugs, then I think we'd have lots of new drugs. But because there's not one in the developed world, we're still struggling.

So those of us who have been really working, you know, on a day-to-day level to try to provide those drugs, we've learned a couple of things. One, intellectual property is important-- but the drug companies, if you keep working with them, they'll see that there is a great philanthropic and humanitarian achievements that they can claim for themselves, by helping to make them accessible. Now we're not there yet. But you know, the Gates Foundation, for example, is working very hard to fill the holes that the market is not filling. You know, we're all-- got our fingers crossed, hoping that Bill and Melinda Gates will be successful in getting us these new drugs and vaccines.

BILL MOYERS: But when you see health fairs where people so poor in this country go because they can't afford to have a toxic tooth pulled, how do you justify spending that much effort and that much money in Africa and Haiti and South America and other places, when we have such desperate need in this country? And that's a question--


BILL MOYERS: --I get a lot.

DR. JIM YONG KIM: If you look at what we're doing in those developing countries-- so for example, all of the efforts that we're making in some of the poorest countries, what we're doing is we're taking annual expenditures on health care from two or three dollars up to maybe 15, 20, or 30 dollars.

Where as in the United States, it's well over $7000 per person per year. So they're two very different problems. Both of them break my heart. So in a country where we're spending, on average, $7000 per person per year, we should be able to find a way to provide health care for everyone. And I think, we can do that. And I think we can do that fairly quickly, if we put our minds to it. The problems with health in the developing world, for example, drug-resistant tuberculosis. The majority of the cases of drug-resistant tuberculosis are among the foreign-born. So it is not a smart idea to think that those kind of diseases are over there, and we're immune from them. We're not, in fact. And you know, with H1N1 and the other pandemic flues, we are-- that has shown us more than anything else-- I was at the World Health Organization and involved in the very later stages of the response to the SARS epidemic. Boy, you know, there's no question that in terms of infectious diseases and other health problems, we are one planet.

BILL MOYERS: You are trained as an anthropologist too, as well as in medicine. What do you think the eye of an anthropologist sees, that a physician on his or her own might not see?

DR. JIM YONG KIM: Well, I think that in medicine, what we're trained to do is to look for patterns, to build order out of great complexity, out of very subtle signs and symptoms, and then have a plan where you can act. Anthropologists are a little bit different, we don't often act on what we do. So I'm sort of in the middle now. I do the ethnography, to try to get a sense of what the culture is.

You know, if you want to know what anthropologists do, one of my great professors, Sally Falk Moore once said, it's very simple. You walk into a room and you say, "Who are these people and what do they want?" So if you're constantly asking that question, over time, you build up a sense of how a particular social system works. That's always what we've done. Paul Farmer's also an anthropologist, we've done this together for many, many years.

What is it that we need to do to actually change policy around HIV treatment or drug resistant TB treatment? And that anthropological piece of it, linked to a physician's approach to solving a problem and putting a solution on the table, taking people through difficult times-- That's been a very good combination for me.

BILL MOYERS: Friends of mine and viewers who are anonymous will write me or say to me, you know, "Moyers, don't bring us any more bad news. We don't want to see any more starving children in Rwanda, sick children in the Congo or dying children in Haiti. If Bill Gates can't save them, there's nothing we can do." What keeps you from getting depressed?

DR. JIM YONG KIM: Well, again, I-- for 25 years, in working with Partners in Health, we've really seen some tremendous changes. I mean, in the central plateau of Haiti, Haiti suffers from so many problems, including deforestation, poor health care, poverty, all these different kinds of problems, but in our one little area, not only have we built a health care system that now sees almost two million patients a year, but the trees have come back.

We just sort of did this almost quixotic little project where we kept planting trees. And the area around our clinic looks almost like the rainforest that it once was. So, in going to those really difficult situations, first of all, it does something to me, make-- you know, it brings out a kind of humility that I don't feel unless I go and see the most excruciating thing in the face of the earth, which to me is a mother who can't feed her child.

So having the experience of seeing those things, I think it does something to me as a person, to my soul. But then in seeing the possibilities, the programs that can turn things around, that's the most inspiring thing that I've ever seen.

BILL MOYERS: Where does this passion come from in you? I mean, if an anthropologist walked in here and said, "Who is that person, where he's from?" What's the answer?

DR. JIM YONG KIM: Well, I've been very fortunate. You know, my father came by himself, across the North Korean border when he was seventeen. And hasn't seen his brothers or sisters or parents since then. And he died some time ago, but never saw any of his relatives. My mother was a refugee, in war-torn Korea. And was plucked, because she was a good student, to come to Scarritt College in Tennessee. So there have been so many accidents of luck that have gotten me to this position.

BILL MOYERS: Where did you all come to from--

DR. JIM YONG KIM: So we first came to Dallas, Texas, where my father-- my father had been a well-established dentist in Korea, but then had to do dental school all over again, because they didn't recognize Korean degrees. So Dallas, Texas, Southern Methodist University-- excuse me, Baylor University -- he did his dental degree--

BILL MOYERS: --There's a big difference, one's Methodist, one's Baptist.

DR. JIM YONG KIM: I know. I know. (LAUGHTER) That's right. I couldn't get that wrong. So he got his dental degree from Baylor dental school, and then we moved to a small town in Iowa, and grew up in Iowa. And even though, you know, we lived a very-- a sheltered kind of existence, I always kind of knew from my mother, who, again, lived through war and then did her master's with Reinhold Niebuhr and Paul Tillich and these folks at Union Theological Seminary.

BILL MOYERS: Two great theologians of the twentieth century.

DR. JIM YONG KIM: Absolutely. It was one of the most exciting intellectual environments in the country at that time, in the 1950s. So we always had the sense from my mother that we should do something great, that there are great things to be done in the world.

BILL MOYERS: What does she say to you? What does she do with you?

DR. JIM YONG KIM: Well, she would read to us the speeches of Martin Luther King in 1968. She would-- she even gave me, at one point, I remember reading Booker T. Washington when I was in grade school. So I had the exposure to a lot of great thinkers.

So she kept trying to convince us that, you know, we had a responsibility in the world. Now my father was a dentist, one of the most practical people on the face of the earth. When I came back from my first semester at Brown University, he picked me up at the airport and we were driving home. And I said to him, I said, "Dad, I think I'm going to study philosophy." So he slowly pulls his car over to the side of the road, looked back at me and says, "Look. When you finish your residency, you can do anything you want."

It was clear. If I was going to make it in this country as an Asian-American, he said, "You're going to need a skill. You can do anything with that. You know, whatever you do after you have that skill is okay. But I can't go to my grave," he basically said, "without knowing that you have some way of supporting yourself, if everything else falls through."

BILL MOYERS: Were you the only Asian family in that little town?

DR. JIM YONG KIM: We were.

BILL MOYERS: What was that experience like?

DR. JIM YONG KIM: Well, we were comfortable, economically. But if you go to a mall, just up the road, where they don't know who you are, of course, back in those days Kung Fu was the big exposure to Asian culture. So you know, everyone would come up to us and either be fearful or mocking. So racism was there. But you know, I've come to understand that the racism that we felt was more like sort of indignant, it was it was embarrassing. It wasn't the kind of racism that, in fact, that impacted, for example, African-Americans in the south in the '30s and '40s. It was different. I think I developed a sensitivity for people who are marginalized and outcast. But I don't have any illusions about me being an oppressed person. I-- you know, my father was a dentist. My mother was a philosopher. We loved Iowa Hawkeye football, so we had a great time there.

BILL MOYERS: I gave the commencement at Dartmouth a few years ago, and I discovered that roughly 80 percent of the students there participate in varsity, club or interactive-- intramural sports. So my only advice I would give you is: don't go without a Frisbee.

DR. JIM YONG KIM: Well, I have to tell you, Bill, I've already played with the women's volleyball team-- I played volleyball in college-- I've already been out throwing the football around with the football team, and that's one of the really great perks of this job, these fantastic young people who are both athletes and students. I happen to believe that athletics is a really important part of one's educational experience. So that's really the fun part of a job.

BILL MOYERS: Doctor Jim Yong Kim, thank you for being with me on the Journal, and good luck at Dartmouth.

DR. JIM YONG KIM: Thank you, Bill.

BILL MOYERS: That's it for the Journal. Don't forget to log onto our Web site at Click on "Bill Moyers Journal" and you can learn more about Dr. Jim Yong Kim and his pioneering work in education and global health. You'll also be able to observe the human cost of war as seen through the eyes of some of the world's finest photojournalists. That's all at I'm Bill Moyers. See you next time.

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