Healthcare Roundtable: The power of teamwork [Extended]

In an era of globalization and budget limits, no single entity can solve medical crises. Industry leaders gathered in New York City for this Kyne-hosted event that underscored communications' role in facilitating multi-stakeholder partnerships.

Participants
-Gabrielle Fitzgerald, former director of global program advocacy, Bill & Melinda Gates Foundation
-Amy Fry, VP of public affairs and communications, Boehringer Ingelheim
-Ray Kerins, SVP and head of comms and public affairs, Bayer
-David Kyne, CEO, Kyne
-Matthew Lynch, director of Global Program on Malaria, Johns Hopkins University
-Dan McIntyre, SVP of public Affairs, Biogen Idec
-Charles Stokes, president and CEO, CDC Foundation
-Jack Watters, VP of external medical affairs, Pfizer

A strong foundation
Gideon Fidelzeid (PRWeek):
What are the building blocks that help ensure those involved in healthcare partnerships can work together effectively?

Charlie Stokes (CDC Foundation): Transparency. Without it, you cannot build trust. And though trust is always important, it is absolutely essential in public-private partnerships in the healthcare arena.

David Kyne (Kyne): It is important to look at the assets being brought to the table. Some of the most successful partnerships are where you marry a public health organization at the state level that knows how hospitals run with a more local group that understands community health. It’s finding entities and matching their expertise around the problem. Great partnerships start with understanding the problem you’re looking to tackle before necessarily picking the right partners.

Amy Fry (Boehringer Ingelheim): We work with patient groups and have a partnership with Ashoka, an NGO that works with social entrepreneurs. As obvious at it sounds, the key to partnering is getting to know each other and understanding everyone’s goals, how they work, and how they arrive at decisions.

We are fundamentally different than Ashoka in how we operate, but we spent the time up front to be honest with each other and truly learn what the other side wanted. That has gotten us through some very challenging conversations. Corporations are often viewed as being out only for themselves. When looking to establish healthcare partnerships, they must show they are not like that.

Gabrielle Fitzgerald (formerly of the Bill & Melinda Gates Foundation): I refer to The Boys in the Boat, a book about the 1936 University of Washington eight-man crew team than won Olympic gold in Berlin. It’s really hard to get eight people to do the same thing simultaneously. In the world of rowing it’s called "swing." How do you get that swing where everyone pulls together? It takes a lot of practice, a lot of trial and error, and a lot of being honest about what works, what doesn't, and working through those problems together. Transparency is the key to get that "swing."

Jack Watters (Pfizer): Everyone needs to know their precise role in the partnership. Moreover, you shouldn’t assume that, because they then know their stated role, they’re fulfilling it. There must be check-ins built into your process. There must also be an opportunity to course correct just in case things aren’t working out the way they should.

Dan McIntyre (Biogen Idec): The partnerships we look for are less about specific projects, at least in the beginning, than they are about building trust. The way I measure the success of a partnership is when something goes wrong, do our allies know and trust us well enough to validate our position, assuming something egregiously wrong didn’t occur? I always start by identifying something the partner I wish to pursue is passionate about that has no benefit to my organization whatsoever – and I just do it without asking questions. You just do that to help them out. You earn the right to build from there.

Ray Kerins (Bayer): It’s like dating. We date a lot of organizations. With some, we have long-lasting relationships. We enter those with the concept that it’s not a one-off. I’m not looking for organizations at which to just throw money. We take a much longer-term view. The key is knowing whether or not you’re going to go beyond that first stage. It takes some intuition, but identifying shared value between the two entities is always a good building block.

Perhaps most important, though, is if you enter a healthcare partnership, you have to be all-in. It’s not about the money. It’s about finding where can we bring other resources and expertise to the situation that have nothing to do with our bottom line. We can bring insights from medical, from regulatory, from other areas.

Matthew Lynch (Johns Hopkins University): A key thing to remember with these coalitions is that everybody comes with a history. Moreover, in public and international health, it’s a fairly small group of people who work on the same disease over time. You can bet some people preparing to enter into partnerships have had arguments in the past. Everyone has to be very clear about how they will work together and what really matters. Everyone must articulate what they expect to gain from this and what they will contribute to that end, which can be remarkably hard. However, if done, it is a very useful first step.

At home, around the world
Fidelzeid (PRWeek):
How have private-sector partnerships helped your organization achieve the CDC’s objectives? As an entity that sits right between the private sector and a government agency, what challenges does that present?

Stokes (CDC Foundation): We are very effective at raising money, but the flexibility we have in spending it as a nonprofit really helps us stretch those dollars. Both the CDC and our donors really appreciate that and it never ceases to amaze me that once you’ve built a trusting partnership, there are all kinds of side benefits that accrue over time.

An example is our long-time partnership with UPS, which just helped us ship some personal protective equipment to West Africa that Henry Schein donated. Years ago, just after SARS cost the global economy billions of dollars, the CDC put together a toolkit for businesses to deal with outbreaks such as that.

Because of our relationship with UPS, I was able to pick up the phone, call the head of international HR, and simply run the toolkit by him. He took a look at it and said, "This is extremely helpful. This is kind of helpful, but why is this in here?" That feedback allowed the CDC to really develop a great product. No money changed hands. It was quick and efficient. An exemplary partnership producing a great result.

Multiple audiences – including citizens, the press, and donors – expect all the partnerships a taxpayer-funded organization is involved in to be crystal clear and one all can be proud of. The challenge for us is to recognize when a partnership may be starting to veer from that path and pulling the players back together. We must make sure science reigns supreme so the public health good can happen.

Fidelzeid (PRWeek): How do you approach healthcare partnerships from a local perspective?

Lynch (Johns Hopkins): The key concept for a local community is relevance. Whatever actions a healthcare partnership wants the households in a community to take have to be relevant to the life those people are living and to the issues they face on a daily basis. The extent to which we can make that connection, ideally on an emotional level, the more successful we will likely be.

My focus is on malaria in Africa. In terms of hitting an emotional chord, it’s fairly easy since virtually every household there has lost someone to the disease, or is close to someone who did. You can craft a message around that to make sure you can develop a social norm or some sort of enabling environment to make the desired behavior fairly easy for people to do and relevant to them.

If you’re talking about a public health tool, the ultimate goal is the actual application of it. And in terms of prevention, it all lives and dies in the households because that’s where it will be used.

Fidelzeid (PRWeek): What are the keys to successful global healthcare partnerships?

Fitzgerald (formerly of the Gates Foundation): The key word is global. Over the course of my career, I’ve seen many efforts seek to have a "global" impact, but were really focused on the US or Europe. However, I am very excited to have been part of some truly "global" campaigns in the past couple of years.

The Gates Foundation’s top priority is to eradicate polio. It works with the CDC, WHO, Rotary International – traditional entities for such an effort. But it was the unusual partners brought into that coalition that really stood out. We worked closely with the crown prince of Abu Dhabi, Sheik Mohammed bin Zayed al-Nahyan, who not only contributed money, but also made introductions to government officials who have access to regions in Pakistan that none of the other traditional partners had. That gives you a sense of how far these coalitions have come. Even Bill Gates giving a message in Pakistan is not as effective as the Crown Prince or the president of the Islamic Development Bank doing so.

Last April, the Gates Foundation cohosted a global vaccine summit with the UN Secretary-General and the Crown Prince of Abu Dhabi. Also taking part were representatives from UAE, the Islamic Development Bank, the Minister of Health from Afghanistan, the Sultan of Sokoto, the top religious leader in Nigeria, and government officials from Europe. Incredibly diverse and global.

Patients are a virtue
Fidelzeid (PRWeek):
Healthcare partnerships seek broad impact. How do you ensure such initiatives maintain focus on the specific patients in need who spurred the partnerships to be formed?

Watters (Pfizer): We often talk about diseases and epidemiology, which is the study of disease and populations. We talk about SARS or Ebola. However, I like to remind my colleagues that what it’s really about is the patient. The best way to describe the impact of a disease is by looking at an infected individual and saying, "Here’s what meningitis looks like." That makes it very real for my colleagues.

Patient advocacy groups do a tremendous job and we must bring them to the table in all of our public-private partnerships. To highlight that point, I have to give kudos to ACT UP. I admire what they have done to bring the patient experience of those with AIDS to our attention, which is what we need to do with all such diseases. Groups such as that remind us that the focus must be on the suffering person whose life we’re hoping to save.

Fidelzeid (PRWeek): What opportunities do healthcare partnerships provide to bring the patient perspective into the mix? Should patient communities be engaged during the R&D phase and, if so, what role do partnerships play in facilitating that?

Fry (Boehringer): We have an external affairs group that works with patient advocacy organizations. Its mission is to bring the patient perspective in to improve our insights as a business that creates medicines.

Their role in R&D is huge. Advocacy groups bring patients in to talk to our researchers. And the researchers love this because they so rarely get to interact with patients. Patients will often tell them, "Well, actually, our biggest issue is not what you’re trying to solve. It’s something else." This really helps direct the researchers toward solving what the patient most needs solved. And with clinical trials, the importance of having a diverse group of patients is paramount to bring a product effectively to market. Partnerships with patient advocacy groups facilitate so much of this.

Fidelzeid (PRWeek): When a company has multiple partnerships that involve very complex and scientific components to address larger medical questions, how can you facilitate broader understanding of those objectives and that the goals are met?

McIntyre (Biogen Idec): Over the years, I have come up with three basic principles on this very closely related to working with patient groups. The first is to be strategic and to make sure the partnership is not only mutually beneficial, which is part of it of course, but also long term and not transactional.

Second, it has to be justifiable. Any time a biopharma tries to mount a program, critics will challenge its motivations. It has to be simple, easy to understand, compelling, and able to survive all the filters it will go through, not the least of which is the media. A key to that: the story you are telling must be functionally true. Many companies come up with an external narrative that sounds good in the conference room, but doesn't meet the pressure test when it’s out in public.

Third, it’s about respect. It took a number of years for me to fully appreciate that the groups we work with – and everything we do involves very serious diseases – are involuntary members of their communities. Nobody with ALS chose to become a member of the ALS community. They are vulnerable. Because of that we have to be as respectful and attentive to their reputation as we are to our own. We have to make sure every interaction leaves them in better shape than when we found them. 

Common ground
Fidelzeid (PRWeek):
What are the keys to effectively bringing together entities with different agendas that have not collaborated before?

Kyne (Kyne): You have to listen to potential partners and understand what their role is and what they’re good at. So many people enter into coalitions or partnerships with an end goal in mind. "I want to be in this role. This is the bit I want to do. I want to get funding for this part. This is what I excel at. I can do all these things." Inherently, that is where the challenge lies. In a position such as mine, the key is to understand who the right person or entity is for the right role.

And the partners have to be the ones who create it from the ground up. When it’s a situation of "Here’s our campaign. Advocacy group, please put your name on it and this is what it’s going to look like," it often doesn't work in the most effective way. It has to start with, "This is the problem. Here are all of the assets around this table. How can we build something and get it funded together?" That way, the partnership belongs to everyone involved. It makes a huge difference.

Fidelzeid (PRWeek): Third-party endorsement is very desired in most comms initiatives, regardless of sector. What role do healthcare partnerships play in getting those coveted external voices to spread your message?

Kerins (Bayer): The greatest challenge our industry has faced is its own credibility. It’s our reputation and our inability to do enough to change it and to get engaged. I’ll often get asked, "Where are the third-party voices to back us?" And my response is always, "Before you ask them to speak up on our behalf, you better come to the game."

I am committed to this cause and to continuing to work more and more with global regulators to find out where the barriers are. You want third parties such as patient groups and other organizations to stand up for you? As an industry, we need to stand up for ourselves first. You can’t fully focus on anything else until that is solidified.

Fidelzeid (PRWeek): Does anyone have a story that exemplifies an unexpected benefit of healthcare partnerships? 

McIntyre (Biogen Idec): Years ago when I was at Bayer, we developed a PR program to support our antibiotic Cipro, focusing on proper hand-washing to prevent infections. The program, Operation Clean Hands, was a joint effort with the CDC and the American Society for Microbiology. We started it in 1995 and ran the program for a number of years. The CDC was particularly invested in the program, comparing it to the national seat belt campaign as something simple, cheap to do, but with powerful impact.

Two years after we began it, the CDC was dealing with a hepatitis outbreak in Michigan caused by tainted strawberries. They needed a supply of hepatitis immune globulin, which the only manufacturer had stopped making. The CDC’s problem was just the beginning: All companies, including ours, were struggling with manufacturing issues that threatened the global supply of immune globulins for many serious conditions. The CDC doctor, remembering Bayer from Operation Clean Hands, called us.

At the time, we didn’t have anything for hepatitis, but we did make a tetanus immune globulin to treat it, which is five times the cost. After much debate, we called the CDC and said, "How much do you want? Where does it have to be sent?" And we charged them what they would have paid for hepatitis immune globulin.

Nine months later, the immune globulin shortage had become a crisis, which made it both a political and media issue. Companies were called before Congress. Major media were all over it. Mike Wallace from 60 Minutes was making calls. Bayer, the whole industry, in fact, was in a real PR crisis. Fortunately, I was able to call the CDC physician, tell him what was going on, and ask him if he would speak his mind about the subject. He went above and beyond. He spoke to the media. He flew to Washington and testified about our commitment before Congress. He did it because we already had built trust with him through Operation Clean Hands, a program completely unrelated to the immune globulin issue.

I don’t know how you measure the value of that. All I know is that our partnership with him paid a very unexpected dividend when we really needed it.

Impact of technology
Fidelzeid (PRWeek):
How has technology changed the healthcare partnership landscape and, in turn, the broader way health issues are being addressed?

Lynch (Johns Hopkins): The availability of information thanks to emails, search engines, and mobile phones enables us to vet that information through more people. We can very easily get a couple of minds to check a document – and two minds are better than one. So the quality of information available to us has improved.

The challenge: there’s so much information, it’s difficult to manage it in a way where you can turn it into effective action.

Here’s the key, though: Technology is a tool for partnerships. It’s not the purpose of the partnership. In the end, you still get back to the human beings sitting around the table and trust, which is perhaps the most important word of the day. If you have a trusting relationship between partners, technology can certainly be used to make things easier. However, for that first meeting, technology or not, I’m a big proponent of face to face, even if it means getting on an airplane.

Kerins (Bayer): I focus on what technology has done for patients, advocacy groups in particular. With technology, it’s not just the fact they can get any information they want any way they want it, but it’s also the unprecedented ability to mobilize. We haven’t even come close to tapping all the power that’s sitting in front of us. In the old days, you communicated with your friends and family. Now, need I say more than the Ice Bucket Challenge?

Some people see technology as the devil, but it can also be the angel or savior, whether it be through fundraising, dialogue, or just sharing information. It amplifies grassroots efforts to a whole new level. Just in the last 10 years, look at what technology has done to increase our ability to communicate about healthcare issues –and I’m not talking about the US. Cell towers throughout Africa, India, and elsewhere are getting information to people who weren’t receiving it before.

McIntyre (Biogen Idec): The Ice Bucket Challenge exemplifies how technology makes a difference in people’s lives. Early on, social media was probably the biggest factor in the areas where my company works. We deal with the worst diseases: MS, ALS, and hemophilia. We’re working in conditions that are extremely isolating and crippling. Social media networks provide a lifeline for people to create communities in ways they never really had before. It’s quite heart-rending to see the depth of emotion expressed through tools you would never expect.

Things like the Ice Bucket Challenge force us to make really quick decisions with a considerable amount of risk. Biogen was one of the early companies challenged. The guy who started the Challenge, Pete Frates, is from Massachusetts, where we are headquartered. He visited our company last year. He’s treated at the UMass Medical School. He got the school to do it and the chancellor challenged our head of ALS research. While we couldn’t get our CEO to take part, we had 300 employees take part and we did it on CNBC.

From there, we challenged a CNBC anchor, who challenged Mark Zuckerberg, who challenged Bill Gates, and $100 million-plus raised later, the rest is history. If anything exemplifies how technology has changed the landscape in health, that’s it.

Watters (Pfizer): The core competence of the pharmaceutical industry is to develop new medicines. That’s why I entered this industry 35 years ago. Back then you dealt with case report forms in remote clinical trials locations and you literally had to travel all over the world to collect them, bring them back to your center, and they were all input into a computer. If you found mistakes, getting them corrected was a major ordeal. Honestly, I’m surprised we ever managed to develop any drugs because it took forever.

Enter data, specifically remote data. Today we have electronic case record forms. We have corrections in real time. It’s still a difficult, time-consuming, and expensive process to develop new medicines, but you can make decisions an awful lot faster. On so many levels, technology has helped us do what we’re supposed to be doing, which is develop new medicines.

Fitzgerald (formerly of the Gates Foundation): At the recent Clinton Global Initiative, President Clinton spoke about how, in today’s world, there has been a democratization of information. As applied to the issues we care about, it really has been game-changing when you look at the role of private citizens in social change.

We mentioned the Ice Bucket Challenge. Before that it was Kony 2012 – and there was backlash with that, too. Who empowered a bunch of 20-somethings in San Diego to set a global campaign to find a terrorist in East Africa? It was the democratization of information. And then it was telling a compelling story in a way that challenged people to act. It was viewed 100 million times in a matter of weeks. And the group that did it, Invisible Children, didn’t just do that video and stop. They have a major policy agenda. They’re talking to the White House all the time. It’s inspiring the role public citizens are taking to make global change. What technology has done to empower anyone to do that at such a powerful level is incredible.

For another example, look no further than David Kyne. With the Ebola situation in West Africa, David – not commissioned by anyone, just of his own volition – has used his skills and connections to put together a series of videos with African celebrities to raise awareness about behavior-change actions people can take to make sure they are protecting themselves. 

Fry (Boehringer): An interesting development in the space is with a company such as Walmart stating its intention to be a leader in integrated healthcare. The retail sector is actually quite well positioned to be a very dominant player because of the technology it has, the access to data it has, and the position it is in to help patients manage their way through this.

It’s exciting, but it’s also daunting, especially in terms of figuring out what this means to patients and how companies such as ours work with them. It also forces us to up our game with what we do for patients through technology in whatever part of the world we’re trying to serve.

Kyne (Kyne): The story of Gavin Glynn, a young cancer patient in Ireland, really illustrates some things technology has enabled in the health world, but also how much more can still be accomplished. [Editor’s Note: Glynn lost his battle to cancer on October 22.]

Gavin’s is a very rare form of cancer [Embryonal Rhabdomyosarcoma, a cancer of the muscles attached to the bones]. Over a year period, his father searched everywhere for treatment. So much information was buried in scientific literature. He went to Germany, Switzerland, and the UK. Gavin was in hospitals in Ireland, but it was all trial and error.

His father then started to blog about his experience. Eventually, MD Anderson Cancer Center in Texas contacted him. Gavin was able to get to Texas for experimental treatment. Social media is the only thing that could have facilitated this. That said, it shouldn’t have taken almost a year to get to that point. There are still way too many silos in research, treatment, and other areas.

Different sectors within healthcare need to use technology to pool their information. Gavin’s father should have been able to find out where to go much sooner than he did.

Stokes (CDC Foundation): Technology has opened up a whole new range of possible partnerships. The CDC is currently working with Georgia Tech to use some of its technology around 3D printing, as well as some of its supercomputer technology to enable us to analyze data 300 times faster than we can now.

In Tanzania, we have a project called mHealth that focuses on using cellphones to better educate women around maternal and child-health issues. That could not have happened 15 years ago. 

Kerins (Bayer): We started using technology this year in dealing with AE [adverse event] reports. With these you are monitoring what’s being said on various chat rooms, websites, and so on. This has prompted us to start reaching out to patients directly on Twitter, in chat rooms, and other such places with members of our medical team. We can tell them, "This is Dr. X. I see you posted some comments. I’d like to talk to you about those. Please contact me." The whole idea is that we do care. But more than that, it’s about the patients we serve, not about us.

Previously, patients would have to call in through a call center to find out anything. The results have made us quite happy. We started doing this with our women’s health division and now we’re expanding it to the other products and areas. Technology is the cornerstone that gets us directly to those patients to find out exactly what is happening with them.

Addressing unmet needs
Fidelzeid (PRWeek):
There is a rise in noncommunicable diseases. While much focus is placed on women’s reproductive health, there are numerous issues related to the aging woman. Bringing it back to the situations that are making healthcare partnerships so necessary, what is being done to focus on such unmet health needs?

Watters (Pfizer): A crucial thing to remember in terms of unmet health needs is that the responsibility for the health of any nation is with its government. Millions of women in emerging economies are suffering from postpartum hemorrhaging. There is malaria, HIV, Ebola, and so on. The government, first and foremost, has the responsibility to identify what the unmet needs are.

After that, then the private sector, NGOs, and philanthropic groups must make themselves completely available to support the government in what needs to be done. We need to be ready to work with our governments when they need it. In doing so, those leaders will see that we can be very reliable partners.

Lynch (Johns Hopkins): The major challenge here is prioritizing where to put your resources. We live in a world of limited resources. I’m an advocate for malaria. When I’m successful advocating with domestic governments in endemic countries, that means the money I’m given is not going to something else and, frankly, roads and bridges are important, too. What tends to happen is that attention and resources go to issues that have passionate advocates that are able to get out there, get well connected, and push their message out.

Stokes (CDC Foundation): Data over time has shown that the top causes of both mortality and morbidity have changed in this country with the advent of vaccines and antibiotics. Whereas communicable diseases used to be those top causes, now it is chronic diseases – and that is actually a need the CDC has identified through its data. There was a time where people inappropriately looked to government to both identify the need and then solve the problem using taxpayer dollars, but that time is gone.

Government resources are less than what they used to be. Collectively, resources in various sectors are less than they used to be, relatively speaking. The only way to successfully solve problems now is for government to identify them, yes, but then join into partnerships to solve them.

Watters (Pfizer): No one can do this alone. Strip away everything else and that is the theme of the day. We can also learn from other governments that have done extremely well. HPV vaccination in the US, for example, is at a miserably low rate of about 28% – and all of these young girls and women could be protected, but it’s appallingly low. If you go to Rwanda, it’s about 85%, and it’s only as low as that because they have only been doing it for about the past four years. Their goal is to get it to 100% of the girls who could potentially benefit from it. This can be done and we need to look to other entities that are displaying excellence. Learning from others is a partnership and it reinforces that nobody can do this alone.

Fidelzeid (PRWeek): Nonprofits, corporate entities, professional organizations, and the like all have very different agendas that can often run counter to the interests of others. This opens up all entities to criticism, even accusations of either selling out or only being interested in commercial gain. How can such conflicts be resolved? How can such accusations be countered?

Kyne (Kyne): It truly goes back to transparency, not just between partners, but also with external audiences in terms of making them understand that there is a strong, rational reason that a private sector entity, an NGO, and a government are coming together. You really have to show that through the collective, needs are going to be met and that without that partnership they won’t. There really has to be a litmus test at the end of it.

Kerins (Bayer): At the risk of sounding too aggressive, I advise you punch back in the face. I’ve experienced this firsthand.

We were doing an education program for the last few years with the National Press Foundation focusing on oncology issues. The whole concept is training journalists on how to report oncology better. One group in particular came out and said we sold out for partnering with the foundation.

You have to understand there is a great challenge in this country as it relates to the lack of education for journalists. Cancer is rampant in this country and people need to know the signs to look for. These reporters reaching millions of patients and caregivers who need the right information. In fact, when we get questioned about a partnership such as this, it makes me want to double down and increase it further because it just underscores the point.

When criticism comes about, we tend to curl up in a ball and sit in the corner. We can’t let it happen any longer. Funding such programs is crucial for the companies in the health sector. As for this being any sort of conflict of interest, I challenged the person who said that to a debate. We’re proud of what we do and we do it openly. Of course the person declined.

Kyne (Kyne): To stick with Ray’s theme on pride, a lot of PR pros shudder because when some of these partnerships come about, they assume everything that happened – who spoke to whom, how it came about, whose idea it was, what the business reasons were  – will end up on the front page of The New York Times. But that’s no reason to shudder. They should be happy about it. Assume it will all be public from the outset of the partnership and you have nothing to worry about.

Fidelzeid (PRWeek): In your educated opinions, how do you see healthcare partnerships progressing in the future?

McIntyre (Biogen Idec): After nearly 40 years in this business, I’m very optimistic about this. One key reason: governments are not doing everything themselves and they are leaving entities such as ours with ample opportunity to fill gaps through partnerships both with government and other entities.

For example, we work with a number of schools around the world to fund post-doctoral programs that will help get some brilliant people into a bioscience career. Such endeavors are far enough removed from our commercial interests that we are able to use a foundation to provide that funding. Our benefit is long-term and indirect. There is really nothing transactional about it. If more such programs get initiated, there will be an increasing sense that corporations can be moral entities as well as commercial ones. The mutual benefits will be clear to all.

Watters (Pfizer): The greatest opportunity lies in all of us learning from each other’s public-private partnerships. Too often at present one such union gets done, but every subsequent one seems to start from scratch and it takes so much time. There really needs to be a better way to identify pitfalls, have a streamlined process, and take the best of all the public-private partnerships. There have been so many successful ones and some stupid ones, too, where you wonder what they were thinking. You can learn from those, too. However, it would be wonderful to have some collective that we could all learn from. The people we are trying to help would benefit far faster.

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